What modifier to use between E/M code & 96101/96102?

Jpad

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Another coder and I are debating on what modifier to use in order to bypass the NCCI edit between 96101/96102 and an E/M code (e.g. 99202-99205, 99212-99215). I am pushing for modifier -59 based on the fact that the 96101 is considered to be a different encounter and since it was done by someone other than the physician (though it was still under the same physician's supervision).

My coworker argues that -25 should be used because it is an E/M paired with a non-E/M code. Any input?
 

jsalzer50

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modifier 25

My understanding of modifier 25 is it's added to an E/M service that is significantly separate from the procedure performed on the same day. My thought process is: the patient comes in for a procedure, then an E/M service that is separate/not related to the procedure gets a modifier -25.

"Note: Modifier 59 should not be appended to an E/M service. To report separate and distinct E/M service when a non-E/M service performed on the same date, see modifier 25." (Appendix A, CPT 2016)

My understanding of modifier 59 is: we use it to distinguish between 2 procedures: 1 being a procedure, and the other being non-E/M related. i.e. "...a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances.." (Appendix A, CPT 2016)

I have also read about using modifiers XE (Separate encounter), XP (Separate practitioner), XS (Separate structure), and XU (Unusual non-overlapping service) in lieu of -59. "*HCPCS modifiers for selective identification of subsets of Distinct Procedural Services [-59 modifier]" (page. 714, CPT 2016) i.e. if one of those fits the bill, they are more specific than -59.

In sum: I'd go with modifier 25 on the E/M code.

Sincerely, Jacob
 
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CodingKing

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I go with modifier 25 on the E&M as well.

The E&M codes are column 2 codes to 96101/96102.
Mod 59 goes on Column 2 codes However, E&M are not eligible for a -59
In addition mod 59 is a modifier of last report and Mod 25 better describes the situation

As a side note, you probably already know but per NCCI guidelines, the Physician must at least admin 1 of the face to face tests in order to bill 96101. If they are all done by the Tech its the 96102
 

Jpad

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Thanks for responding, guys!

Would it be safe to say that using the modifier -59 would be useful when the insurance companies still refuse to pay for both treatments despite the utilization of -25?
 

jsalzer50

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Modifier 59

If we have an E/M service, my understanding is we don't use -59. If you use -59 on a procedure to distinguish itself from an E/M service, I'm pretty sure insurance is going to deny it. Essentially, this modifier is used for 2 separate non-EM procedures/surgeries.

Under the description of -59, it even says: "However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used." (CPT 2016, Appendix A)

With that in mind, I can't remember if it was an AAPC article or an AHIMA article, but I read there is a prediction that modifier 59 is actually going to go away eventually because the XE, XP, XS, and XU modifiers are more specific.

Here is a more basic example where modifier 59 would work:

Patient had a 1.0cm excision of a benign lesion on her arm, and a 2.0 cm excision of a benign lesion on her foot. Code selection is: 11422, 11401-59.

But....in this case, 11422, 11401-XS seems to be even more accurate, XS being Separate structure: A service that is distinct because it was performed on a separate organ/structure.

Hope this helps!
 
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