Wiki using Mod 25 with minor procedure in ASC same day

[Karen78]

I have a group of providers (spine and pain management) that the spine provider is referring the patient to the pain management provider for an injection such as an ESI. The pain management provider is wanting to bill a new/estab. patient visit with a 25 modifier the same day he takes the patient to the ASC (2nd floor of the practice) to do the ESI. The visits that he is documenting is going over what he will do and if they agree. would this E/M be considered as separately billable? my provider says it is but per the AMA march 2023 guidelines it seems as though everything he documents should be considered the pre-op documentation that is included. Any suggestions or guidance would greatly be appreciated.

 

[NRaizman]

If the Spine provider refers specifically for the ESI, then the PM doc shouldn’t bill for E&M.

If the PM doc receives a referral for “eval and treat” and PM does a clearly separate and identifiable evaluation, then you might have a case. Depending on procedure, it would be a -25 or -57 modifier.

If PM doc is part of the same practice as Spine, you would likely get a denial for the second E&M from many payors but that is a contractual issue.