Wiki E/M and Procedure using a -25 modifier

[tlh4hart]

Hello,

I just got a phone call from another coder in another practice, as she received a call from an upset mutual patient, stating that we can not bill an E/M with a procedure. From my understanding while reading the -25 modifier guideline that if the patient is seen and a workup leads to the procedure then the E/M is approriate if you append a -25 modifier to.
It also states there doesn't need to be a separate dx, that you can use it if there was documentation as to the E/M with approriate level.

 

[mitchellde]

yes you are correct. If the patient were scheduled for the procedure though there would be no E&M.

 

[gramatangirl]

modifier 25

yes you can bill this with an E/M using the modifier 25 and the same dx, but the notes must specify that decision for surgery.

 

[tlh4hart]

Thank You for the reply

We are an Urgent Care with a walk in basis only so no scheduling of procedures, as pts come through the door with problem.

 

[jsa1517]

we are internal medicine so i can relate to this happening alot.. if the patient is coming in for a follow up appointment and during the visit patient complains of continuous shoulder pain our Dr.'s may decide if necessary to give the patient an injection (procedure) for example 20610 arthrocentesis of major joint.. we would bill the e/m service -25 and the procedure with -59 & RT, LT or 50 for site specifics. We use the dx for the procedure with the procedure code and all other dx codes with the visit.

If the patient had a procedure planned or came in for visit and no procedure was done and the Dr. sent patient back in next week for the procedure... only the procedure code should be billed no e/m.

These insurances these days have become difficult with how they want the modifiers appended
(esp mod -25 & -59) and when they want to pay for them.