Forum - Questions & Answers

Aug 20th, 2010 - Jen1971

Modifier 25 and 59 Questions..

Need some guidance on Modifier 25 and 59.... when do you use it.... see examples below... also does this depend on the insurance you are billing....

DX V72.31.... Dr Billing 99396 and 88143 does 99396 need a modifier 25...

DX V25.02.... Dr Billing 99215 and 96372 does 99215 need a modifier 25...

DX 795.03.... Dr Billing 99215 and 81000 does 99215 need a modifier 25....



DX 795.03 and 616.11.... Dr is billing 99215 with 57454 and 57505.... does 99215 need Modifier 25 and 57505 need Modifier 59...??

DX 625.9 and 623.8.... Dr billing 58558 with 58120 and 81007.... does 58120 need Modifier 59 and 81007 need Modifier 59...??

DX 626.2 and 795.10.... Dr is billing 58120 with 57522... does 57522 need Modifier 59...??

Thanks for you help.... Jen

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Aug 20th, 2010 -

My commentary

There are a lot of 99215 codes on that list. Are they really high complexity visits? Contraceptive counseling and abnormal pap do not seem to justify 99215 at face value...
As to the modifier, for the 81000- no modifier, 96372-no modifier, 88143- no modifier.

I'll leave the surgical procedures to someone more knowledgeable.

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Aug 20th, 2010 - jschmutz   323 

Bundling

First, I agree with 99215 seeming like an unusually high level for some of these things. I am also wondering if these E/M's were separately identifiable to the procedures being performed. According the diagnoses you included, they don't appear to be. In fact, I'm wondering if the patient came to the clinic knowing she was having those procedures.

57454 and 57505 - it is inappropriate to report these procedures together.

58558 and 58120 - it is inappropriate to report these procedures together.

57522 and 58120 - without seeing the procedure note, I can not help you determine if it is appropriate to report these two procedures together. Based on the above coding you provided, my instinct is to say that it isn't.

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