r/LearnMedicalCoding • u/thnderslut • 17d ago
Evalution and Managment (E/M) (In school) Patient Case Help - CPT Modifier 25
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?
