# Moderate Sedation in Office w/ E&M



## Ldari (Sep 16, 2011)

Hoping someone could help me clarify this. If billing for established or new E&M at same time physician perform procedure is there a problem with billing 99144? I have been adding modifier 25 to the E&M visit in this case but someone else mentioned that modifier 59 might be needed. I understand there is a CCI edit but I thought the 25 would be all that's needed. How would you bill the following?

99213
62310
77003
99144
J0702
A4550

Thank you for your help in advance. I am also new to physician billing so any help would be appreciated.


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## tnmacs@comcast.net (Sep 17, 2011)

who are you billing , medicare medicaid or commercial different rules apply to each


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## tnmacs@comcast.net (Sep 17, 2011)

NOT -59 you can NEVER append 59 to an EM code


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## dwaldman (Sep 21, 2011)

If it is a planned injection w/ sedation, it typically would not be reasonable to also bill the carrier a follow up visit unless a significant, separately identifiable EM service was required that went above and beyond the pre- and post- work for the procedure. I would think providing routine RXs would not be separately, identifiable nor would a templated looking HPI or exam with limited amount of additional treatment options being set forth.


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## dwaldman (Sep 21, 2011)

As seen in my previous post, I am not in favor of billing follow up visits with injections, but I thought i would provide additional resources from NCCI Policy manual and CPT Assistant

If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. The E&M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services  apply. The fact that the patient is “new” to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure. NCCI does contain some edits based on these principles, but the Medicare Carriers (A/B MACs processing practitioner service claims) have separate edits. Neither the NCCI nor Carriers (A/B MACs processing  practitioner service claims) have all possible edits based on these principles.

Above is from the NCCI policy manual and below is from CPT Assistant

Coding Consultation

Question

Please explain the difference between modifiers -59 and -25. Is modifier -59 intended to be appended to evaluation and management codes?

AMA Comment

Modifier -59 is intended to be used to indicate that a procedure or service is distinct or independent from other services or procedures performed on the same day. This modifier is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances, and not intended to be appended to evaluation and management (E/M) codes. Rather, modifier -59 is appended to the procedure code to designate that procedure as a "distinct procedural service."

Modifier -25 is intended to be used to indicate that on the day a procedure or service identified by a CPT code is performed, the patient's condition requires 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 performed. This circumstance is reported by appending the -25 modifier to the E/M level of service reported. Appending modifier -25 to the level of E/M service reported will communicate that the E/M service provided is above and beyond the usual E/M service associated with that procedure.

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Modifier -25

-25    Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Day of a Procedure: The physician may need to indicate that on the day a procedure or service identified by a OPT code was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the usual preoperative and postoperative care associated with the procedure that was performed. This circumstance may be reported by adding the modifier '-25' to the appropriate level of E/M service, or the separate five digit modifier 09925 may be used.

An example of how this modifier could be used to report a significant, separately identifiable E/M service by the same physician on the day of a procedure is as follows:

A new patient is seen by the physician to evaluate his arthritis, hypertension and diabetes. While examining the patient, the physician determines that an arthrocentesis of the patient's knee joint needs to be performed. Because the evaluation and management services pertaining to the hypertension, diabetes and arthritis exceed those E/M services that are directly related to a joint aspiration, appending the -25 modifier to the E/M service provided indicates that a significant, separately identifiable E/M service by the same physician on the date of a procedure was performed. Both the E/M service (with the -25 modifier) and the joint aspiration would be reported on that day. The documentation should indicate all the evaluation and management services provided related to the diabetes, hypertension, arthritis and joint aspiration.


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