E/M Modifiers


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I recently returned to coding and billing. I have been out of the loop since 2005 but am currently in ISP and on my way to certification, hopefully before the end of this year. I am a little rusty but trying to jump back in. I have been hired part time/temp to help a local Internist clean up some problems with his medicare billing. I have found several technical problems but have fixed those. I am now reviewing actual claims and am finding coding errors.

Here is my question: How do I explain to the permanent biller/coder that a claim that was paid should not have been. I see several claims coded the same way that were denied and a hand full of claims that were actually paid (99214-25,99354-59).

Please help me come up with a diplomatic way to let Dr and biller know those few should not have been paid and why they were.

mkimbrell :eek:
San Diego, CA
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I've read many articles and billing guides that state that overuse of the (-25) and (-59) modifiers leads to scrutiny on claims submitted by a provider (audit). In many cases, it is completely valid and appropriate to append an "unbundling" modifier, however, why do so when billing protoccol doesn't even require it? My experience has been that a modifier (-59) is usually only utilized in order to bill for components of services that are typically considered bundled and therefore not billable and/or payable without it (CCI Edits). There are no restrictions on billing an E/M and a prolonged services code together. In fact, the prolonged services code is an add-on code to the E/M.

I would make broach the subject to your co-worker with this concise, "matter of fact" point...perhaps even as a question? Something like..."If CCI Edits doesn't require the use of a (-59) modifier on a 99354 with a 99214, why do we append it?" Sometimes it's all in the approach....the initial way in which you speak to someone usually sets the tone for the rest of the conversation, you know? If you come at her, her first reaction will be to get defensive, shut down, and not listen. If you genuinely show interest as to what her understanding of this coding scenario is, then I think you'll get further with her.

Good Luck!