Wiki Modifier help

[Desirae1]

I have a billing question I need help with please. I have a patient who was seen in the office for a procedure but was then later admitted to the hospital by a different doctor on the same day. My procedure claim is getting denied stating a modifier is needed since the patient was considered inpatient that day. I can't use 25 since my procedure wasn't an E&M and can't use 59 since the doctor who admitted billed an E&M. What modifier would be appropriate in this situation please?

 

[CBLENNIE]

Who is the payer for this patient, is it Medicare or commercial insurance? If it is Medicare here is what I found regarding how you could bill this service to bypass the edit.

Is the other provider who admitted the patient to the hospital after your provider performed the service in the same provider group and has the same specialty as your provider? If so, you should be able to use modifier XP according to Noridian, WPS and Palmetto GBA. If your provider isn't of the same specialty and in the same provider group according to Noridian, WPS and Palmetto GBA you cannot use XP in this case.

However, it appears your Part B MAC is Novitas based on your location being Texas. Per the following guidelines from Novitas Modifiers 59 and X(EPSU) they do not specify that the providers have to be of the same specialty and in the same provider group, so if your provider is not of the same specialty and in the same provider group as the admitting physician you may be able to use XP.

Per the linked Novitas article it defines XP as follows:

If the the payer is a commercial insurance company you need to check to see what their requirements are for using the XP modifier since they don't necessarily follow Medicare guidelines.