Wiki Appropriate Use Of 59 Modifier??

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ABridgman

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I have a question regarding the use of the 59 Modifier, and I am not clear on the correct coding.

I have two Scenarios, the first, I am pretty sure I am correct on...the second, not as much.

Scenario #1
Patient has a routine office visit WITH THE PHYSICIAN, and, on the same day, receives a B-12 injection from the nurse, which is not related to the causes the doctor saw this patient on the same day.

MY coding answer would say you bill the following:

99213 with no Modifier for the Physician Visit
AND
96372-59 for the administering of the B-12 by the nurse
AND
J3420-59 for the actual B12 serum.
(or would I also need the 25 Modifier on the 99213?)

This, I am fairly certain, can be done.

Scenario #2 is something I am more unclear about.
It is said one cannot bill 99211 and 96372 on same day, using the 25 Modifier on the 99211.
However, in this case:

Patient comes in, does NOT see the physician, BUT...the nurse gives the B-12 injection AND also checks the patient's vitals.

In this case, can one bill the 99211 and the 96372?
If so, what is the correct coding?

Would you bill this as
99211 (no modifier) with a ICD of V70.0
96372-59
J3420-59

Is that an acceptable coding?
Or can we just simply not charge for the E/M visit in this Scenario, and only bill the normal 96372 and J3420?

Opinions?
 
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Understanding NCCI edits are key to how to use the modifier 59. There needs to be two procedures, an E&M is not considered a "procedure" by definition. Here are two articles that should be helpful in understanding the criteria necessary to append a modifier 59, from CMS.
http://www.cms.gov/Outreach-and-Edu...k-MLN/MLNMattersArticles/downloads/se0715.pdf
http://wpsmedicare.com/j5macpartb/resources/modifiers/modifier-59.shtml

Scenario #1
Modifier 25 on the E&M only, no modifier 59 necessary as you only have one procedure. Modifier 59 is never applied to drugs.

Scenario #2
99211 and 96372 bundle and a modifier is NOT allowed, ever. Only bill the 96372 and drug. Checking vitals by the nurse is pre-procedural work and is inclusive to the procedure.
 
Thanks, OCD.
This is what I thought, myself...but I did not want to actually tell my doctor this without some additional backup.

The articles you referenced were helpful in this.

With that I should be able to show the practice where this Scenario B...cannot actually be done.

So, no 59 modifier is needed for the B12 when the doctor sees the patient on the same day, just bill as, say

99213-25
96372
J3420

But, as I had thought 99211 could not be billed for nurse's services checking vitals, etc....not even using a modifier on the 96372. even if the checking of vitals is in no way related to the B-12.

Example, the patient has hypertension. The patient comes in for B-12 injection by nurse. While there, the nurse checks and record blood pressure...as an ongoing procedure to the hypertension diagnosis, and it has NOTHING to do with the B-12 injection. One STILL cannot bill the 99211 in addition to the B-12.

But if the DOCTOR sees her, then it can be done. In which case, you'd bill
99212-25 (diagnosis code 401.9)
96372
J3420
And the documentation would need to show that the patient actually SAW the doctor. In this case 99211 would not be used, because 99211 implies "did not see actual physician"

If the nurse does both procedures...bill only the 96372.

Have I got this right now...so that I can present this to the doctor?

I told the doctor what I thought already, but did tell him I'd research it and look into it for a more definitive answer.

The definitive answer is that 99211 can NEVER be billed with 96372, not with any modifier. Right?
 
Thanks, appreciate it.

Always a good resource to ask questions about things one isn't clear on - but in your case, you also provided references, so I could read it for myself, so, three thumbs up for your help, OCD!!
 
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