Wiki Billing modifier 59

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nancy.anselmo@ccrheart.com

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Scenerio: Pt comes to see the Dr for an office visit/EKG so I bill
99214-25
93000-59
Dr then decides to put a holter on the pt so on a seperate claim I bill
93224 all of this is for the same DOS.
Now the insurance denies the 93000 as incidential to the other procedure and I called the Provider rep for this ins and she says that w/59 modifier it will deny w/o clinical notes. Is this billed correctly or not? Thank You Nancy
 
well neither of those procedures have any global days listed. They are XXX so you shouldn't have needed a -25. As for the -59, the 93000 is a component of column one code 93224 but a modifier is allowed to differentiate so it looks like it should be paid
 
Hi,

You were right to put the 25 mod on the E/M charge. If not, it would have been denied since they were done on the same date of service. Did you apply the 59 modifier to the procedure that pays the least?? This may be your problem. The 59 mod should be on the procedure that pays the least no matter which came first. This always works for me. Hope this helps you.
 
tobieforte said:
Hi,

You were right to put the 25 mod on the E/M charge. If not, it would have been denied since they were done on the same date of service. Did you apply the 59 modifier to the procedure that pays the least?? This may be your problem. The 59 mod should be on the procedure that pays the least no matter which came first. This always works for me. Hope this helps you.
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the 59 does not necessarily go on the procedure that pays the least it goes on the column 2 procedure, not always is that the least paying.
 
But what is the reasoning behind adding a -59 modifier to the EKG? Just because it was peformed seperately from holter?
 
I run into this scenario a lot in my office. If the patient is scheduled in the office for an OV and an EKG is required, lets say for instance because the patient has CAD and the EKG is done and shows a new arrhythmia or the patient has a new complaint such as palpitations and the MD decides to put a holter on the patient, I would bill the following:

99214 Prim dx CAD
93224 Prim dx AFib
93000-59 Prim dx CAD

The trick is knowing why each was performed. You do not need to put a modifier on the visit. The biggest thing is billing the correct primary diagnosis for each procedure that was performed. As long as you had a reason to perform the initial EKG and something else occured after that led to the Holter being applied just bill the correct primary diagnosis for each and you should not have an issue getting paid. If there was not a seperate diagnosis for the EKG and Holter than I would bill them both just as I did above and then appeal the denial explaining why the patient had it done. The reason payors want you to not bill the EKG and Holter together is because the Holter is considered the "higher" service as it is a "continuous EKG" persay. That is why you have to put a modifier on the EKG if the situation warrants it. Hope this helps.
 
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