Wiki Correct usage of modifier 25

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tng141@aol.com

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Hello Everyone! My coworkers and I are trying to figure out the correct usage of modifier 25.

We recently had a patient come to the hospital with periumbilical pain for an umbilical hernia that they have had for several years. Our doctor did a consult with a review of systems and physical exam. On that same day our doctor did an umbilical hernia repair (CPT code 49592). Our coder billed CPT code 99222 with a 25 modifier and CPT code 49592. This was all done on the same day. We were paid by Anthem for the surgery but not for the consult. One of my billers is saying that we can not bill for the consult on the same day of the surgery even with a 25 modifier. Others are saying that we can because the doctor did a full consult with review of systems, physical exam , and decision for surgery was made on the same day as the procedure.

Are we able to bill a consul/H&P on the same day as an umbilical hernia repair with a 25 modifier?

Thank You all in advance for you answers.
 
I believe the correct modifier that should have been used was 57, since the visit resulted in a decision to do the surgery on the same day of the visit. However, that modifier is usually used with an E/M code, not a consult code.
 
Modifier -57 is used for decision for surgery when the surgery has a 90 day global. The newer hernia repair codes (like 49592 in this example) have 0 day global. For procedures with 0 or 10 day global, -25 would be the appropriate code to unbundle when supported. -57 and -25 are not interchangeable. A visit could easily meet the requirements for -57 but not meet the requirements for -25. All procedures with a 0 or 10 day global have some amount of E&M built into the value. For -25 to be appropriate, the visit must include work that is above and beyond the typical pre/postoperative work. Don't forget that some payors may have policies regarding -25 and even if appropriate from a coding perspective, it may not be reimbursed.
 
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