Wiki Can I use Mod 25?!

[mmhubb]

I have an established pediatric pt that came in for an abscess to the buttock. Dr. did a simple incision and drainage to send for culture. Can we code this case like this:
99213 - 25 Dx 682.9
10060 Dx 682.9

I thought that the 99213 had to have a seperate Dx code in order to use the modifier 25 becuase the office visit portion of the visit is included in the procedure 10060.
Correct?

 

[KSanders1983]

I thought if the patient was there for another reason and there is enough documentation to support it then you can bill for a visit with 25 mod.

 

[mmhubb]

Right...by "another reason" I assume you mean a different diagnosis...correct?
This patient only came in for the abscess. I guess my question should be is a seperate office visit (99213) necessary?
I'm sure the patient or the Dr. did'nt know an incision and drainage would be done until looking at the abscess... so does that justify the seperate office visit?

I just need to know does it make sense to bill both the office visit and the procedure with a modifier 25 without a seperate issue/complaint. After all the modifier is used for "significant, separately identifiable" E/M service.

 

[Saedron]

I think you are on track with the "significantly separate" visit.

If the provider did the I&D on the abscess and that is ALL that was done, then you code the procedure and diagnosis. No E/M code and no modifier.

Now if the provider did the I&D and then mom started talking about a persistent earache or what have you, then the provider engaged in the E/M of a completely separate thing. Then both the procedure code/dx AND the E/M code/dx -25 would be appropriate.

 

[mitchellde]

You do not need a separate dx code to use the 25 modifier. You do need an evaluation that is significant in that it relates to why the patient is there and yet separately identifiable from the evaluation necessary to perform the procedure. Every procedure has an evaluation as a necessary component of the procedure, you need to extract that part of the evaluation and then see if you have any thing left that is significant to determine a visit level.