# Modifer 25 - We are having issues



## zztoolzz (Aug 7, 2013)

We are having issues with knowing when to add a 25 modifier or not. A pt comes in asking about a lesion on the leg and ends up having a full skin exam, we do a biopsy and we perform cryotherapy on a different lesion found during the exam. We attach 238.2 to the biopsy 11100 and 702.0 to the cryo 17000. The charge comes through with the e/m 99203 or 99213 with diagnosis of 238.2 and 702.0. Should we add a modifier 25 or because both of both diagnosis codes were treated and billed for are the charges for an e/m included in the biopsy and cryo codes? Would we need another diagnosis attached to the e/m that did not have something performed on it?


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## pscott (Aug 7, 2013)

It depends on weather or not the patient specifically came in for lesion removal or not.
If they did, then you cannot charge for the E&M. If the decision was made during the visit, you can charge for the E&M, and you use the 25 mod.


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## zztoolzz (Aug 7, 2013)

This is what we are seeing:

The patient is a 73 year old female who presents with a complaint of Skin Check. The patient has had new lesions (pink spot on the left shin, no bleeding, non-tender, present for 3 months). The patient prefers a skin exam of the following areas: complete skin exam except all undergarments. The patient has not had a basal cell carcinoma. The patient has had a squamous cell carcinoma (left arm). The patient has not had a melanoma. There is a family history of melanoma (Brother).

She came in wanting the lesion looked at, we did the biopsy. We found another lesion and we did cryo on it. Because the pt came in knowing the first lesion was there, we cant charge an e/m. Because we found the second lesion ourselves, we can charge the e/m?


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## MikeEnos (Aug 7, 2013)

I see no reason why you couldn't bill for an E/M service with a modifier -25, if the second lesion was found.  The fact is, this patient did not come in for a planned procedure --they came in for an evaluation.  As a result of that evaluation, it was determined that a procedure was necessary, and that procedure was carried out.  I see nothing wrong with that.  It should be documented and billed as such.


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## zztoolzz (Aug 7, 2013)

But as it states in the CPT manual, the surgery codes do include an E/M visit prior to the surgery. So would we need to find something that didn't require the surgery to bill the E/M since all the surgery codes include an E/M already?


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## MikeEnos (Aug 7, 2013)

If there is an additional diagnosis that supports that a significant, separately identifiable evaluation and management service occurred, that's the key.  Routine pre and post procedural evaluation is included in payment for the procedure.  If something required significant extra work, then I would say to bill an additional E/M.  Basically, if that portion would stand on its own even without the procedure, go ahead.


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## mitchellde (Aug 7, 2013)

swolfe said:


> We are having issues with knowing when to add a 25 modifier or not. A pt comes in asking about a lesion on the leg and ends up having a full skin exam, we do a biopsy and we perform cryotherapy on a different lesion found during the exam. We attach 238.2 to the biopsy 11100 and 702.0 to the cryo 17000. The charge comes through with the e/m 99203 or 99213 with diagnosis of 238.2 and 702.0. Should we add a modifier 25 or because both of both diagnosis codes were treated and billed for are the charges for an e/m included in the biopsy and cryo codes? Would we need another diagnosis attached to the e/m that did not have something performed on it?



From what you have stated it looks fine for appending the 25 modifier, however it truely depends on the chart note.  However you cannot assign the 238.2 dx code withoutthe path report.  That set of codes was not created to indicate provider uncertainty, it is to indicate that per a path report the patient has a neoplasm which cannot be classified as either benign or malignant.  you will have to use a 709 code for this.


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## Peter Davidyock (Aug 8, 2013)

E/M related to a procedure with a ten day global is included in the procedure.
If the patient came in and said "look at this lesion" and the physician did and removed it there is no separately identifiable E/M. As a result no E/M is billable.
Here is where it gets a little convoluted, I will try to keep it simple.
The identification of the second lesion is a separately billable E/M from the 1st lesion.
But the physician removed the 2nd lesion so a measurable amount of E/M is included in the removal of that lesion also.
The 25 modifier you wish to use is not because he located a second lesion. The 25 modifier is for all of the other skin surfaces he evaluated on his way to and all the skin surfaces he evaluated after the identification of the second lesion.

  You may have to appeal an initial denial but so long as the documentation demonstrates that the physician evaluated anything other than the two locations the E/M is a payable service.


Edit 1: I agree 100% with Debra about the diagnosis code. You must wait for the path report before assigning a dx.
Edit 2: I asked a question on a duplicate post of this thread, please disregard. This thread showed me what I needed to know.


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## MnTwins29 (Aug 9, 2013)

Oceanlivin, thanks for this gem.   Change skin lesions to laceration repairs, and I get similar questions from our urgent care docs about modifier -25.   Documenting the examination of other skin areas and finding the lesion is excellent.  Thank you. 

"The 25 modifier you wish to use is not because he located a second lesion. The 25 modifier is for all of the other skin surfaces he evaluated on his way to and all the skin surfaces he evaluated after the identification of the second lesion"


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