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Posted By Mary Peabody on 06-02-2020, 16:57:51 in Ob-Gyn
Hello Melanie,

Is modifier 25 required on an E/M if billed on the same with CPT 99358?. the provider reviews the records of the patient before the visit and bills for record review and the E/M. Example 9905-25 + 99358
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Posted By Melanie Witt on 06-04-2020, 19:10:52
I would only bill for this if the record review was beyond that normally expected at the time of any E/M service. Per CPT guidelines "These services may consist of, but are not limited to, prolonged communication/consulting with QHPs related to ongoing management of the patient, extensive record review related to an E/M service performed earlier on the patient, or prolonged review of an extensive health record and diagnostic test results regarding the patient.: And of course all if this extensive review must be well documented including the start and stop time of the record review. I believe that a modifier -25 will be needed (to be on the safe side) so that the service is not bundled, just as you would have to use the -25 if you billed both a problem and preventive E/M service on the same date of service. If the record review is on a different date of service, no modifier is required.
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