Medical Billing Coding - modifier 25 with inpatient ESRD pt, cpt, codes
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Thread Topic: modifier 25 with inpatient ESRD pt
Topic Originator: Kathy
Post Date August 29, 2007 @ 10:40 AM
modifier 25 with inpatient ESRD pt

August 29, 2007 @ 10:40 AM Reply  |  Email Friend   |  |Print  |  Top

If the physcian is referred to see an ESRD patient for a hospital consultation, how would you code this to get paid for the consult & the dialysis??  I know that the 90935 code includes payment for any E&M services that are related to the patient's renal disease and are provided on the same date as the dialysis service, therefore, the payment is bundled. The rule also states that these services may be reported as provided on the same date as a dialysis service if the service is significant & separately identifiable, using modifier 25. My question is, do you code the E&M with the admitting diagnosis (exp. CHF) and code the 90935 with 585.6 only??

Steve Verno
August 29, 2007 @ 12:02 PM Reply  |  Email Friend   |  |Print  |  Top

As you showed, the E/M would need to be justified as a significant and separate visit and supported by a diagnosis that would also be separate.  Modifier 25 is telling the carrier that something else happened during the visit to warrant an E/M.  

For example, a patient comes to you with an open wound of the hand. The provider performs a simple closure.  To bill an E/M you would need something to support the E/M other than the open wound diagnosis.  The patient could have other injuries such as sprains and strains, abrasions or contusions of other anatomical areas.

August 30, 2007 @ 8:50 AM Reply  |  Email Friend   |  |Print  |  Top

Thanks Steve. The problem we are having is that when we billed for example 99254-25 & 99035 using codes 585.6, 403.11, 250.40, 583.81, 825.20, Medicare only paid the 99035 (dialysis). So, if a patient was admitted for a fx. we didn't code it, we just coded the nephrology codes. And the reason why we do it this way is we were told to code in the order the doctor has under his impression on the dictated E&M. 99% of the time the renal codes are listed first. Is this the correct way to code?? Also, if the physcian was requested to see this patient for renal management, would this be coded as a initial inpatient consult or a subsequent hospital care??

September 4, 2007 @ 12:26 PM Reply  |  Email Friend   |  |Print  |  Top

Hi, Kathy -

You may want to try the E/M charge with modifier -25 with diagnoses  403.11, 585.6 (should come after 403.11), 250.40, and 583.81 ... AND... append a modifier 59 to the 90935 charge with diagnosis 585.6 only.

The medical documentation should support that the patient was evaluated for the other diagnoses in addition to receiving the hemo for 585.6.  

In addition to modifier 25, Medicare (in my area, at least) wants to see the additional confirmation that two separately identifiable services were provided by using modifier 59.  

Good luck!

September 4, 2007 @ 4:44 PM Reply  |  Email Friend   |  |Print  |  Top

Can you use modifer 59 on an Evaluation & Management charge??  I was told that only modifiers 24, 25, & 57 can be used on E&M charges!!

Steve Vernoi
September 5, 2007 @ 6:27 PM Reply  |  Email Friend   |  |Print  |  Top

Modifier -59 is not used with an E/M. It is used with multiple non-E/M procedures that are performed during the same visit when no other modifier can be used.  This is per your CPT Manual. Look in your E/M guidelines and the guidelines for other sections and they show you the modifiers used with those codes.

Modifier 25 is only used with an E/M code.

Be careful when using modifier 59 as it is one of the modifiers that are being misused and under review by the OIG.

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