Primary Care Coding Alert

Question: When a family physician performs an office visit and an EKG, should I use modifier 25?


Kansas Subscriber

Answer: The answer depends on the insurer. Your Medicare carrier does not require modifier 25 on an E/M code/EKG claim. You do not need to append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) on the E/M code unless the National Correct Coding Initiative bundles the pair, states Medicare Part B for Kansas, Nebraska and Northwestern Missouri.

Why: The National Physician Fee Schedule assigns -XXX- global days to 93000 (Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report). This designation means the global concept does not apply. -Therefore, modifier 25 does not apply to CPT code 93000 and should not be appended to the evaluation and office visit when a minor procedure or service is performed on the same day,- recommends North Carolina's Medicaid October 2000 Bulletin.

Disaster averted: Check with private insurers for their modifier 25/ECG policy. Even XXX global-procedure codes include a minor, related history, evaluation and management service, according to NCCI version 7.3's introduction. Some payers may, therefore, bundle 99201-99215 (Office or other outpatient visit for the evaluation and management of a new or established patient -) into 93000 unless you attach modifier 25 to the office visit code.

If you can't find a payer's policy, monitor your evaluation of benefits for E/M with ECG denials. Try using modifier 25 for insurers that include the office visit in the diagnostic test.

Resources: View the insurer decisions referenced at http://www.kansasmedicare.com/part_B/faqs/wksp_ChooseTop.htm and http://www.dhhs.state.nc.us/dma/bulletin/102000Bulletin.htm#correctionmodifier.