Wiki Sherin

Create Wiki
S

sherin

Contributor
Messages
10
Best answers
0
HELP - I need clarification on modifier 25. Here is a scenario: we are seeing an established patient for a new diagnosis of shoulder pain and at that visit it is decided to do a joint injection. How do I justify an E&M with a 25 modifier along with the joint injection if I only have the one diagnosis? In the past I have received denials from the insurance stating it is a bundled service and they pay on the lesser of the two billed which ends up being the office visit and I have to write off the procedure. Please give me web sites to confirm.
Thanks for any feedback
Sheri
 
There is absolutely no need to use 2 dx codes just because you have an office visit and a procedure. You should not be writing these off you should appeal them. Payers make payment decisions decisions based on trends. Trending has told them that rarely is there sufficient documentation to support the parameters of the 25 modifier. You need to appeal to prove you have an assessment that is over above and beyond the procedure. Such as does he include assessment of the opposit sholder and look at the neck and decide a joint injection instead of a muscle injection. If the documentation is not there then it should not be billed. If the documentation supports and it is not paid then you need to appeal!
 
sherin said:
HELP - I need clarification on modifier 25. Here is a scenario: we are seeing an established patient for a new diagnosis of shoulder pain and at that visit it is decided to do a joint injection. How do I justify an E&M with a 25 modifier along with the joint injection if I only have the one diagnosis? In the past I have received denials from the insurance stating it is a bundled service and they pay on the lesser of the two billed which ends up being the office visit and I have to write off the procedure. Please give me web sites to confirm.
Thanks for any feedback
Sheri
Click to expand...

You dont have to have a different diagnosis - CPT guidelines state that as long as the physician documents a significant/separately identifiable evaluation and management service, above the usual pre-service and post-service work usually associated with the procedure, you can report the E/M in addition to the procedure. The condition prompting the procedure can be the same one that is being evaluated and managed, so different diagnoses aren't required. As long as this wasn't a previously scheduled injection, and the provider documented all of the necessary elements to show that he gathered the relevant history of the present illness, examined the problematic body area /organ system, and made a medical decision as to how to treat the condition, you can report the E/M with a 25 modifier 25...see this for more info:
https://questions.cms.hhs.gov/app/answers/detail/a_id/7387/~/when-should-cpt-modifier--25-be-used?:)

http://www.aafp.org/fpm/2004/1000/p21.html
 
Last edited:
Thanks, information was great. I will start appealing the denials when I use the -25 modifier on OV/procedure combos.
Sheri
 
Thank you. I will definitely be looking at these services more closely.
Sheri
 
You must log in or register to reply here.
Top