# Modifier 25 Again UGGGGHHH



## gherimicheleCPC (Apr 12, 2011)

Sometimes I really feel stupid.  I just got back from conference and I am now really confused.  I asked the speaker this:  A pt comes in with chest pain and shortness of breath.  THe doctor orders an EKG 93000 and a PFT 94010. THe pt is Medicare.  Wouldn't I bill a Office visit with a modifier 25 and then a EKG and PfT?  I then thought I understood her when she said if the patient came in with chest pain and shortness of breath then the tests performed were not seperate and were related to the office visit.  Tell me I am wrong someone.  It doesn't make sense that the EKG and PFT would be included in the OV.  Did I hear it wrong.


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## mitchellde (Apr 12, 2011)

It will all depend on the documentation.  I just have to assume in this case that the provider did not just decide that an EKG and PFT were automatically what was needed.  So I assume that the documentation will support that after a thorough exam the provider decides that the EKG and PFT would bring forth additional information.  This clearly makes the visit significant ( over above and beyond what is needed just for the procedure or test).   Truely a diagnostic test should not require the use of the 25 modifier since they enhance the providers ability to render a diagnosis.  However there is no problem in using the 25 modifier since I am sure the documentation will more than support its use.  Let me know if this helps you.


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## btadlock1 (Apr 12, 2011)

You should also know that an ekg (93000) doesn't bundle to outpatient/office E/M's, so no modifier is required to report them together. 94010 does, though. 

To know when to use the 25 modifier, you need to be able to tell when an E/M is considered "significant and separately identifiable". It's not as hard to spot as it seems...When a patient comes in, there's a reason (obviously). If that reason is to receive some sort of treatment *that's already been determined *(like a shot, or to have labs or other diagnostic procedures done), then it wouldn't be appropriate to bill a separate E/M.

*But*, if the patient has a problem that the provider has to evaluate/assess, decide how to treat it, and then carry out a treatment plan, you now have an E/M service that's reportable. Using the example you provided: if a patient comes in with chest pain and SOB, the doctor doesn't necessarily_ know _that the cause is related to their heart. He has to perform the EKG to confirm or rule-out a _suspected_ heart condition, but the EKG alone will not determine the diagnosis, and it certainly won't formulate a treatment plan. Although it contributes to the evaluation/management process, the EKG doesn't convey the amount of work the doctor did. 

Another example would be, when a patient comes in with an acute condition, like bronchitis, and requires an antibiotic injection. The E/M will bundle to the injection administration (96372), without a modifier. If the provider evaluated the patient's condition during the visit, and decided that the injection would be the best course of treatment for the problem, then you can bill the office visit separately. But, if a patient already has a treatment plan established that doesn't need to be re-evaluated at the time of service, then you shouldn't bill an E/M with it. An example of this would be for male patients that receive regular testosterone injections - they may come in every 2 weeks for injections, but it would only be appropriate to bill an E/M once every few months, as needed to make sure that the injections are working effectively.

When you're trying to decide if you can bill services for E/M separately, keep these things in mind:
1. If something's going to bundle to something else, it's probably going to be the E/M that denies. It's rare to see services that are incidental to E/M services (except in critical care). Most of the time, you have to prove that the assessment of the patient went further than is normally required to perform a procedure, which is the whole purpose of the 25 modifier.
2. Was it *necessary* for the *doctor *to examine the patient during the visit?
3. Did the doctor make a new decision about the patient's treatment (including keeping the same treatment plan, if it's working), or had he already figured out what needed to be done during a previous encounter?

If you can answer "yes" to both #'s 2 & 3, you should be able to bill a separate E/M with confidence. 
Hope that helps!


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