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Wiki Modifier 25

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meeramohanakrishnan

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Hi All,



It would be great if anyone an provide examples and scenarios on Modifier 25.





Thanks in advance for your help.



Meera
 
-25

A parent takes a 9yr old to the child's physician for an oral poliomyelitis vaccine. The physician's assistant evaluates the child (established pt) & administers the vaccine orally to the child.
90712(Vaccines,Poliovirus,Live,Oral)
90473 (Immuniz. Admin.,One Vaccine/Toxoid)
99211-25 (Eval. & Mangmnt.)
 
-25

Photochemotherapy is provided for a 34 yr old consultative pt w/ severe dermatosis. The pt receives 8 hrs of treatment. The physician provides a comprehensive history & physical exam w/ moderatley complex medical desicion making.
99244-25 (Consultation,Office &/or Other Outpt)
96913 (Photochemotherapy)
 
Last edited:
-25

Modifier -25 is used to report an E/M service on a day when another service was provided to the pt by the same physician. Or, if a pt came into the office for a visit early in the day & then later in the day needed to return for a separate service, you would report both services using E/M codes & add -25 to the second code.
Modifier -25 requests payment for both E/M & a minor procedure or two E/M services on same day.
 
What type of service was rendered during the second encounter? a procedure or an E/M?
If it was a 2nd E/M, my suggestion would be to charge one E/M for the whole day but to increase it's level of service (to a level that documentation supports).
If the patient returned the same day for a procedure or service other that E/M, charge 1 E/M with mod. 25 and than the procedure/service (increase the level of the E/M if the documentation supports it).
I am not sure that any insurance will pay for 2 visits on the same day, regardless that they were for 2 separate issues......

JB
CT ENT
 
Pt presents to the office as a New Patient. CC Sinus Congestion. MD performs a Complete physical exam. addressing areas of the sinus, reviewing Ct scans etc.
upon physical exam he notices patient has cerumen impaction and debrides the cerumen

99203 -25 Dx 478.19
69210 Dx 380.4

The 99203 was a distinct seperately reported E/M during the same session as a procedure
 
Is anyone billing for Wound Care Centers? These are recurring patients usually returning once a week - the doc says he must evaluate the wound before deciding for certain if another debridement is required. Based on this I have been billing the E/M level documented w -25 then the debridement. However today we had a meeting with the reimbursement director over the WCC who advised that we could only bill for both if there was another medical reason for the E/M or if a new wound was present. I thought the -25 could be used as a decision for surgery for minor procedures (0-10 day global). Is that incorrect?
 
modifier 25

mgord said:
Is anyone billing for Wound Care Centers? These are recurring patients usually returning once a week - the doc says he must evaluate the wound before deciding for certain if another debridement is required. Based on this I have been billing the E/M level documented w -25 then the debridement. However today we had a meeting with the reimbursement director over the WCC who advised that we could only bill for both if there was another medical reason for the E/M or if a new wound was present. I thought the -25 could be used as a decision for surgery for minor procedures (0-10 day global). Is that incorrect?
Click to expand...

It's incorrect. When the patient returns for follow up after previous debridement they already know they have a wound, the E/M must be separate and identifiable, treatment of something else, not anything associated with the wound. We ran into this same issue. The E/M must have all qualifications met, must be separate and identifiable issue (besides the wound they are presenting for) and then you can charge the E/M with 25 modifier.
I found in wound care, just about the only time we can charge E/M is for first visit when they are meeting the patient and the last visit when wound is healed.
 
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