Does this situation sound familiar? Your patient comes in on the day of a scheduled procedure and says, “Oh by the way … .” If your encounter, instead of being a scheduled procedure, turns into something more, you can bill Medicare for the E/M visit by adding modifier -25 to the E/M procedure code if appropriate.
Explore This IssueMarch 2009
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This visit should be billed with a mid-level E/M visit—99213-25 (an expanded history and exam was performed on the patient because of his new diagnosis, wrist pain with a medical decision making of low complexity), along with the following procedural and diagnosis codes:
20610 – Major joint or bursa (e.g., shoulder, hip, knee joint, subacromial bursa)
J3303 x 4 – Injection, triamcinolone hexacetonide, per 5mg
73100 – Radiologic examination, wrist; two views (to determine fracture)
715.16 – Osteoarthrosis, localized, primary; lower leg
719.43 – Pain in joint; wrist
Appropriate use of modifier -25 is important. Remember to use modifier -25 on the E/M service only when billed with a scheduled procedure, and verify that the patient’s records clearly document that the E/M visit was a significant and separately identifiable service. Keep in mind that Medicare will bundle the E/M service with your procedure as inclusive if the modifier is not listed on the E/M code.