Wiki OV with Mod 25

[Prada]

I have a question regarding proper use of mod 25 - whether it will apply in this scenario
WE bill for doctors with different specialties under the same tax id (same group)
One doctor - Pain management specialty does the office visit and recommends an EMG be done for diagnostic purposes. (Dx M54.16 /M54.12 or similar)
Second Doctor - PM&R specialty - does the EMG on the same day as as the Office visit- uses the same Dx code for billing

Can we bill - same tax ID but different NPI
Dr. 1 - EMcode-25 ( 1. Can EM be billed as its the same DX? 2. If it can be billed will Mod 25 apply as they are under same tax id? or 3. mod 25 does not apply as they are different specialty?)
Dr. 2 - EMG codes with same Dx

Thank you

 

[thomas7331]

I have a question regarding proper use of mod 25 - whether it will apply in this scenario
WE bill for doctors with different specialties under the same tax id (same group)
One doctor - Pain management specialty does the office visit and recommends an EMG be done for diagnostic purposes. (Dx M54.16 /M54.12 or similar)
Second Doctor - PM&R specialty - does the EMG on the same day as as the Office visit- uses the same Dx code for billing

Can we bill - same tax ID but different NPI
Dr. 1 - EMcode-25 ( 1. Can EM be billed as its the same DX? 2. If it can be billed will Mod 25 apply as they are under same tax id? or 3. mod 25 does not apply as they are different specialty?)
Dr. 2 - EMG codes with same Dx

Thank you

If the two providers are of different specialties, then the modifier is not appropriate and not necessary. The description of the modifier 25 includes the wording "...by the same physician...on the same day".

While most payers will consider two physicians of the same specialty in the same group to be the "same physician", they will not if the specialty is different.

 

[Prada]

If the two providers are of different specialties, then the modifier is not appropriate and not necessary. The description of the modifier 25 includes the wording "...by the same physician...on the same day".

While most payers will consider two physicians of the same specialty in the same group to be the "same physician", they will not if the specialty is different.

Thank you for your response. Can you please advice if there is any reference material I can use to quote in appeals.

 

[thomas7331]

Thank you for your response. Can you please advice if there is any reference material I can use to quote in appeals.

The exact wording in the definition of modifier 25 can be found in Appendix A of the CPT book.

If you are appealing a denial though, you may need to review the payer's policy and/or your contract for language showing that it should have been paid in order to make an effective appeal. Coding guidelines and reimbursement policies are two different things - denials don't always mean that a claim was coded incorrectly and just arguing that your claim was coded correctly is not necessarily going to overturn it.

 

[Prada]

I agree on the payer policy part, thanks for the direction..
The exact wording in the definition of modifier 25 can be found in Appendix A of the CPT book.

"... The E/M service may be prompted by the symptom or condition for which the procedure and/service was provided. As such different diagnoses are not required for reporting of the E/M services on the same date. this circumstance may be reported by adding modifier 25 to the appropriate level of EM service."

Looks like same diagnosis is allowed too!!