Wiki HELP!!!! Session Billing

[TMB1965]

When a retinal provider is wanting to bill the same procedure code again that has a description "1 or more sessions" within the global period on the same eye, because they are seperate holes or tears can any modifier be used?

Sometimes she does the same procedures on the same eye twice in the same day at the same encounter also, once for a hole in an area of the eye, and also for a horseshoe tear which is unrelated. I really need help with these 1 or more sessions codes, because I have been told to use modifier 59 & 79,76, 78 & 58.

Example: my provider had a patient who had 3 holes/tears in the right eye so she lasered (67145) 2 of them first on 9/18/14 , then on 10/9/14 she had the patient come back and lasered (67145) the other one, but it was a different location in the same eye, and a different day/session, so my provider thinks I can use modifiers 79 & 59 for the 2nd procedure.

I heard modifier 59 sends up a red flag with medicare, so I want to make sure this patient's circumstances supports the use of modifer 59. I am so totally confused , so any modifer usage resources anyone can give me would be greatly appreciated! I tried going to medicares website, but its not very user friendly and can't seem to find the answers i need!:

 

[mzkandyd]

First, are you looking at this from a coding stand point or billing stand point? We don't always see eye to eye . I personally sit on both sides of the fence so I know where you are coming from.

As a coder, we aren't worried about "red flags" too much, if CPT or payor guidelines guide you, follow them.

As for your question, it depends on if the return for the additional holes was planned or not. Look at 78, 79. Remember, eyes are different anatomical sites. Does the procedure require a 2 part surgery? If so, its bundled.

Please email me off line if you need more help: mzkandyd@gmail.com