Wiki Another modifier for EM plus -25 codes HELP

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c2anderson

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Greetings~

Our client performs minor office procedures on the same DOS as E/Ms. He states that the work he does, to determine if the procedure needs to be done (sometimes as a 4 part treatment) is necessary, and should be reimbursed by the insurance company.

He does not agree that this is covered by/in the "pre-op" portion of the RVU.

Of note, most of the procedure codes he utilizes show 99212-99215 and 99241-99245 as part of the NCCI Edits but "a modifier is allowed."

We are adding the -25 modifier to the E/M (when billed with a minor procedure code). Yes, we make sure the E/M code has a different ICD9 code than the minor procedure code, when the documentation supports it.

So... can anyone think of an additional modifier for the E/M code that would be applicable in this situation?

Thank you,

Christine
 
If you 25 please 59

Place the 59 modifier on the procedure to unbundle and identify it as a separate part of the treatment.
 
you didn't say what type of work your physician does. I'm not even sure if this modifier would be appropriate, but take a look at modifier EJ to see if it applies to your situation. Just a thought....EJ = subsequent claims for a define course of therapy e.g., EPO, sodium hyaluronate, infliximab. It would go on the procedure code, not EM. Google a search...
 
c2anderson said:
Greetings~

Our client performs minor office procedures on the same DOS as E/Ms. He states that the work he does, to determine if the procedure needs to be done (sometimes as a 4 part treatment) is necessary, and should be reimbursed by the insurance company.

He does not agree that this is covered by/in the "pre-op" portion of the RVU.

Of note, most of the procedure codes he utilizes show 99212-99215 and 99241-99245 as part of the NCCI Edits but "a modifier is allowed."

We are adding the -25 modifier to the E/M (when billed with a minor procedure code). Yes, we make sure the E/M code has a different ICD9 code than the minor procedure code, when the documentation supports it.

So... can anyone think of an additional modifier for the E/M code that would be applicable in this situation?

Thank you,

Christine
Click to expand...

In my opinion I dont think adding a 25 to the E/M is apropriate just because he thinks he should get paid. That is not how it works. Applying a different diagnosis does not justify the use of the 25. 25 represents something "Significant and Seperate" from the procedure that has the high RVU. For example the patient had a laceration repair and "oh by the way I've had a cold can you check that out too"
Applying the 59 to the procedure code i feel is inaccurate as well.
The RVU's are there for a reason and have a algorithm to include the evaluation portion of a procedure with a global day. Thats why it is global, it includes evaluation & treatment (follow up days)
Just my opinion.
 
E/M code 57

You might want to consider modifier 57 for decision for surgery. Especially if the physician is seeing the patients for this problem the first time, depending on the procedure.
 
The work to determine that the minor procedure is needed is included in the procedure and no E&M should be billed regardless of whether a separate diagnosis is used. Only if the work that is done goes over and above what is needed to determine that the procedure is needed and to perform the procedure, can a separate E&M be charged, or if they address a problem unrelated to the procedure and have the elements needed for an E&M separated from the evaluation for the procedure.
 
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