Wiki Modifier 25 in the office URGENT!!!

[ljhollis]

I have a question regarding the 25 modifier, I know the answer but need it in writing. When in the office and the patient comes in for an office visit and the provider ends up doing a shave biopsy, is it a CMS rule that the office visit and the biopsy have different diagnosis' to be able to bill both and use the 25 modifier? When you respond if you could tell me where you got the information that would be wonderful that way I can point the person that is questioning this in that direction.

 

[kperazzoli]

Modifier 25 in the office URGENT!!!! - Reply

POLICY NARRATIVES UPDATED BY THE CENTERS FOR MEDICARE AND MEDICAID SERVICES (CMS) EFFECTIVE JANUARY 1, 2012 THROUGH DECEMBER 31, 2012 - Chapter 1, General Correct Coding Policy; Section D. Evaluation & Management (E&M) Services, paragraph 5 (p. 28)

If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. The E&M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is ?new? to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure. NCCI does contain some edits based on these principles, but the Medicare Carriers (A/B MACs processing practitioner service claims) have separate edits. Neither the NCCI nor Carriers (A/B MACs processing practitioner service claims) have all possible edits based on these principles.

 

[AprilSueMadison]

https://www.aapc.com/memberarea/forums/showthread.php?t=108160

The above thread my help you somewhat.

You do not have to have a different diagnosis code to append a modifier 25 to an office visit where a procedure takes place. You DO have to have a "significant, separately identifiable E/M service, above and beyond the usual pre and post-operative care associated with the procedure or service performed."

For example, the AAD (American Academy of Dermatology) has the following work included in a biopsy procedure code:

11100 (biopsy)

Pre-service: one obtains a pertinent history including previous skin cancer, prior treatments, and sun protection. Indications for the biopsy, expected benefits, and a description of the procedure and its risks are discussed. Consent is obtained and the biopsy tray is prepared.

Intra-service: selection of the optimal biopsy site and lesion inspection and palpation, and then the biopsy procedure itself from start to bandaging.

Post-service: patient instruction on care and follow-up, charting, and communication with any referring physician.

This means the doctor has to go BEYOND what is included in the biopsy code in order to bill an office visit with a modifier 25.

I hope this helped a little.