Wiki 59 Modifier - feedback/interpretation

Create Wiki
D

Dvega110

Guest
Messages
3
Best answers
0
Good morning-

I'm new to coding and I'm receiving different feedback/interpretation on the use of the 59 modifier. One coder said if an office visit and a code like 96120 is billed the office visit would have a 25 modifier on it and nothing on the 96120 since no other prodecure was done. I've also heard no 25 modifier of OV, but a 59 modifier should be on the 96120. Is it correct coding to put a 59 modifier on the procedure just because the payer wants it on a code just so the code gets paid? I also noticed that the NCCI edits does show a modifier can be used o the 96120. I'm just trying to find out what is the most appropriate way to code. Thank you!
 
https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html

https://www.cms.gov/Medicare/Coding...ndex.html?redirect=/nationalcorrectcodinited/

https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html

These areas of CMS are very helpful. See above links. Read through what they publish there. There is a lot of information there & appears very confusing at first. Don't give up, once you understand the NCCI edits & rules - it will all make sense.

The most basic way I know how to explain the difference in using mod 25 & 59is:

A modifier 59 is appended to a non E/M code & it distinguishes between procedure codes, not an E/M & a procedure code.
A modifier 25 is appended to an E/M code & it distinguishes between that E/M code & a procedure code, not a procedure code & a procedure code.

If billing an E/M code & a procedure code & you are unsure if a modifier 25 is necessary on the E/M code, search for the CPT codes in question in the "column 1/column 2" documents on the CMS website.

If billing two procedure codes or two radiology codes at the same encounter & you are unsure if a modifier 59 is necessary on one of the codes you are billing together, search for the CPT codes in question in the "column 1/column 2" documents on the CMS website.

If just an E/M code & 96120 are billed on an encounter - According to the CMS NCCI column 1/column 2 reports:
CPT 96120 has a bundling edit with various E/M codes. A modifier 25 should be appended to the E/M code & nothing on the 96120.

If an E/M code, 96120 & some other procedure code are billed on an encounter - According to the CMS NCCI column 1/column 2 reports:
Modifier 25 should be appended to the E/M code & then you'll need to search for the relationship between 96120 & whatever other procedure codes you are billing for the same DOS to determine if a modifier 59 is also necessary.

No matter what modifiers are allowed in order to bypass a bundling edit -ALWAYS verify the provider's documentation supports the usage of that modifier. Overuse of these modifiers to "just get the claim paid" may open your provider to payer audits.

Good luck!
 
59 vs XE 2016

We are coding Dermatology and Mohs Surgery, one of the insurance carriers told us that we should be replacing the 59 with XE. Is anyone using the XE for 2016 or can we continue to use 59? Thank you! Lisa Chavez, CPC
 
You must log in or register to reply here.
Top