Billing Modifier 59 to an E/M code

[vvazquez8649]

Hello, we are recently getting denial from varies insurance such as Humana denying 99213/99214 with modifier 25 when patient has had a phlebectomy done day(s) prior. For clarification, can you bill modifier 59 to an E/M code? What is the best way to approach this issue?

 

[sls314]

Hello, we are recently getting denial from varies insurance such as Humana denying 99213/99214 with modifier 25 when patient has had a phlebectomy done day(s) prior. For clarification, can you bill modifier 59 to an E/M code? What is the best way to approach this issue?

Modifier 59 is not used with E/M procedures.

What is the purpose of the E/M visit? If the E/M visit is related to the procedure and is within the global period, it would not be billable.

If it's not related to the procedure, Modifier 24 may be appropriate. Modifier 24 is "Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period."

 

[vvazquez8649]

Modifier 59 is not used with E/M procedures.

What is the purpose of the E/M visit? If the E/M visit is related to the procedure and is within the global period, it would not be billable.

If it's not related to the procedure, Modifier 24 may be appropriate. Modifier 24 is "Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period."

Therefore, it patient come back a week later after procedure(s) were done for a procedure follow up the consultation is being included in the global period and should not be billed. And if the patient come back a week later after procedure(s) were done for a pain follow up we can bill the consultation with modifier 24. Is that correct?

 

[csperoni]

Time to pull out the Medicare global surgery booklet reference (a personal fave ): https://www.cms.gov/files/document/mln907166-global-surgery-booklet.pdf
If the carrier follows Medicare's definition of global surgical package, a follow up for a complication that does not require a return to the operating room IS INCLUDED in the global surgical package. AMA's definition is a bit looser, and does permit billing E&Ms for complications.
"A pain follow up" sounds pretty likely like just routine postop care and if performed during the global period, that work was included in the value of the procedure.