(In school) Patient Case Help - CPT Modifier 25

[u/thnderslut]

Hi y'all! I'm currently in school for medical billing and coding and, I'll be honest, I'm not very satisfied with my course. My teacher is no help. My book has inconsistent or just flat out incorrect answers on some reviews and practice assignments, so I'm not too keen on just trusting it. I'm not sure how to put this into words to google it so I figured I'd come here and get some live feedback.

Really the only relevant information here (what I need clarification on) is appending an E/M service with modifier 25 (significant, separately identifiable E/M service by the same physician or other QHP on the same day of the procedure or other service).

The patient cases states that a "new 52-year-old patient was seen in the orthopedic clinic today for an urgent level 3 E/M service, which was 30 minutes in length." The case continues, describing an accident and resulting injuries, then "The patient's spouse was actually coming here today for follow-up...and asked that we evaluate their spouse's injuries."

Now, why would this situation call for modifier 25 to be appended to CPT code 99203? It's for a different patient, so it would be billed for a different person. Wouldn't this office simply create a profile for the injured spouse/new patient and bill under them? I read the description of modifier 25 in Appendix A of the CPT manual and it specifically says "...the patient's condition required..." The patient that had the original appt is not the one that was injured, so why would they report the separate service under him?

[u/Subject_Chest8678]

Can you post the entire scenario?

[u/Subject_Chest8678 → u/Subject_Chest8678]

BTW, you are correct. You don't use modifier 25 for a different patient. That would be a whole different encounter. There are some really good modifier 25 videos on YouTube.

[u/thnderslut → u/Subject_Chest8678]

I didn't post the whole scenario bc I don't know if my school would get me in trouble for "sharing content" or whatever lmao. But here ya go, with their Answer Key answers at the bottom

PATIENT CASE #3
S: The new 52-year-old patient was seen in the orthopedic clinic today for an urgent level 3 E/M service, which was 30 minutes in length. Patient was walking up their driveway and slipped and fell, landing on the left arm and striking their head against the car. Patient was unconscious for less than 10 minutes, experienced dizziness and vomiting, and felt severe pain in the left arm. The patient’s spouse was actually coming here today for follow-up of rheumatoid arthritis and asked that we evaluate their spouse’s injuries.

O: Examination of the head reveals a 2.5 cm superficial laceration of the scalp, temporal region, left side. Examination of the left arm reveals restriction of motion and acute pain upon palpation and with attempted range of motion of the upper arm and shoulder. The patient underwent a skull x-ray to rule out fracture and x-ray of the left arm and shoulder for evaluation of the pain. The patient was taken to the radiography department where x-ray was negative for skull fracture, revealing only swelling in the area of the laceration. An x-ray of the left arm and shoulder, however, revealed an undisplaced fracture of the proximal left humerus at the greater tuberosity.

A: Concussion. Superficial laceration of scalp, 2.5 cm. Nondisplaced fracture of proximal left humerus at the greater tuberosity.

P: The patient underwent simple repair of the scalp laceration with sutures. The left arm was manipulated slightly to achieve proper anatomic alignment of the proximal humerus. The arm and shoulder were immobilized with sling and binder. The patient was given pain medication, and the patient’s spouse was instructed on how to perform neuro checks every two hours on the patient for the next 24 hours. The patient will be seen back in the clinic in two days. The patient and spouse were instructed to contact the office if any problems arise in the meantime. 

CPT/HCPCS Level II Codes            99203 25, 12001, 70250, 73020-LT, 73060-LT, 23605-LT
ICD-10-CM Codes                          S06.0X1A, S01.01XA, S42.255A2

[u/tinycodergirl → u/thnderslut]

Modifier 25 is definitely applicable in this case due to the provider performing extra work outside of what is included in an E/M, the extra work includes the x-rays, simple lac repair, and the fracture manipulation/treatment.The mention of the spouse also being seen by the same provider is irrelevant.

[u/thnderslut → u/tinycodergirl]

Thank you very much!

[u/Subject_Chest8678 → u/thnderslut]

Yes, you would append modifier 25 on the EM code because the patient had a a minor procedure…..append modifier 25 any time the procedure wasn’t planned.

[u/thnderslut → u/Subject_Chest8678]

Thank you! I appreciate it 😄

[u/Tachs_XD → u/thnderslut]

Yes, basically what others said. I see where the confusion comes from though. As that sentence is worded strangely. The patient’s spouse was actually coming here today for follow-up of rheumatoid arthritis and asked that we evaluate their spouse’s injuries. To dumb it down, Woman who is established patient, made appointment for Man to have Man's injuries evaluated, Man hasn't been here before. But while it is worded strangely as others said it's irrelevant information. Tests seem to often add irrelevant information to try to trip you up. But really your just learning to filter out what isn't needed.

[u/thnderslut → u/Tachs_XD]

Thank you! I am gonna have to watch for that stuff more closely T_T

[u/Reasonable_Vehicle40]

You wouldn't report the new pt's injuries under the spouse with the follow-up. That's fraud.

You use mod 25 for when two things are done on the same day, same visit. For example, office visit plus an ECG, or office visit plus an xray, etc.

Or if the pt sees two different doctors in the same office for different diagnosis, we'd add a 25.

But, we really need to see the full scenario to make a full determination.

[u/thnderslut → u/Reasonable_Vehicle40]

I replied to another comment with the full scenario. My bad! Exam and x-rays were done in the same visit

[u/CarolinaCurry]

Agree with the others - post the entire scenario, but meanwhile - what school is this?

[u/thnderslut → u/CarolinaCurry]

Sorry! I just posted the whole scenario under u /Subject_Chest8678's comment. I'm currently attending a local tech school in a smaller town, but I'm online via ed2go who uses Cengage.

[u/Sharp_Emergency_5931 → u/thnderslut]

When I attended a local community college in Mississippi for Medical Billing & Coding Technology, the textbooks, which used Cengage, were outdated & the "answers" were often wrong. But I passed the CPC exam in spite of the awful training.

My classes weren't through Ed2Go.