Podiatry Coding & Billing Alert

Question: I’ve been coding existing patients using the new patient evaluation and management (E/M) codes 99202-99205 and using modifier 25 when a procedure is performed with an E/M service on the same day. I’ve been told by a co-worker that I should be also using modifier 25 with some of these new patient encounters, but I thought you didn’t use modifier 25 on new patients?

Connecticut Subscriber

Answer: Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) applies when a provider or other qualified healthcare professional performs an E/M service on the same day as another service to the patient by the same physician, regardless of whether a patient is new or established.

Consider the following two examples:

Example 1: A patient reports to your podiatrist, who diagnoses the patient with a bunion. During the exam, the podiatrist notices that the patient has an infected foot wound and administers an intravenous antibiotic.

In this scenario, in addition to the appropriate code for the antibiotic infusion, you can report a separate and significant E/M service for the unrelated bunion condition, appending modifier 25 to the appropriate E/M code. You can do this for Medicare claims no matter whether the patient is established to your practice or not. Private payers may not allow this, however, so you should verify with them in advance of billing for such and encounter.

Example 2: A patient reports to your practice for a procedure that has been scheduled in advance. During the preprocedural exam, the podiatrist discovers a condition that is separate and significant from the condition the scheduled procedure was due to treat. The podiatrist evaluates and manages the second condition, then proceeds with the originally scheduled procedure.

Again, in this scenario, you can bill for both the procedure and the E/M service using modifier 25, regardless of the patient’s status as new or established to your practice.

Simply put, the status of the patient in either scenario is not in question. What is in question is whether the provider treats a problem that is separate from another problem that originally caused the patient to present for the encounter. If the problem is separate, and significant, you can bill for both the procedure and the appropriate E/M code from 99202-99205 (Office or other outpatient visit for the evaluation and management of a new patient …) or 99211-99215 (Office or other outpatient visit for the evaluation and management of an established patient …), appending modifier 25 to the E/M code.