E & M guidelines direct the use of modifier 25 to indicate that the patient ’ s condition required a significant , separately identifiable E & M service beyond the usual pre-service or post-service care associated with the procedure that was performed . For example , a claim is billed with CPT code 99213 ( Office or other outpatient visit for the evaluation and management of an established patient ) with CPT code 90772 ( Therapeutic , prophylactic or diagnostic injection [ specify substance or drug ] subcutaneous or intramuscular ). The claims review edit will identify CPT code 99213 as included in procedure 90772 . If the claim is billed with modifier 25 attached to the E & M code , the claim will be flagged for review and appropriate billing .
The edit comment may indicate “ NEW VISIT FREQUENCY or MEDICAL VISIT INCLUDED IN PROCEDURE ”
Incidental Procedures Edit
The purpose of this edit is to identify procedures that are performed at the same time as a more complex primary procedure . The incidental procedure does not require significant physician resources and / or is clinically integral to the performance of the primary procedure . For example , a claim is billed with CPT code 28270 ( Capsulotomy ; metatarsophalangeal joint , with or without tenorrhaphy , each joint ( separate procedure ) and CPT code 28285 for the same date of service . The claims review system will identify CPT code 28270 as incidental to CPT code 28285 .
The edit comments may indicate “ INCIDENTAL PX ” Intensity of Service Edit
The purpose of the edit is to identify claims with excessive utilization of comprehensive and detailed evaluation and management services performed by the same provider for the same patient on the same date of service .
Based upon standard treatment protocols , certain diagnoses typically require limited medical evaluation services . Claims with these diagnoses are audited to detect instances of coding to a higher level of medical evaluation service than is typically indicated . In cases where the intensity of the medical evaluation service is higher than excepted for the diagnosis , the evaluation service is replaced with a lower intensity procedure . For example , if a claim is submitted with a high intensity visit code , such as procedures 99214 or 99215 , for a diagnosis form the “ Minor Viral Infections ” category , then our system may recommend a lower intensity visit code 99213 .
The edit comment may indicate “ 99214 IS HIGHER THAN EXPECTED FOR DX AND SHOULD BE REPLACED WITH 99213 ”
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