Wiki 25 modifier - procedure was done

[nscoder]

I'm having trouble with the 25 modifier. I'm being told certain codes are included in an E&M, such as a blood draw 36415, And not to append a modifier 25. In the past I've had whole claims denied for not adding a 25 modifier so this would indicate that I should only code the E&M? I was taught if a service/procedure was done, it should be coded. If this is the case, how would I code this visit? Would it be coded with an E&M only?
I've also had immunizations with E&M denied unless a 25 mod is used (for example in a case of well child visit), but I'm now being told I don't have to use the 25 modifer.
If a patient comes in for a sore throat and the provider does a full hpi & exam, takes a strep test and determines it is strep and gives a penicillin injection, what would I code? Should I only code the injection w/o the E&M? or the E&M with out the injection? How about the rapid strep test? Is that included in the E&M?

So I guess my question is, what IS and IS NOT included in the E&M?

I appreciate any insight you can give me, thank you.

 

[marybrady1]

25 Modifier

It has been my experience that a 25 modifier is not required on an E & M code when billed with 36415. If the carrier denies the E & M because there isn't a 25 modifier, then I would add it, whether it's for blood work, immunizations, or a minor office procedure. (as long as the note clearly indicates the E & M is a separately identifiable service by the same physician on the same date of procedure or other service.

CMS website also lists CCI edits where you can find what codes are bundled with E & M codes and if unbundling is appropriate.