To qualify for modifier 59, you must be able to document :. How can you figure out when you can appropriately apply modifier 59 to unbundle a code pair and qualify for payment? The first thing you need to do is rule out all of the other modifiers. Statistics suggest that modifier 25 is misused nearly 50 percent of the time. A lot of confusion arises between these two modifiers because they both deal with different services by the same provider on the same day. Modifier 25 indicates a significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service.
Just before the injection, she complains of a sore wrist. The physician administering her knee injection also provides the separate service of evaluating her wrist during her office visit. Modifier 25 is the correct choice appended to the office visit code such as CPT codes Modifier 50 is used to report bilateral procedures that are performed at the same operative session by the same physician.
Bilateral means that the same procedure is done on the same body part on both the left and right sides of the body. Example 1 : A patient has osteoarthritis of both knees and undergoes bilateral knee injections The second injection would be correctly coded by appending modifier 50 to indicate the services provided were bilateral on both knees. Tip: Depending on your carriers, you may need to bill with right RT and left LT modifiers , or a quantity of two instead of modifier Learning and adapting to any changing necessity of modifiers will help the practice as a whole stay ahead of the billing curve.
For instance, Medicare no longer requires modifier 51, as their internal systems are programmed to add 51 internally to the correct procedure code s , and make the appropriate reductions to the remaining services billed.
Many payers follow suit to the standards of Medicare, so it is evident that with modifier 51, knowing what payer requirements are in your area will be key to appending modifier 51 correctly avoiding unnecessarily denied claims. Understanding correct and appropriate use of modifier 51 will be key to filing correct claims, which will then result in correct payment. Not only does the 51 modifier allow us to code physician services to the highest level of specificity possible, but it ensures the physician is paid accordingly for those services.
Procedure Coding: When to Use the Modifier Curious if you have the right staff in the right roles? If this procedure is: Performed alone e. Performed as an integral part of another procedure e.
Code only the surgical arthroscopy RT Arthroscopy, knee, surgical; osteochondral autograft s eg, mosaicplasty includes harvesting of the autograft[s].
Performed as a distinct procedure e. As with modifier 51, list first the more resource-intense procedure in this case, the surgical approach. Author Recent Posts. Nancy Clark. She applies her skills to assist physician and hospital clients with revenue cycle management. Clark focuses on coding and documentation reviews, assistance with payer audits, and providing education for physicians and their staff. She is also an AAPC certified instructor, a contributing author to health care publications, and a presenter at seminars.
She is proud to support the AAPC for recognizing the value of medical coding professionals and enjoys working with its members. Latest posts by Nancy Clark see all. About Nancy Clark Has 14 Posts. Tim Lowney says:. June 10, at am. Kar says:. June 13, at pm. Jody says:. June 20, at pm. Yesi says:. August 22, at pm. September 12, at am. April 27, at am. Beth says:. June 30, at am.
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It can be used to document two procedures in two different coding categories performed on the same day, just like EGD and colonoscopy. To report this modifier right, the coder should list the procedure with the highest RVU highest paying first, and use modifier 51 on the subsequent service s with lower RVU lowest paying. There are instances where multiple procedures are performed but modifier 51 is not appropriate.
Modifier 51 is not appended to add-on codes like CPT code
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