Ob-Gyn Coding Alert

Question: A patient comes in for her annual, and then the doctor treats a complication appropriate for a level-three E/M visit. He then orders an ultrasound. If we append a modifier to the E/M service, the annual doesn't seem to get paid, and we have to appeal. Is there any reason why we can't use modifier 25 on both lines?

Ohio Subscriber

Answer: The real issue is whether this payer accepts both a preventive service and a problem-based E/M service on the same date. Although CPT includes a guideline just before the preventive services codes that tells you how and when to bill a problem and preventive service, many payers out there still don't allow this.

So if the patient has a major problem on the date of the scheduled annual, you would be better off having the physician address that problem only and then reschedule the annual. 'Good advice: If you let your patients know this in advance of their appointments, they are less likely to show up with a laundry list of problems at the time of the annual.

Keep in mind: You would add modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to both the preventive and problem E/M service only if the physician did a procedure on the same date (such as a biopsy). Payers don't normally require this modifier when an ob-gyn performs an ultrasound on the same date. If he only ordered but did not perform the ultrasound, you don't need a modifier on the preventive service.

Don't forget: Under CPT guidelines, modifier 25 goes on the E/M service that was separate and significant, which would be the problem service.