Wiki Possible Use of Modifier 78?

[SJones52]

A patient visited our practice and had an endometrial sampling biopsy performed. She later visited another one of our locations (seeing a different provider than the earlier appointment) due to severe cramping and nausea and received an injection of promethazine.

Would this be one or two separate claims? Would the injection be an addition to the original procedure on one claim or would we add an additional office visit with modifier 78 and the injection?

Please help!

 

[martinni1974]

Good Afternoon,

First thing to remember is modifier 78 cannot be appended to an E&M code. That modifier is reserved for return to OR/procedure room and is appended to surgical codes. Also, an E&M would not likely be covered on the same date given the 000 global days designation to CPT 58558. Even though it is 000 days, there are still global rules and the injection was related to the primary proc for the date. Payer editing software will likely kick out an E&M on the same date as the biopsy than an injection with appropriate modifier on the same date as the primary procedure. Both scenarios would be understandable upon appeal but the key is to not have to do an appeal if you can help it and mainain compliance.

What you may be able to bill since there are 000 global days associated with the endometrial biopsy code (58558) is bill for the injection of Phenergan (promethazine) and the biopsy all together as follows:

58558
96372-59
J2550 (depending on quanitity/type)

You may still end up with this bundled into the primary procedure (58558) and initialy get denied however, upon appeal you may be able to get the denial overturned.

It doesn't matter how many claims are submitted, it's collectively based on all the services provided on a given date by the same provider/tax ID/specialty.

This is just an opinion. I am currently a coding/documentation auditor for a payer and worked on the physician side for 15 years. I am giving you a very rounded perspective.

Good Luck!