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MOD 25 & ICD CODE

Alea Posted Sat 01st of December, 2012 01:05:22 AM

Since mod 25 states a sinficantly separate identifiable E/M, does the ICD code has to be different from the procedure code e.g. yag pi or pp insertion, performed on the same day?

SuperCoder Answered Mon 03rd of December, 2012 10:21:55 AM

YOU DO NOT NEED A SEPARATE DIAGNOSIS FOR MODIFIER -25, Although Some Payors Seem to Think That You Do
It is a commonly-believed myth that, to use this modifier, the patient must have a "significant separately identifiable" problem that is managed on this visit. But the AMA definition of modifier -25 clearly denotes that this is not true:
"The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date."
A problem arises when overzealous payors (in direct contradiction of AMA guidelines) require physicians to treat a second condition before they will give payment for an E/M with modifier -25. It is the E/M note, not a second presenting problem, which must be "significant and separately identifiable." Nonetheless, quite a few large payors will not reimburse for E/M codes with this modifier unless documentation of a second diagnosis and medical records supporting separate E/M services for that second diagnosis are provided.

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