# Consults and mod 25



## spirving (Jun 10, 2008)

We are getting denials from a medicaid payor stating the the 25 mod cannot be used on consult codes unless a different Dx is used.  I have searched the oh-so-easy to navigate CMS website and came up with bubkus.  I see a few threads on here discussing the use of new pt e/m with the 25.  But has anyone had any issues with the 25 and consult codes or found anything for documentation?  Much appreciated.


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## rjconnell (Jun 10, 2008)

Medicaid is the key word here. Even when we follow all coding guidelines that are published and appeal with the documentation we have not had luck with Texas Medicaid paying. It would seem that simply follow their own rules, I just wish they would share a copy, then I wouldn't waste my time appealing


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## spirving (Jun 11, 2008)

Thanks...that is pretty much what I am assuming at this point.  It's their own internal rule because I am not having much luck finding anything elsewhere.  Of course, my lovely company does not supply us with CPT assistant which would help.


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## Lisa Bledsoe (Jun 11, 2008)

From what I recall, some Medicaid carriers do not recognize modifiers in general...it's been awhile since I worked with Medicaid.  Have you tried filing the claims without the modifier?


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## racheleporterwilliams (Jun 11, 2008)

*response to consults and mod 25*

is the consult done on the same day as the originating E/M service?
are there any procedures done by the consulting provider?
wondering why you are using -25 on a consult...



spirving said:


> We are getting denials from a medicaid payor stating the the 25 mod cannot be used on consult codes unless a different Dx is used.  I have searched the oh-so-easy to navigate CMS website and came up with bubkus.  I see a few threads on here discussing the use of new pt e/m with the 25.  But has anyone had any issues with the 25 and consult codes or found anything for documentation?  Much appreciated.


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## spirving (Jun 19, 2008)

racheleporter said:


> is the consult done on the same day as the originating E/M service?
> are there any procedures done by the consulting provider?
> wondering why you are using -25 on a consult...



There is no other E/M service on the same day, it's procedures that are being performed. My examples are allergy testing 95004 & 94060 bronchodilation.

I'm actually not doing the coding on these.  I'm working the denial/audits and have to find a reason to fight the denials or argue my case with the coding dept that we're billing incorrectly. Thx.


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## zaidaaquino (Jun 20, 2008)

I went to www.trailblazerhealth.com and found Medicare's Modifiers Manual.  Under the section for modifier -25 it states "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.  The circumstance may by reported by adding modifier -25 to the appropriate level of E/M service."  Also, the CPT book states the following for billing your 95004 code: "Do not report E/M services for test interpretation and report.  If a significat separately identifiable E/M services is performed, the appropriate E/M service code should be reported using modifier 25."  I realize you are dealing with a denial from Medicaid; however, based on the above I would still try appealing their denial with this information.  They've already denied the E/M...what have you got to loose? 

Zaida, CPC


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## eRicK@ (Jun 21, 2008)

spirving said:


> There is no other E/M service on the same day, it's procedures that are being performed. My examples are allergy testing 95004 & 94060 bronchodilation.
> 
> I'm actually not doing the coding on these.  I'm working the denial/audits and have to find a reason to fight the denials or argue my case with the coding dept that we're billing incorrectly. Thx.



If there is no E/M service then you should not use modifier -25.


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## spirving (Jun 23, 2008)

Zaida, thank you for your insight.  I always get hung up on that statement also in the CPT book.  But like you noticed, this is a medicaid.  We will definitely try appealing first.  I have not seen that link on the trailblazer website.  I will check it out. Thanks!

Ericka, thank you for your response.  However, per the CPT book, mod 25 does not always apply to two E/M codes.  "it may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed..."  I recently attended a seminar on modifiers and the instructor confirmed that. Unfortunately, my question on this matter came up after the seminar. lol


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## racheleporterwilliams (Jun 23, 2008)

well I've coded an ER visit where the ER MD did a procedure....the orthopedist consulted and did a procedure, therefore I used -25 on both like this (ortho's notes didn't qualify for consult code so ED code was used):
99284-25
90774
99283-25
20610



spirving said:


> We are getting denials from a medicaid payor stating the the 25 mod cannot be used on consult codes unless a different Dx is used.  I have searched the oh-so-easy to navigate CMS website and came up with bubkus.  I see a few threads on here discussing the use of new pt e/m with the 25.  But has anyone had any issues with the 25 and consult codes or found anything for documentation?  Much appreciated.


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