Wiki Coverage Analyst/Coder, CPC, CHONC

[miltonhalex]

I have a question on billing an E/M visit on the same day as the initial treatment planning for a course of radiation therapy. The E/M is done first prior to the planning, which could be billed with codes 77290, 77334, or 7726 The E/M visit will get denied by the Ins. carrier if a modifier '25' is not attached. If this is done and the E/M visit is fully documented, shouldn't the E/M be paid, or do there have to be special circumstances involved, in order to use the '25' modifier?

 

[rcrouch@crmchealth.org]

Was the E & M for a new patient visit where the decision was made to Sim and Treat? If so I would append the 25 modifier. If not, and there was not an identifiable problem or reason why the patient needed to see the physician that day, I would not charge.

Hope that helps.

 

[miltonhalex]

Coverage Analyst/Coder

Thank you for your response. The E & M would be for a new consult with the planning, and simulation done on the same day, right after the new consult.
I believe in this case, the E & M is payable with a '25' modifier, but there are some coders that say the E & M has to be a significant, and separate procedure, meaning that there has to be an urgency shown in the new consult note, such as patient pain, etc. Please help. Thanks.