Billing same-day procedures

August 1, 2008

We are having difficulty getting paid for visits that occur on the same day that procedures are done in the office, even though we are using modifier 25. Any suggestions?

Key Points

We are having difficulty getting paid for visits that occur on the same day that procedures are done in our office, even though we are using modifier 25. In many instances, the procedure is the result of the visit that day, so billing both the E/M and procedure is appropriate. Any suggestions?

One reason you may be experiencing rejections is that the visit occurs in the global period of another procedure. Even if you indicate a different diagnosis, insurer edits may not pick it up. If that is the case, modifier 24 ("Unrelated E/M Service by the Same Physician During a Postoperative Period") would be more appropriate.

In addition, if the decision for a major surgery (90-day global period) is truly made during a visit, modifier 57 should be used when billing the service.

The author, vice president of operations for Reed Medical Systems in Monroe, MI, has more than 30 years' experience as a practice management consultant, as well as being a certified coding specialist, certified compliance officer, and a certified medical assistant.