Which Modifier Indicates A Significant, Separately Identifiable E/m Service?

Learn proper coding for modifiers 59 and 25

Learn how to properly use two similar evaluation and management codes to avoid later denials and challenges.

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Recently, ACP has received several member inquiries regarding the utilize of CPT modifiers 59 and 25 in conjunction with evaluation and direction (E/One thousand) codes. The 2 modifiers are very similar, but not interchangeable. Because they are and then similar, many physicians unintentionally miscode their claims and so have to bargain with challenging the denials later. This article volition explain how to make up one's mind which modifier is appropriate.

Modifier 25

The offset modifier to consider is 25. Its complete definition, defined by the American Medical Association Current Procedural Terminology 2012, is "a pregnant, separately identifiable E/Grand service by the same physician on the same mean solar day of the procedure or other service. It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable Due east/G service above and across the other service provided or across the usual preoperative intendance associated with the procedure that was performed. A significant, separately identifiable E/Thousand service is divers or substantiated by documentation that satisfies the relevant criteria for the respective E/Thousand service to be reported."

The keys hither are "E/M service," "higher up and across," and "same doctor on the same twenty-four hour period."

Every bit an case, modifier 25 will exist used when the physician performs a minor surgical procedure on the same day equally an E/M service. The physician will need to provide separately identifiable documentation of the components of the E/M service and of the not-E/M service.

Documentation must be all-encompassing enough that the additional service is readily identifiable to auditors who might review the merits. The E/M service must require additional history, examination, knowledge, skill, work time and/or risk to a higher place and beyond what is usually required for the procedure, and these must be included in the documentation.

None of the E/M service's documentation components may also support the performance of the procedure itself; at that place must be separately identifiable documentation to report the procedure.

A second case would exist if the physician performs an initial or subsequent Medicare Annual Wellness Visit (coded as HCPCS codes G0438 or G0439) to plant or maintain the patient's personalized prevention plan, and too provides an Due east/M service (CPT codes 99201-99215) for a medical condition on the same date of service. Then, the physician must add modifier 25 to the medically necessary Due east/M service, to be reimbursed for both services. The same coding logic applies when an Initial Preventive Concrete Examination (IPPE) is provided on the same engagement as a medically necessary E/M service.

Both services must exist fully documented. CMS cautions that the elements of the Annual Wellness Visit should not exist included in the documentation for the E/1000 service if only for the purpose of generating a higher intensity lawmaking. Information technology is disquisitional to note that some of the components of a medically necessary E/M service (such as a portion of the history or of the physical examination) may have actually been part of the IPPE or Almanac Wellness Visit. In that case, those elements should not be included when determining the most advisable level of Eastward/M service to be billed for the medically necessary, separately identifiable E/K service.

As ever, medical decision making and clinical complexity are the of import factors when selecting the appropriate code.

Modifier 59

Modifier 59 identifies procedures or services that are non normally reported together. The full definition of modifier 59, once more from the AMA's CPT 2012, is:"Distinct Procedural Service: Nether certain circumstances, information technology may be necessary to indicate that a process or service was distinct or independent from other non-E/M services performed on the same 24-hour interval. Modifier 59 is used to place procedures/services, other than E/M services, that are not normally reported together, just are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ arrangement, separate incision/excision, separate lesion, or separate injury (or the area of injury in all-encompassing injuries) not unremarkably encountered or performed on the same twenty-four hour period past the same individual. Notwithstanding, when some other already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used."

To appropriately use modifier 59, physicians should not use it on an E/Grand service code. When billing for an East/M service and a procedure that is not typically included in an E/K visit, or is not typically done on the aforementioned solar day, physicians should use the 59 modifier on the non-E/M service code.

Modifier 59 should be used to distinguish a different session or patient encounter, or a dissimilar process or surgery, or a dissimilar anatomical site, or a split up injury.

It should also be used when an intravenous (IV) protocol calls for two carve up 4 sites. Information technology volition indicate the second initial injection, or when the patient has returned on the same engagement of service for a separately identifiable service.

Finally, modifier 59 should be used when no other existing modifier applies to distinguish appropriately billable services.

Modifier 59 and the NCCI edits

The National Correct Coding Initiative (NCCI) edits, congenital into the Medicare contractors' claims processing systems, command improper payment of Office B claims by disallowing co-billing of sure combinations of CPT codes. With the NCCI edits, the coding gets a bit trickier considering CMS forces modifier 59 to operate in ways reverse to its original pattern.

For the NCCI edits, CMS recently clarified in a MedLearn Matters article (see sidebar on page eight) that the main purpose of modifier 59 is to "indicate that two or more than procedures are performed at dissimilar anatomical sites or during different patient encounters. Information technology should merely be used if no other modifier more accordingly describes the human relationship of the two or more process codes." This is dissimilar from the way CPT defines modifier 59.

In other words, a physician can utilise modifier 59 to bill the secondary, additional, or lesser process in an NCCI edit combination. If the edit shows indicator "1," modifier 59 can be used to communicate to the payer that the two billed services or procedures were appropriately performed together in that circumstance, such that either of the post-obit is true:

• The procedures were done at different anatomic sites on the same date or
• The procedures were done during different patient encounters, for the aforementioned patient, past the aforementioned physician, on the same date.

In this way, modifier 59 is essentially a tool to bypass or override the NCCI edit.

At that place are relatively few NCCI edits that involve E/M services, but hither are two examples:

• If the circumstance calls for a Level iii established patient visit (CPT code 99213) to be billed with psychological testing (such equally CPT code 96101), modifier 59 would be appended to the testing code.
• If the circumstance calls for a Level iii established patient visit (CPT code 99213) to be billed with a sit-in of home monitoring of a patient'due south international normalized ratio (e.g., HCPCS code G0248), modifier 59 would be appended to the demonstration code.

The overall effect of modifiers is to alarm the payer to adequate deviations from the CPT coding rules. The modifiers will non be used on all claims; the popular wisdom is that modifier use will be the exception rather than the dominion. But there volition be times when a modifier is needed. In all cases, physicians should remember that the documentation must show that the two services were split and distinct.

Source: https://acpinternist.org/archives/2012/07/coding.htm

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