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Inpatient level 1

  1. Default Inpatient level 1
    Medical Coding Books
    If the documentation for initial hospital care level one (99221) isnt met, would you put a modifier 52 on it or change it to a subsequent level ov?

  2. Default
    I would down code it to a follow up day.

  3. #3
    Location
    Milwaukee WI
    Posts
    4,466
    Default 99499
    Check with the carrier - some prefer that you use 99499 Unlisted E/M service.

    F Tessa Bartels, CPC, CEMC

  4. #4
    Location
    Columbia, MO
    Posts
    12,867
    Default
    You are not allowed to use the 52 modifier with an E&M code, I am not certain how you would code it if it does not meet at least a level one, not with an OV code, I would probably go with the unlisted.

  5. #5
    Location
    Duluth, Minnesota
    Posts
    1,133
    Default
    *i* wouldn't down code anything! (ever)
    and yes, you can use the .52 modifier on an E/M (it isn't very common but may be appropriate, depending on the circumstances of the encounter

    HOWEVER - I think Tessa says it best - check with the carrier...
    Donna, CPC, CPC-H

  6. #6
    Location
    Columbia, MO
    Posts
    12,867
    Default
    CR1776 states a 52 modifier is never to be used with E&M codes. Do you have access to something that states something different? I have always been told never use a 52 with an E&M as is it is not an E&M modifier. I know you say it may be appropriate yet I cannot think of any scenario. Thanks!

  7. #7
    Location
    Duluth, Minnesota
    Posts
    1,133
    Default
    well, one area in which modifier .52 is used quite often is in the event of a "sports physical". Since this physical typically doesn't require the work of a "full preventive physical",... age appropriate E/M preventive code is used along with the modifier .52 to signify the fact that this was NOT a regular physical and as such is being billed/coded as a reduced service.
    (that's just one example)
    it's important to note that: the use of this modifier isn't always accepted by certain carriers. (hence, "the check with carrier" statement). and again, isn't very common but may be appropriate, depending on the circumstances of the encounter.
    Donna, CPC, CPC-H

  8. #8
    Location
    North Carolina
    Posts
    3,126
    Default
    I'm inclined to agree with 99499...However, not all carriers follow Medicare guidelines.

    In the rare circumstance when a physician (or NPP) provides a service that does not reflect a CPT code description, the service must be reported as an unlisted service with CPT code 99499. A description of the service provided must accompany the claim. The carrier has the discretion to value the service when the service does not meet the full terms of a CPT code description (e.g., only a history is performed). The carrier also determines the payment based on the applicable percentage of the physician fee schedule depending on whether the claim is paid at the physician rate or the non-physician practitioner rate. CPT modifier -52 (reduced services) must not be used with an evaluation and management service. Medicare does not recognize modifier -52 for this purpose.

    http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf

  9. Default thank, I think!
    All this discussion about M-52 is an example of why "coding" is so difficult ...so many interpretations of the same codes and/or modifiers. Why can't there be one place to go to for answers to coding questions so you can feel confident in the decisions of which codes/modifiers you choose?!!
    signed,
    a confused "coder"

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