Taylor Posted Mon 25th of November, 2019 11:47:32 AM
For the ED MD, if all of the documentation is present and the ED MD does a good exam of the body part in question and other systems as well, should and E/M be applied with a 25 modifier? Would this be acceptable, rx sent- 99283-25, cpt 10060? What about same good documentation for pt with oral pain, … 99283-25, 64400?
SuperCoder Answered Tue 26th of November, 2019 07:13:25 AM
According to CMS, physicians and qualified nonphysician practitioners (NPP) should use modifier 25 to designate a significant, separately identifiable E/M service provided by the same physician/qualified NPP to the same patient on the same day as another procedure or other service with a global fee period. In other words, you should not use modifier 25 when the procedure that occurred on the same day as a procedure that has no global days.
When using modifier 25, you should remember this maxim: If you don't have a HEM, you can't bill an E/M. Here, HEM stands for history, exam and medical decision–making. All procedures include some service related to patient evaluation and management, but a separate E/M should include its own HEM. In other words, the physician needs to determine whether the problem is significant enough to require additional work to perform the key components of the problem–oriented E/M service.
If your documentation supports that physician had work on other system as well, than you can bill E/M service with 25 modifier.
If physician has performed 10060 (Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single) and separately identifiable evaluation and management service, than you can bill 99283-25 and 10060.
Note:The CMS definition is still commonly misunderstood by many practices. Because many commonly billed procedures, such as EKGs, don't have a global period, modifier 25 should not be necessary for many claims. However, some payers do require the modifier even in these circumstances, so you should check with your payer to see whether you should include modifier 25.