Diagnoses: 714.0, 535.00, E943.8
Modifier -25 is used to indicate that the patient required a significant, separately identifiable evaluation and management (E/M) service on the same day as the patient received a minor procedure. E/M services that result in the decision to perform a procedure on the same day are considered to be part of the evaluation for the procedure and are not separately billable. However, this patient had a separate problem (gastritis) which required E/M services and therefore the portion of the encounter related to the diagnosis and treatment of the patient’s gastritis are separately billable with the use of modifier -25. The E/M services related to the patient’s gastric symptoms included:
- Expanded problem-focused history
- Detailed exam
- Moderate complexity decision making—treatment side effect (gastritis) requiring change in medication therapy and additional prescription medication to treat gastritis.
The arthrocentesis and intraarticular corticosteroid injections of both knees could be billed in two different ways. When billing for bilateral procedures, the procedures can be billed with an –LT or –RT modifier or it could be billed with a -50 modifier on the second procedure. Both ways are correct coding, and it is up to your carrier as to which way they will accept bilateral procedures. The biller can verify with the carrier before billing out the codes to avoid rejection.
Even though ultrasound guidance was performed on each knee, this code is only allowed to be billed once. The Centers for Medicare and Medicaid Services (CMS) states, “An MUE for a HCPCS/CPT code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service.” The MUEs, or medically unlikely edits, were put into place by CMS on January 1, 2007, and are used to reduce the error rate for claims paid under Part B.
For more information on MUEs, visit the CMS website at www.cms.gov/MedicaidNCCICoding/06_NCCIand MUEEdits.asp.
