Wiki Victoria Holmes, CPC

[victoriaholmes]

Our office is instructing us to bill an office visit and a joint injection with a modifier 57. The coders are aware that this is fraudulent. We should be billing with a modifier 25, since there is no decision for a major surgery occuring.

How can I get my supervisor to agree? I refuse to bill out these services with the invalid modifier.

Any help would be greatly appreciated.

Sincerely, Vicky Holmes, CPC

 

[mitchellde]

I would not say this is fraud so much as it is non compliant and incorrect given the definition of the modifiers. You may need to obtain a copy of the CMS transmittal on the 57 vs 25 modifier where they identify the definition of a major vs a minor procedure. Sorry I do not remember which transmittal as there are actually several along thisline. Just do a search for 25 vs 57 and you should find more than enough.

 

[mdoyle53]

The issue you should bring up to the MD's is audit. At the point of an audit, the insurance carrier could take the money back and hence the claim could be OTL and therefore lost revenue.

Is the injection based on a first E/M visit or is it subsequent visit and injection. For subsequent injections, be careful as many times the short E/M is included and cannot be billed. So again, you have the possibility of having to return money in the future once there are some chart audits.