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Claims rejections with modifier 25
What modifier should you use to bill for a physical and pneumonia vaccine? A physical with an office visit? Find out.
Q: We billed Medicare for a physical and pneumonia vaccine with modifier 25. Medicare paid only for the vaccine and its administration, rejecting the physical. We also billed a physical with an office visit; during the physical, the patient had a problem with her eye and also sought to renew medications. Again, Medicare rejected the physical, stating that modifier 25 is not the correct one to use. Which modifier should we use?
A: Modifier 25 is not needed when a preventive medicine code is billed with a vaccine on a Medicare claim, as it was in your first example. V70.0 (routine general medical examination at a healthcare facility) should be linked to the preventive medicine code (99381–99397), and V04.81 (need for prophylactic vaccination and inoculation against influenza) should be linked to the vaccine and administration codes. Use code G0008 (administration of influenza virus vaccine) for Medicare beneficiaries.
In your second example, double-check to ensure that you’ve appended modifier 25 to the correct code. Modifier 25 should only be appended to an E/M code, not the preventive medicine code (99381–99429). If you submit the claim in this manner, then modifier 25 is the correct one to use.
Link your diagnosis codes to the correct Current Procedural Terminology codes on the claim to support medical necessity (for instance, the diagnosis code for the patient’s eye problem should be linked to the E/M-problem oriented-code, not the preventive medicine code).
If this patient was new to your practice, then a new-patient preventive medicine code and an established-patient E/M code need to be billed, because two new-patient codes cannot be billed on the same claim.
If you billed the claims appropriately, appeal the decisions.
The author is a billing and coding consultant for VEI Consulting Services, Indianapolis, Indiana. Do you have a primary care-related coding question? Send it to medec@advanstar.com. Also engage at www.twitter.com/MedEconomics and www.facebook.com/MedicalEconomics.
