Nextgen has added an edit (ILE ID 1) asking us to append a 59 modifier onto a 92228 billed w/ E&M. We do not feel that this is correct, and that a 25 modifier should be used on the E/M. I cannot find any guidance from CMS, only recommendation to add 59 modifier to 92228 to unbundle from another procedure. Can anyone recommend a credible source we can use to argue this point with Nextgen?
The edit is being described as telling them to add a 59 to 92228, not a 25. 92228 is not an E&M, it's in the medicine section. If you run it through another edit checker such as Optum, etc. it suggests the same thing, to append a 59 to the 92228 (provided documentation supports).Modifier 25 is only used on E/M procedures. It's the literal definition of the modifier - if they can't understand that, then I wouldn't trust anything they had to say about coding or modifiers!
I guess if you want to refer them to the NCCI Manual they can read the definition for themselves. Here's the link: https://www.cms.gov/files/document/chapter1generalcorrectcodingpoliciesfinal11.pdf
The portion below is pasted from page 17, which is part of Section E - Modifiers and Modifier Indicators
b) Modifier 25: The “CPT Manual” defines modifier 25 as a “Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service.” Modifier 25 may be appended to an evaluation and management (E&M) CPT code to indicate that the E&M service is significant and separately identifiable from other services reported on the same date of service. The E&M service may be related to the same or different diagnosis as the other procedure(s).
The edit is being described as telling them to add a 59 to 92228, not a 25. 92228 is not an E&M, it's in the medicine section. If you run it through another edit checker such as Optum, etc. it suggests the same thing, to append a 59 to the 92228 (provided documentation supports).
I agree with the OP, it doesn't make sense to append a 59 to 92228 in this scenario, it would seem modifier 25 should be appended to the E&M like you state. If you read the definition of modifier 59 it specifically states, "To report a separate and distinct E/M service with a non E/M service performed on the same date, see modifier 25." This should be all you need to explain to NG.
The only thing is, there were no other procedures being reported on the same date for this particular edit you see, correct? The 92228 wasn't bumping up against something else when you ran the edits?
If it's a new update they just did, you may want to check with the NG team. Also, did you make sure they are NG edits and not custom practice ones?
Unless there is some specific guidance from the payer or it's only firing for a certain payer, it doesn't seem correct. It seems odd to me that Optum and other edit checkers say to do this too though.