# 25 modifier w/ov, new pt.



## Willingham

Can someone share with me if you are aware, whether or not the 25 modifier is acceptable with a new office visit?  I read early part of the year that the 
OIG had audited and cited a high error rate when using this modifier with an ov for a new pt. because the new-pt visit is by definition a stand-alone billiable visit.  Any thoughts of this???? thanks.  Also when coding this ov with a procedure the CCI edits tells you, you need to append the 25 to pass the edit.  ????????????????????


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## coder911

If the documentation supports billing both an E/M visit and a procedure code - then by all means append the modifier 25. It specifically applies to E/M coding and therefore is applicable in this case. I don't think that only new patient E/M services have been targeted. I've read many an article that generally "harps" on the OIG zeroing in on modifiers 25 and 59. Simply because they override edits and get extra payments that might not have been "earned" properly.

---But as long as you're covered in the dictation, then bill it with modifier 25.


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## thompsonsyl

Hi....after reading your initial question I researched using -25 modifier on new patient visits & OIG's restriction on this because I'd never heard it said that new visits couldn't be appended with this modifier.  Low and behold, I did find it in "black and white", so to speak.  

http://www.mpro.org/news/pdf/articles/rmc011606.pdf

It had always been my understanding that use of modifier -25 was appropriate if a "significantly identifiable" E/M service was also rendered and documented on the same DOS; even if a patient is "new".  I mean what if a patient comes in for impacted cerumen and then decides to have a wart cryo'd on his finger?

Now I'm second guessing myself too...I'm eager to see what other coders will respond to your question.


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## Willingham

*OV/25 modifier*

to coder 911, I understand the rule for applying mod.25 and that is for ov but, I was trying to find out if in deed it is justifiable with a new pt.visit, thanks anyway.


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## blackiez1

*25 modifier and new pt ov*

I do auditing and see this all the time. It would appear to me that it IS inappropriate to append a 25 modifier on a new patient visit. It does not affect anything.
Think about it: The provider has never seen this patient before; therefore, any procedure performed is ok without the 25, because there is not an established history with the patient to indicate anything was significantly, seperately identifiable from the e/m service. 25 is grossly misused by applying it to a new pt ov, it is all fair game on the first visit. New patient never been seen; new problem. The 25 modifier does not have to be appended to get reimbersment for a procedure performed on a new patient. 
We need to remember: Modifiers are there to indicate a procedure was a modified from its original course.  
There is no modification on a new patient visit. The dr has no idea what is coming in the door when the patient arrives for the first visit; therefore, nothing to modify.
This how we review our new pt ov for  fraud.


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## raelewlov

Yes, that is true, but I have gotten claims denied for new patient or new consult from medicare and other insurance without the modifier 25.  I have had to submit appeals with corrected claims.


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## SScoder

I would be concerned about using information to validate the non use of modifier 25 to NP from a source other than Medicare, AMA, CPT or NCCI.

The informatin from the ATLANTIC INFORMATION SERVICES,Inc. states at the bottom that they "are not affiliated with any government agency" etc..

Look at the CMS Manual, Pub 100-4 Medicare Claims Processing, Transmittal 954.  

I will continue to use modifier 25 as long as it is "significant an Separate"  according to the Medicare , AMA, and CPT guidlines.

Hope this helps and have a great day!!


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## tekocz04

*Modifier 25*

Hi, From what I learned recently on my externship, a modifier 25 (problem oriented) is appropriately appended second after the initial visit (i.e., physical exam)--you'll get more revenue for the physical and probably half (depending on insurance carriers) on the mod-25 visit.  Hope I explained this correctly.  New to coding but have more confidence after billing/coding from encounter former and documentation. 


Terry
CPC-A
tkoczor767@aol.com




Willingham said:


> Can someone share with me if you are aware, whether or not the 25 modifier is acceptable with a new office visit?  I read early part of the year that the
> OIG had audited and cited a high error rate when using this modifier with an ov for a new pt. because the new-pt visit is by definition a stand-alone billiable visit.  Any thoughts of this???? thanks.  Also when coding this ov with a procedure the CCI edits tells you, you need to append the 25 to pass the edit.  ????????????????????


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## 00032036

If You End Up Doing A Procedure Of Any Kind Along With The First Visit You Need To Use The Modifier 25 On The E/m.  Dale In Salmon, Idaho


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## Lisa Bledsoe

I have never heard of not using modifier 25 on an E/M if it is separately identifiable from the procedure performed.  You could certainly see a new patient for an URI and remove a lesion at the same visit...for which modifier 25 would be appended to the E/M.


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## karencollins

I have found that if the new patient comes in and ends up haveing a procedure that you can bill the 25 modifier along with the new patient e/m code


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## boodiful1

*25 modifier not needed for new patient visits*

It is a general misconception that a 25 modifier is needed for new patient E/M codes when other procedures are being performed on the same day.  it is not, however, necessary.  This is per many sources but the one that I taking the text below from is:  www.medicarenhic.com/cal_prov/articles/modifier25_1006.htm[/url]

The exception is that if a  NEW patient E/M service is explicitly bundled to the procedure by an NCCI edit.  In that case, a 25 modifier would be appropriate.

This is not to say that you will not have inapproptiate denials from payers when a procedure is done on the same day as an E/M visit.  I have found that attaching a copy of the modifier guidelines with the claim upon appeal usually works.  Not that any of us have time to prepare appeals on claims that are denied in error!!!

......................................................................................................

_SPECIAL USAGE GUIDELINES

New patient E/M.  A new patient E/M service, as defined by CPT, is, by its very nature, considered to be a significant, separately identifiable evaluation and management service when documentation guidelines for the E/M service are met.  A new patient E/M service does not need to have a modifier -25 appended when a minor procedure/surgery (global period: 000 [same day only] or 010 [10 days]) is performed on the same date.  Therefore when billing any global procedures/surgeries, including foot care codes (CMS dropped the NCCI edit), modifier -25 does not need to be appended to the new patient E/M service code.

If the new patient E/M service is explicitly bundled to the procedure by an NCCI edit, then use modifier -25, when the new patient E/M service has a significant, separately identifiable component(s)._
-------------------------------------------------------------------------

Hope this helps


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## tvspringer

It should be a stand alone code, but from a billing and claims processing perspective the majority of payers opt to process the visit as global if the modifier is not attached.


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## sunchips

*Modifier 25*

Hi! I have a little expertise with modifier 25. There was a Biller in our office that kept using 57 on a consult and when I looked it up I told her to use 25 because this applies specifically to E/M codes (consults in paticular; new and established pt.). I use it when the doctor says he has done a consult in the hospital (99254) and then decides to do a minor procedure. I ended up calling Medicare to emphasize to the biller why we were not getting paid and they explained that they preferred 25 and 57 is reserved for major surgeries. However, that being said, I have learned through some trial and error that some of the other payers (commercial) don't like 25. They actually prefer 57 <gasp>, Lol. So, be careful with it, okay. I hope this helps.


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## thompsonsyl

Hi,

I wanted to let you know that the difference between modifiers 25 and 57 is based on post-op/global days.  They can both be used for all e/m codes - not just consults.  You use modifier -25 for "minor" procedures with no-10 day post op days and -57 for "major" procedures requiring +10 days of post op.  Hope this helps.


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## she803

Well I work as a claim examiner for health insurance company. If another procedure takes place during that same office visit (new or established patient) unrelated to primary reason patient came in then modifier 25 is used for office visit.


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## landryi

*25 modifier w/ov, new patient*

Just a couple of things. The following is out of the CMS manual under B. Services Not Included in the Global Surgical Package:

"These services may be paid for separately.
*The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery.  Please note that this policy only applies to major surgical procedures.  The initial evaluation is always included in the allowance for a minor surgical procedure;" This can be found on page 71.

On page 75-76:
4. Evaluation and Management Service Resulting in the Intial Decision to Perform Surgery
"Moreover, where the decision to  perform the minor proecedure is typically done immedicately before the service, it is considered a routine preoperative service and a visit or consultation is not billed in addition to the procedure."

So, I think that you need to ask yourself of your provider the following question.
1. At the encounter did the provider do more then what they would normally do if they saw a patient soley for "x" procedure?

If the answer is yes, then the 25 modifier on the new patient CPT code is valid. If the answer is no then only the procedure code is warranted.

Good luck with that.  You also need to remember the global rules for procedures who have the XXX as their globals as insurance companies will deny the office visit regardless if you have the 25 on them.  Here is the guidance on that.  This is found in the CCI information on the CMS website.

Procedures with a global surgery indicator of “XXX” are not covered by these rules.  Many of these “XXX” procedures are performed by physicians and have inherent pre-procedure, intra-procedure, and post-procedure work usually performed each time the procedure is completed.  This work should never be reported as a separate E&M code.  Other “XXX” procedures are not usually performed by a physician and have no physician work relative value units associated with them.  A physician should never report a separate E&M code with these procedures for the supervision of others performing the procedure or for the interpretation of the procedure.  With most “XXX” procedures, the physician may, however, perform a significant and separately identifiable E&M service on the same day of service which may be reported by appending modifier –25 to the E&M code. This 
E&M service may be related to the same diagnosis necessitating performance of the “XXX” procedure but cannot include any work inherent in the “XXX” procedure, supervision of others performing the “XXX” procedure, or time for interpreting the result of the “XXX” procedure.  Appending modifier –25 to a significant, separately identifiable E&M service when performed on the same date of service as an “XXX” procedure is correct coding.


Ida Landry, CPC
Traveling Coding Auditor, Geilenkirchen Germany


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## adonis_laurenteCPC

*-25*

Guidance and Outreach
Guidance to providers regarding the use of modifier 25 is available
through a variety of sources, such as newsletters, bulletins, and letters
from contractors and the Centers for Medicare & Medicaid Services
(CMS). However, the governing source for determining appropriate
payment is CMS's “Internet-Only Manual.”9 Chapter 12, section 40.2 of
the manual states:
Modifier 25 is used to facilitate billing of evaluation and
management services on the day of a procedure for which separate
payment may be made. It is used to report a significant,
separately identifiable evaluation and management service
performed by the same physician on the day of a procedure. The
physician may need to indicate that on the day a procedure or
service that is identified with a [Current Procedural Terminology]
code was performed, the patient's condition required a significant,
separately identifiable evaluation and management service above
and beyond the usual preoperative and postoperative care
associated with the procedure or service that was performed.
In addition, CMS allows providers to use the Current Procedural
Terminology (CPT) Manual, published by the American Medical
Association, as a source of information regarding the use of modifier 25.
The CPT Manual contains detailed descriptions of the procedure codes

http://oig.hhs.gov/oei/reports/oei-07-03-00470.pdf


I guess it doesn't matter if it's a new or established patient as long as a significant, separately identifiable evaluation and management service above
and beyond the usual preoperative and postoperative care
associated with the procedure or service that was performed.


thanks,
adonis


Originally Posted by Willingham  
Can someone share with me if you are aware, whether or not the 25 modifier is acceptable with a new office visit? I read early part of the year that the 
OIG had audited and cited a high error rate when using this modifier with an ov for a new pt. because the new-pt visit is by definition a stand-alone billiable visit. Any thoughts of this???? thanks. Also when coding this ov with a procedure the CCI edits tells you, you need to append the 25 to pass the edit. ????????????????????


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## dbranker

*The Key*

The key here is documentation and the CC (chief complaint)

As an auditor one of the frequent problems I see is lack of appropriate documentation. Let's start with -25. Like any other modifier you have to ensure that the documentation justifies what you are coding.

In any procedure, minor or major, there is a preprocedure/preoperative examination. For example, if a new pt with complaints of knee pain comes in to see an ortho and has had a history of success with Hyalgan injections and would like to have another series. The physican may do an injection at the visit.  Keep in mind that the E/M code may be relatively low. The docs hx would focus on the knee, the review of symptoms may also be low given that the pt has had the series previously so many of the contraindications may be ruled out. The physical examination would be limited to the knee and ensuring that the pt does not have a fever (indication of underlying infection) and the MDM is relatively straightforward given that the pt is not refractory to the tx. The diagnoses and managment options are  also low and there is minimal to no risk at all.

However by definition the pt is new. Since the OV level is really low the physician just needs to ensure there are no contraindications of doing the injections and he would carry out the injection as normal, meaning the only codeable service here would be the injection with the injectable. 

The guidelines for -25 state that the E/M must "be above and beyond the usual preoperative/postoperative care associated with the procedure." It helps to look at the actual procedure note as a stand alone (when no E/M is coded) to get an idea of what your docs do prior to a procedure or query your doc if you have such access.

I hope this helps


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## valleycoder

i am in agreeance with being conservative with modifier -25 but i think we are focusing on the first half of the modifier -25 description that states "It is used to report a significant, separately identifiable evaluation and management service performed by the same physician on the day of a procedure" and are not seeing the rest of the statement that says " the patient's condition required a significant, separately identifiable evaluation and management service *above and beyond the usual preoperative and postoperative care* associated with the procedure or service that was performed.
As we all know, procedures carry a little bit of an e/m service in them but if a provider has to thoroughly evaluate a symptom/condition (and documents it) i believe -25 is justified.  
As for whether its a new pt or not, i know new pts shouldnt typically need the -25 but most payers do bundle it into the procedure if the claim presents without -25..........what do you do???


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## mmelcam

Medicare rules state that you only need a 25 modifier on an e&m code if the procedure being performed on the same day has a 10 day global period. If the procedure does not have a global period then you do not need a modifier at all. With this said, other insurance companies may deny the claim unless you put a 25 modifier on the e&m code regardless if there is a 10 day global period or not. In each case make sure that the documentation is there to support billing both an e&m and procedure on the same day.


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## BerniceNixon

*25 Modifier on new patient o/v*

When a patient is seen for a first visit, they must be evaluated before any procedures are performed. It is up to the provider to document a complete new patient visit and state that a decision was made to perform a procedure in that visit. Much depends on the providers documentation.


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## mcpalmeter

I think the OIG identified numerous instances when the decision to perform a procedure was already made and the patient was presenting to have the procedure performed.  The E&M part was simply the pre-op on the patient and as such should not be billed in addition to the procedure unless there was something significant that would constitute additional work beyond the usual pre-op.  Most of the time if a procedure is performed AFTER the provider does the work up on the patient, as part of his/her plan of treatment, then it would be appropriate to bill both the visit and the procedure. Of course the 25 modifier would be appended to the procedure (if the procedure was not considered major).

Best Regards,

Maryann Palmeter


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## fcallahan

*25 Modifier and New Patient*

Hi, Willingham

25 Modifier is *NOT*needed on New Patients.  This is referring to CPT codes 99203 or 99202 the E/M codes with the "0" in them...

I work Medicaid at a OB/GYN office in Tifton, Ga and when I "POP" the new patient's codes on Medicaid's portal, I don't use the 25 Modifier and it pays.  

Once a upon a time I tried this with the modifier 25 and it denied stating "Confilict with Modifier and Procedure".  So, I tried without the modifier and it paid this is how I know for sure.  

So if you work Medicaid don't use 25 Modifier on New Patient codes.  And really I have noticed that when I don't use 25 modifier on established patient's codes it doesn't matter one way or the other....

Hope this helps..

Freda Callahan, CPC-A


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## Susan R

Willingham said:


> Can someone share with me if you are aware, whether or not the 25 modifier is acceptable with a new office visit?  I read early part of the year that the
> OIG had audited and cited a high error rate when using this modifier with an ov for a new pt. because the new-pt visit is by definition a stand-alone billiable visit.  Any thoughts of this???? thanks.  Also when coding this ov with a procedure the CCI edits tells you, you need to append the 25 to pass the edit.  ????????????????????


Hey Willingham! Great question. I'm not sure who AIS Inc out of DC is. If you look at their editorial board that published this information, you have Attorneys, a Pharmaceutical person and one PhD. No CPC's, no affiliation with CMS, Medicare, Local Medical Assn's, AHIMA, AAPC, any of the coding greats. According to the guidelines for the modifier -25 Significant, separately identifiable E/M service... It does not differentiate between new and established patients. Modifier 25 is intended for new E/M Office Visits as well as established OV. Following the guidelines as put forth by the AMA is the best advice. Hope that helps! Susan R, CPC


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## catie

*Mod 25*

I have read most of the chain regarding modifier 25.  A little over a year ago I went to CMS's MedLearn website.  It contains lots of useful information within the Web-based Training Modules (and free CEU's!!!).  Within the Evaluation and Management presentation the information provided was that modifier 25 IS NOT NECESSARY on new patient E/M codes when a separately identifiable service is provided.  According to the presentation, although the modifier is not required, the E/M documentation must still meet the definition of a separately identifiable service in order for you to assign the E/M and the CPT on the same date of service.  It also had case examples to help the coder/biller understand when it is appropriate for Mod 25 to be used on the E/M in conjunction with the procedure.  

I checked today and I couldn't find the WBT on E/M Modifiers again.  Maybe someone else will be able to locate it.  

Here is the web address:
http://cms.meridianksi.com/kc/main/kc_frame.asp?kc_ident=kc0001&loc=1

Another good one to look at is www.trailblazerhealth.com.  They have several WBT's on E/M coding and they are one of the fiscal intermediaries for CMS.

Hope this helps.


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## Alan Tolleson

Medicare guidelines never include New Patient visits (99201-99205) in the global fee; therefore, modifier -25 is not required on those E&M codes and Medicare will pay for them separately regardless.

Thanks.


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## ARCPC9491

Here's what I've been taught:

If you know why the patient is coming in, it is not appropriate to bill for an evaluation and management and procedure on the same day.  Unless, the patient wants to be seen for something other than what they're getting the procedure for.  

Anytime a patient says, "oh by the way..." Red flag that a possible seperate service is warranted.  

For new patients: you've never seen them so you have to see and evaluate them - and then bill for whatever procedure you are doing.  NOW, some payers will fight this and say it's included in the surgery - or just pay the lesser of the two charges.

Anytime a procedure is billed in conjunction with an E/M - we've ALWAYS put on the 25 modifier (except for new patients, because you aren't modifying anything) If the payers don't want it - they'll tell you - then fix it on the back end - but it's certainly not going to "hurt you".

I've come to find out that we may be "billing appropriately for seperately identifiable services" HOWEVER - it varies from payer to payer.  They're going to do what they want to do anyway so it all boils down to how they want it.  If it were cut and dry across the board, we'd never be in this forum to start with.


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## sm9jack

I totally agree with you.  I am a coding analyst and I also flag providers that over use the 25 modifier. Now if the patient come in for a URI and a lesion is removed that is different and a 25 modifier should be used but to just use a 25 modifer on an E/M....no.


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## sundaey

*modifier 25*

Hello,
I have used mod 25 on a new pt if they have had a procedure done. One of my colorectal docs will do a hemorrhoidectomy for a new pt if they are in so much pain that they cannot wait until the next visit. Or, she will destroy anal warts on a new pt if they are bad enough. I have always appended the mod 25 b/c she does a complete history/exam, then she uses an anoscope to see how extensive the warts are. 

I hope that this helps.


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## rhondatalley

*25 modifier w/ new ov*

The 25 modifier is appropriate if the E/M is for a significantly different reason from any procedure performed same day, however, in some cases, applying a 57 to the procedure may be more appropriate if the exam for the new ov led the provider to make the decision to do the procedure.


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## relong

we bill out new patient E&M with a 25 if it is justified. We've never had an issue with it getting paid but we make sure we have documentation to back it up just in case.


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## mvalcof1

*Worried*

Please note that the article you are quoting, and the decision tree that indicates not to use a 25 modifier on a new visit, are NOT written by the OIG, but are independent opinions of AIS health. I quote from the beginning of the decision tree: "Here are decision trees to help. They were developed by Nickie Braxton, former vice president of corporate compliance and legal services at Masonicare in Connecticut. Contact Braxton at nickiebraxton@gmail.com."


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## sbridges

*SBridges, billing supervisor*

A good rule of thumb for modifier -25 is to ask yourself, when the patient arrived, did the physician know he would be performing this test or procedure?  If your scheduler or documented patient's chief complaint does not indicate a specific reason for the visit, your physician took time to evaluate and determine a course of action which should be reimbursed separately from the procedure itself.


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## lmtufts

*Modifier 27 Question*

I have a multidisciplinary clinic that sees patients once a week for the patient's convience.  The patient has an E/M visit with the Cardiac EP MD and a separate E/M visit with the Cardiac Heart Failure MD.  Do I need to append the modifier 25 to the second E/M visit for that day?  The IDX system that we use won't accept the modifier 27.  Also, I don't know if it's read as being the same speciality even though it's a different subspeciality.

Thanks LT


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## sadamcik

*Mod 25 w/new pt visit*

I have never seen a denial from using mod 25 BECAUSE it was used with a new pt visit.  There have been many times in the 20+ yrs I have coded OB/GYN where a pt is referred to the GYN dr because of specific problems.  At the initial visit, the dr decides to do a procedure, the 25 is used to if it is a procedure with a 10day or less global, we use 57 (dec for surg) if it is a longer global period.  Example  Postmenopausal woman with bleeding problems referred to specialist.  At initial exam, due to bleeding dr decides to perform an endometrial bx.  New pt OV code with 25 mod and then the Endo Bx code.  We occasionally have to appeal with documentation, but most of the time this is paid.  Hope this helps.


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## sundaey

ok, well, how about this:

My ENT doc does a scope (either 31231 or 31575) on just about every new pt that comes into the office, and he wants both coded out for the same reason. If the patient has cancer, he wants the new pt visit as well as the laryngoscope. I think that he should get either/or. He does not dictate, he either hand writes or draws diagrams as to what his findings are from the scope.

I would appreciate some input.


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## joangilhooly

*E/M with modfier -25 and a procedure*

Sundaey

Why is the patient coming in?  Is the doctor working up a problem?  (say hoarseness or lump/mass in the neck/throat area or something like that?).  Is he trying to figure out what's causing the patient's symptoms?  Or if the patient has an established diagnosis, does the physician need to do a laryngoscopy to establish a baseline from which he'll be measure the efficacy of his treatment of the patient over time as part of that initial work up?

All of those are VERY valid reasons for charging both the E/M *and* the procedure.  The E/M is for the work up of the problem.  The scope is simply a diagnostic test that he's using to further refine the differential diagnosis or to gather more information needed to know how to treat it. 

Or let me give you another example.  Let's say you were working with an orthopedic surgeon and the patient come in with a complaint of pain in their wrist.  The doctor takes a history, does an exam -- and decides that they want to do a diagnostic test to gather some more information, but in this case, the diagnostic test is an xray. Would you be saying that the orthopedic doc should bill the E/M code or the xray, but not both? (that's a rhetorical question -- of course you'd say that he should bill both the E/M and the xray!).

The only difference between an xray and a laryngoscopy in this case is that one is a non-invasive diagnostic test (xray) and the other is an invasive diagnostic test (the laryngoscopy).  Invasive diagnostic tests don't fall into the radiology or lab section of the CPT manual.  There are lots of them in the medicine section of your CPT manual (90000 series), but there are also a bunch of them in the 10000-69999 series as well.  If the decision to do the invasive diagnostic test came about as a result of his work up of the patient's presenting problem, that's a classic case for the use of modifier -25 on the E/M service and billing it along with the procedure.

Also, there's nothing that says that he has to *dictate* the report from the scope.  His documentation DOES need to indicate whether he used the direct technique or an indirect technique (so you know which of the two codes to use).  And the results of this test are literally the drawings that you referred to.  I'd probably like to see him indicate something about the size of any nodules he saw, and any other pertinent characteristics.  I've included some information below off WebMD about this procedure.  Essentially, he should probably be including information about his what he's seen beyond the pictures he's drawing -- although if you look at his dictation of the E/M service, I would suspect that you'll see information like this included in his dictation of the entire encounter.

 "Normal: The throat (larynx) does not have swelling, an injury, narrowing (strictures), or foreign bodies. Your vocal cords do not have scar tissue, growths (tumors), or signs of not moving correctly (paralysis).

Abnormal: Your larynx has inflammation, injury, strictures, tumors, or foreign bodies. Your vocal cords have scar tissue or signs of paralysis."

Bottom line, depending on the kinds of patients he's seeing in these first visits (whether they are consults or new patients), this is going to be a test that will be medically indicated fairly frequently.  Obviously, not all presenting complaints will require it.  For example, my son and I both see an ENT.  My son was sent to him for evaluation of a suspected broken nose with a possible deviated septum.  I went to the same doctor a couple of years latter with unilateral tinnitus.  Neither of those presenting complaints are ones that you'd expect that the doctor would need to do a laryngoscopy for.  But that same WebMD article listed the following as typical indications for this test:

*Find the cause of voice problems, such as a breathy voice, hoarse voice, weak voice, or no voice. 
*Find the cause of throat and ear pain. 
*Find the cause for difficulty in swallowing, a feeling of a lump in the throat, or mucus with blood in it. 
*Check injuries to the throat, narrowing of the throat (strictures), or blockages in the airway. 

So if your doctor is seeing alot of patients with those kinds of complaints, yes, it's a perfectly valid test to be billing along with the E/M service, even if the patient doesn't end up having cancer.

Hope this helps!

Joan Gilhooly, CPC, CHCC
Medical Business Resources, LLC
847-550-0618


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## amydenn07

*OB GYN coding companion???*

Does anyone know what the "diamond looking" symbol beside the codes 57520 and 58120 in the 2008 coding companion mean?
Thanks in advance.


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## jaldrich

I don't have that companion..but my recollection with those is that it had something to do with CCI edits...maybe mutually exclusive? I may be WAY off..going off memory.


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## brianbenny

Willingham said:


> Can someone share with me if you are aware, whether or not the 25 modifier is acceptable with a new office visit?  I read early part of the year that the
> OIG had audited and cited a high error rate when using this modifier with an ov for a new pt. because the new-pt visit is by definition a stand-alone billiable visit.  Any thoughts of this???? thanks.  Also when coding this ov with a procedure the CCI edits tells you, you need to append the 25 to pass the edit.  ????????????????????



yes we can append 25 modifier along with a new EM visit but we need to ensure that we append 2 seperate diagnosis for EM and the procedure, so that the usage of 25 modifier becomes very appropriate for the EM


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## MsMaddy

*mod 25*

If you look at appendex A in ama cpt book, no where does it say that mod
25 is only used for established patient cpx, therefore it can be used for new
or established patient that come in for cpx and have a seperate procedure done. I work at a family practice and I have been using the mod 25 and
we don't seem to have any problem.  Of course you have to used it correctly.

Msmaddy cpc-a


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## Roberta P

*Modifier 25*

There is a discussion in the office that I currently work and I need some advice.  In the past they have coded a E/M code for an established patient and if this patient requires lab or x-ray they are attaching modifier 25 to this, I feel this is wrong.  I dont think that they are using this modifier appropriatly, but I am getting great resistance to stop using the modifier.  Are they using this modifier correctly?


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## Treetoad

Has anyone ever received a denial for payment on a legitimately performed new patient exam when performed on the same date as a procedure with 0-10 day global period solely because they appended modifier 25 to the E&M service?  My guess would be not.  If the service was denied, it was probably due to some other reason.  As far as I'm concerned, I will continue to add this modifier to my new patient E&M service.


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## mshelly87

*mofifer 25 question*

Here is a scenario in the office i work at. A pcp will refer a pt to us for a cardiac catheterization based on lets says a positive nuclear stress test. A service that we provide is that we will schedule them for what we call a same day cath. We see the pt in consult and our interventionalist review all the data to a complete exam and decide if they are going to procede with a cath. We always have to put a 25 modifier on the consult or we do not get paid. Now a PCP may think that the pt needs a cath but our interventionalist do the work and decide. They have not cathed people on many occasions because they want further testing or whatever. I feel that this is a completely legitimate use of modifier 25 what do you thing?


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## Treetoad

I believe you are doing the right thing, Mshelley87.  That's the say I would handle it.


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## CindyNorling

*Modifier 25 on new patient*

Many payers have edits in their system that if a 25 modifier is not added on the E/M code, new or established, the office visit will be denied.  Medicare goes so far to say that even if it is a new patient, you may not automatically add an E/M visit code.  The description on the Minnesota local carrier WPS states "The following statements are false: _I can always use this modifier for a new patient_."
To me this statement is saying, even if you have a new patient and procedure on the same day, it does not mean you can always just add the modifier 25 for payment.  If the new patient E/M visit is appropriate (medically necessary), and documentation clearly shows it, you will be coding correctly billing both.  If the documentation and the medical necessity is not there, you should not automatically add a new patient E/M code with the modifier 25.
I believe in the "old" days before all of the claims edits, it was typically thought of that for new patients and consults that you did not need to add the modifier 25 when a procedure was preformed on the same day.  Those days are gone, with all the advanced claim checks. 
Here is the link for the WPS fact sheet on modifier 25:
http://www.wpsmedicare.com/part_b/education/modifier_25.pdf


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## CindyNorling

Bobbiep8 said:


> There is a discussion in the office that I currently work and I need some advice.  In the past they have coded a E/M code for an established patient and if this patient requires lab or x-ray they are attaching modifier 25 to this, I feel this is wrong.  I dont think that they are using this modifier appropriatly, but I am getting great resistance to stop using the modifier.  Are they using this modifier correctly?



No, you do not need a modifier 25 on an E/M visit when typical office lab and x-rays are performed.  You are correct, it would be wrong to add the modifier 25.
Cindy Norling, CCS-P, CPC-H


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## gcoppa

My thought on this is that the "25" modifier refers to a significant separate procedure so that depends on the reason for the initial visit. The patient came in complaining of severe back pain  the physician is writing a plan of care for this condition during this evaluation the patient stated that he/she has been having trouble urinatiing, the doc does a urine test and note both findings in his documentation, I think that validates a 25 modifier. I agree it's all once it's in the documentation. 


Gobin 
Alabama


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## scottshar

*25 Mod on New Pt Visits*

We recently had 2 CMS reps  speak at one of our Chapter meetings and they both said that a 25 modifier is not required on new patient visits.


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## joann4_2000

You can use a mod 25 with a new patient consult visit as long as the dictation in your visit covers you. I think they are just worried about the misuse of that particular modifier. It will be ok, ESP on the pateints first visit.


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## lkozak30

*Professional Coder*

Per NHIC's Modifier Billing Guide dated 10/2008; the 25 modifier should NOT be submitted with E/M codes that are explicitly for new patients only (92002, 92004, 99201-99205, 99281-99285, 99321-99323 and 99341-99345)


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## Anna Weaver

*modifier 25*

In my modifier book "Coding with Modifiers" third edition concerning modifier 25, some carriers do not want a modifier, but:
CMS guidelines (page 64):
The CMS recognizes the use of modifier 25 with E/M services within the range of CPT codes 99201-99499, 92002-92014, and Healthcare Common Procedure Coding System (HCPCS) level II codes G0101-G0175.


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## SCanterbury

There is nothing in CPT or in the Medicare claims processing manuals that would indicate Modifier 25 should not be used with new patient services.

That said, SOME Medicare contractors have stated that Modifier 25 is not necessary when submitting claims involving new patient visits to them, but this is a MEDICARE CONTRACTOR-SPECIFIC claims processing issue. We must recognize that there are variations in how each Medicare contractor processes claims.

It's possible that one or more of you out there may have YOUR Medicare contractor telling you it is not needed when submitting claims TO THEM, but that doesn't mean that it is a universal rule among all insurers, or even all Medicare contractors.

Seth Canterbury, CPC, ACS-EM


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## medmom

Hi, I am new to the forum but I would like some clarification on the 25 modifier.  I generally do the insurance follow up with the cardiology group I work for but also do coding;  recently we have been discussing the use of 25 modifier when billing an ov w/echo exams. I believe it is not necessary because there is no issue of bundling. Can someone please clarify this for me?  

Thanks
New and Confused


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## sanjeeno2008

*-25 modifier*

new visit need no modifier 
succeeding usually needs one if 
appropriated by the documents


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## cpccoder2008

Our new patient visits are being paid with/ without -25. I also read somewhere's that new patient do not require -25.


http://www.medicarenhic.com/providers/pubs/Modifiers%20Guide.pdf


Page 24

Billing Tips:
No supporting documentation is required with the claim when this modifier is submitted.
However, the patient's medical records must contain information to support the use of modifier -25 and be available upon request. The following are the exceptions:

_o This modifier should not be submitted with E/M codes that are explicitly for new patients only: 92002, 92004, 99201-99205, 99281-99285, 99321-99323, and 99341- 99345. These services are not considered part of the global surgical policy._

o Use modifier -25 on initial hospital visit (99221-99223), an initial inpatient
consultation (99251-99255) and a hospital discharge service (99238 and 99239) ,when billed for the same date as an inpatient dialysis service.


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## cpccoder2008

http://www.accuchecker.com/acculibrary/articles/modifier25em.asp

_It would be appropriate to perform an evaluation and use the modifier –25 for consultations on new patients who are to have or need a procedure on the same day of service. It is not necessary, however, to attach modifier-25 for an initial visit. _


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## cpccoder2008

lkozak30 said:


> Per NHIC's Modifier Billing Guide dated 10/2008; the 25 modifier should NOT be submitted with E/M codes that are explicitly for new patients only (92002, 92004, 99201-99205, 99281-99285, 99321-99323 and 99341-99345)



I have the same article. I added the link for anyone who wants to read it themselves.


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## RebeccaWoodward*

I wholeheartedly agree with Seth.  Medicare came out with the statment about mod 25 and new patients *years* ago.  My own carrier has statements about this 10+ years ago.  Since then, *CMS* does not include this verbiage in the regs.  Chapter 12...nothing.  MedLearn bulletins...nothing.  You will find some independant Medicare contractors that may submit to this old mentality but CMS as a whole, no.  My own carrier, who once heeded to this way of thinking, now denies claims without modifier 25. CMS keeps evolving and so will their regs.


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## efeatherston22

*25 modifier w/ov, new pt*

Hi Willingham,  I saw your response and wanted to let you know that I attended an audio conference here at my job and it was in regards to Modifiers and it was done by Medicare. They did state that modifier 25 should not be submitted on an E&M code for a new patient. All of us in the conference were shocked because we had never heard of this before.  If you go to the Palmetto GBA website under Ohio Part B Carriers then under modifier look up you will find information on all modifiers. I copied and pasted from there website about modifier 25:

*This modifier should not be submitted with E/M codes that are explicitly for new patients only: CPT codes 92002, 92004, 99201-99205, 99281-99285, and 99341-99345. These codes are "new patient" codes and are automatically excluded from the global surgery package, meaning that they are reimbursed separately from surgical procedures. No modifier is required in order for these codes to be separately reimbursed. *


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## kamala

*OV with -25 modifier*

Hi , 

We recieve payment for the OV (In case of Established pts )Visit with -25 modifier the level of Visit should be more than 99211 .ie 99212 - 99215. I hope it applies similar to the New pts too .. Certain cases the Cerumen impaction would be only reason for the encounter ,then it is not appropriate to bill both the removal of cerumen and OV code . 

In case of Established pts :
Most of the Family care Physician provides , just an B12 injection or any vaccination and they bill for both the Visit and admin . Medicare denies the same and pays only for the Admin code . Usually the admin code is inclusive in 99211 . 

It is the Coders responsibility to make aware of the Physician office to ensure that , they are aware of this rule . 

As said by others it is appropriate to use -25 to OV when the level of visit is more than the first level , if there is distingiushable service rendered by the provider and the reason of the visit should be clearly understood and there is correct E/M level is choosen .Dont link the primary dx as same for both the OV and the other service rendered , this may also provoke necessity for denial .

Note : refer the clinical Example section in Appendix C in CPT book for the CPT codes .

Regards,
Kamala CPC


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## balloju

*About 96372 adn 99211*

Dear Kamala, 

Thank you for sending the reply. I unmderstood about modifier 25, but regardomg 99211 with adminitstration of injection either Depo or vaccination or B12 ext; for administration they pay for 96372 adn also for 99211.

I am working in private billing company who are working on the defaulte claims like above and insurance paid too. I certainly couldnt understand the correct rules and regulations of these insurances, they change for their conveniances. 

Thanks any way 

B Alloju

In case of Established pts :
Most of the Family care Physician provides , just an B12 injection or any vaccination and they bill for both the Visit and admin . Medicare denies the same and pays only for the Admin code . Usually the admin code is inclusive in 99211 .


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## dja214

Then let me ask you this...if a new pt comes in and can barely walk do to a fall. The pt's ankle is swollen, black & blue, and is experiencing a lot of pain. How can the provider assess the problem without an x-ray? You would need to add a -25 with the new pt o/v because the x-ray is being done the same day and to be interrupted by the same provider?


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## haugdebbie

*Hospital Consults w/heart cath*

When a patient comes in to the hospital with chest pain, our Cardiologist is asked to see the patient and determines the patient needs to have a heart cath on that same day, to me, that is a reason to use the 25. Anybody else deal with this issue? 

Thanks,
Debbie
Cardiology
KCMO


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## mbort

dja214 said:


> Then let me ask you this...if a new pt comes in and can barely walk do to a fall. The pt's ankle is swollen, black & blue, and is experiencing a lot of pain. How can the provider assess the problem without an x-ray? You would need to add a -25 with the new pt o/v because the x-ray is being done the same day and to be interrupted by the same provider?



if you are talking about just an OV and an X-ray, no modifiier is needed on the office visit.  The x-ray is diagnostic and not consider a procedure per say.


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## 00032036

Can anybody site where I might find info regarding using the modifier 25 on the E/M when having labs drawn in the physicians office?


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## bkp385

You should not have to use a modifier on E/M when drawing labs. These are consider diagnostic.  Not a procedure to something else done.


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## 00032036

*modifier 25*

Thanks, can you find an official site regarding that?  My manager/co-worker doesn't agree but I've not use that modifier when also drawing labs even with a Clea based office but for the life of me don't remember where that came from!!!


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## Cuteyr

*Modifier 25*

Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service: It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59. (01/01/2008).

If the claim meets all the above criteria,then it is valid


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## alexson.marsha@yahoo.com

my question is, if a new patient comes into an urgent care facility and has an i&d 10061, can you also bill an office visit with a modifer 25?


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## sspain

Whether or not you need the -25 for a new patient may vary by payer, but it would not be incorrect to expect to be paid for BOTH a new patient E&M and a procedure done on the same day, like an I&D.  Check your payer rules to determine if the -25 is needed.  If the provider had to take some history, determine med allergies and past health issues as part of the evaluation for the condition requiring the procedure, then clearly and E&M service was performed and should be appropriately coded and submitted for reimbursement.


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