# Modifier 25



## meeramohanakrishnan (Oct 25, 2008)

Hi All,



It would be great if anyone an provide examples and scenarios on *Modifier 25*.





Thanks in advance for your help.



Meera


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## lmartinez07 (Oct 25, 2008)

Well Woman Exam W/ Problem Visit...

99396
V72.31


99213 -25
626.0


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## christyms (Oct 25, 2008)

*-25*

A parent takes a 9yr old to the child's physician for an oral poliomyelitis vaccine. The physician's assistant evaluates the child (established pt) & administers the vaccine orally to the child.
90712(Vaccines,Poliovirus,Live,Oral)
90473 (Immuniz. Admin.,One Vaccine/Toxoid)
*99211-25 (Eval. & Mangmnt.)*


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## christyms (Oct 25, 2008)

*-25*

Photochemotherapy is provided for a 34 yr old consultative pt w/ severe dermatosis. The pt receives 8 hrs of treatment. The physician provides a comprehensive history & physical exam w/ moderatley complex medical desicion making.
*99244-25* (Consultation,Office &/or Other Outpt)
96913 (Photochemotherapy)


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## christyms (Oct 25, 2008)

*-25*

Modifier -25 is used to report an E/M service on a day when another service was provided to the pt by the same physician. Or,  if a pt came into the office for a visit early in the day & then later in the day needed to return for a separate service, you would report both services using E/M codes & add -25 to the second code.
Modifier -25 requests payment for both E/M & a minor procedure or two E/M services on same day.


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## jackjones62 (Oct 25, 2008)

What type of service was rendered during the second encounter?  a procedure or an E/M?
If it was a 2nd E/M, my suggestion would be to charge one E/M for the whole day but to increase it's level of service (to a level that documentation supports).
If the patient returned the same day for a procedure or service other that E/M, charge 1 E/M with mod. 25 and than the procedure/service (increase the level of the E/M if the documentation supports it). 
I am not sure that any insurance will pay for 2 visits on the same day, regardless that they were for 2 separate issues......

JB 
CT ENT


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## jackjones62 (Oct 25, 2008)

I am sorry, I apparently had cranial flagylation when reading and responding to this........

Confused in CT.......)

JB 
CT ENT


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## Candice_Fenildo (Oct 25, 2008)

Pt presents to the office as a New Patient. CC Sinus Congestion. MD performs a Complete physical exam. addressing areas of the sinus, reviewing Ct scans etc. 
upon physical exam he notices patient has cerumen impaction and debrides the cerumen

99203 -25 Dx 478.19
69210       Dx 380.4

The 99203 was a distinct seperately reported E/M during the same session as a procedure


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## meeramohanakrishnan (Nov 4, 2008)

*25*

Hi All,

Thank you  so much.

Regards,
Meera


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## mgord (Feb 10, 2009)

Is anyone billing for Wound Care Centers? These are recurring patients usually returning once a week - the doc says he must evaluate the wound before deciding for certain if another debridement is required. Based on this I have been billing the E/M level documented w -25 then the debridement. However today we had a meeting with the reimbursement director over the WCC who advised that we could only bill for both if there was another medical reason for the E/M or if a new wound was present. I thought the -25 could be used as a decision for surgery for minor procedures (0-10 day global). Is that incorrect?


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## Anna Weaver (Feb 11, 2009)

*modifier 25*



mgord said:


> Is anyone billing for Wound Care Centers? These are recurring patients usually returning once a week - the doc says he must evaluate the wound before deciding for certain if another debridement is required. Based on this I have been billing the E/M level documented w -25 then the debridement. However today we had a meeting with the reimbursement director over the WCC who advised that we could only bill for both if there was another medical reason for the E/M or if a new wound was present. I thought the -25 could be used as a decision for surgery for minor procedures (0-10 day global). Is that incorrect?



It's incorrect. When the patient returns for follow up after previous debridement they already know they have a wound, the E/M must be separate and identifiable, treatment of something else, not anything associated with the wound. We ran into this same issue. The E/M must have all qualifications met, must be separate and identifiable issue (besides the wound they are presenting for) and then you can charge the E/M with 25 modifier. 
I found in wound care, just about the only time we can charge E/M is for first visit when they are meeting the patient and the last visit when wound is healed.


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