Urology Coding Alert

Question: I saw the coding edits for 99221 and 99212 have a modifier indicator of "1." What does that mean?

Virginia Subscriber

Answer: When looking at the Correct Coding Initiative (CCI) edits, you'll find some edits that indicate the CPT^® and HCPCS code pairs you should normally not report together (known as procedure-to-procedure, or PTP, edits).

According to the latest 2017 CCI edits, 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making ...) is a Column 2 code for 99221 (Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: a detailed or comprehensive history; a detailed or comprehensive examination; and medical decision making that is straightforward or of low complexity ...).

This is where that modifier indicator comes in. Although PTP edits normally show which CPT^® codes you should not report together, under some circumstances, you can use a modifier to override these edits. In this case, a modifier indicator of 1 means you can use a modifier to override the edit when appropriate.

Caution: The documentation and clinical circumstances must always support your decision to use a modifier. Examples include separate sites or sessions for the services. Although modifier 25 may be appropriate in this circumstance, you should never append a modifier just to bypass an edit. Payers may also have policies around billing for inpatient and outpatient services on the same day.