Wiki Modifier 25 with sequential trigger injection

[CECKERMAN1]

Patient's first office visit with the Dr he reports triggering, difficulty with flexion and tenderness. This visit is the decision for injection, but the injection is not done until the second visit three weeks later.

During the second office visit, they report triggering and locking locking and the injection was performed. Is the locking enough to substantiate use of the 25 on the E/M code

Six weeks later on the third office visit he reports better motion, conditioned tenderness and locking. Is the continued locking enough to substantiate use of the 25 on the E/M code

 

[swilliams2]

mod 25

My understanding is yes, a worsening problem, properly evaluated and documented is enough to substantiate the mod 25.

 

[kagal0816@verizon.net]

Use of Modifier 25

Hi - I must disagree. The first visit included in the plan that the patient will return for the injection (based on my understanding of the scenario). Therefore, using 25 on an E&M is inappropriate. The condition was not treated the first visit, treatment was scheduled (the injection) in three weeks. What exactly worsened to substantiate another E&M?

This is a very slippery slope and one should be careful. Modifer 25 is very much on the radar with insurers, auditors, etc. There must be by CPT definition: "Significant, separately identifiable E&M svc by the same physician on the day of procedure or other service." Based on the information provided, billing E&M visits may put your physician at risk in these types of scenarios.

Karen

 

[mitchellde]

Once the procedure is scheduled then you cannot code an E&M if it is related to the procedure, the locking is part of the surgical decision and not separately reported. Therefore no to the E&M after the decision for the procedure.