Wiki Modifier 25

[AprilSueMadison]

I've been told two different things regarding new patients....

1 - If we don't have a distinct E/M separate from the procedure, we cannot charge a new patient office visit.

2 - We can always charge a new patient office visit even if the exam/hpi/and such relates to the procedure.

What is true? Should I not be using 25 on new patient office visits first off? Second, do procedures matter for new patients or should I just be charging an office visit each new patient?

Thank you!

 

[capricew]

I've been told two different things regarding new patients....

1 - If we don't have a distinct E/M separate from the procedure, we cannot charge a new patient office visit.

2 - We can always charge a new patient office visit even if the exam/hpi/and such relates to the procedure.

What is true? Should I not be using 25 on new patient office visits first off? Second, do procedures matter for new patients or should I just be charging an office visit each new patient?

Thank you!

it really depends on what type of procedure you are doing......
can you give an example of what you are doing?
IE.... when you say procedure - what are you referring to on new patients?

For example if you have a patient come in for shortness of breath as the cc, and you end up giving them a breathing treatment, you cannot bill the breathing treatment separately as it is related to their visit. You would only bill the E/M.

but.... if your patient came in for their annual wellness, and it was noted on exam that the range of motion in the shoulder was limited and the physician decided to give a cortisone shot, then you could bill the E/M with mod 25 as well as the shoulder injection and medications because the two are distinct from one another.

If you are talking about surgical procedures, then typically E/M visits within 24 hours of a procedure are not reimbursable as they are looked at as a pre-op visit which is included in the surgical procedure. But, if an E/M visit is the direct result of a decision for surgery which needs to take place promptly (ie broken bone) then you can bill the E/M code with modifier -57 to indicate to your payer that the E/M was the time the decision for surgery occurred and that it was not for pre-op purposes.

hope this helps.....

Caprice Walder, CPC

 

[AprilSueMadison]

Example -
New patient comes in for a suspicious lesion on their arm. We do the entire workup, and end up doing a biopsy on the lesion.

Do I have a new office visit? I was told no, we do not have an office visit in that case so I don't bill one and use the modifier of 25, in this case I bill only the procedure.

BUT, I've just read some information that leads me to believe we should always be submitting a new patient office visit no matter what. I don't know what to do.

https://www.aapc.com/memberarea/forums/showthread.php?t=36467 < This seems to support me in that I'm coding these sort of things correctly. BUT, this is older. I just need to make sure I'm handing new office visits and procedures correctly. Thank you.

 

[AprilSueMadison]

See, I keep finding stuff like the following:

"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."

This is what I've always thought was the case. If you don't have a sep and distinct E/M, then you don't report a new patient E/M code. If you do, then you report it with a modifier of 25.

This is driving me crazy.