Modifier 25 for Radiology Services

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Joined: Sat Dec 16, 2017 10:58 am

Wed Aug 08, 2018 10:27 am

I am currently doing a primary care audit. Our billing office has been instructing providers to add a 25 modifier to E&M services if they order radiology services for the same date. I say it isn't needed, because even though they are the same TIN, radiology is a separate specialty (similar to new patient criteria). Of course if the primary care doc reads the study they would need the modifier. Thoughts?

Thanks in advance!
Shelly L. Kubacki, BS, MPA, CPC, CPMA
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Mon Aug 20, 2018 9:50 am

There are no CCI edits for E&M and x-ray services, so from a correct coding perspective there is no need for modifier -25 when these services are rendered together, regardless of who is reading the x-ray. (See example below copied from AAPC Coder). However, we know that all carriers do not have the same policies about claims processing, so sometimes we must follow the carrier’s rules if we want to be paid for the services. Since overuse of modifier -25 has been on the carrier and OIG radars for a number of years, we do not want to have a blanket policy that -25 should be on all claims for E&M with an x-ray. Instead, only “break” the coding rule for the specific carrier that has an exception.


Your question has been answered by Pam Vanderbilt, CPC, CPMA, CPPM, CPC-I, CEMC, CEMA
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