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Thread: Need help with an easy question

  1. #1

    Unhappy Need help with an easy question

    AAPC: Back to School
    Hi I have been coding for my husbands part time office for years. I am an RN and decided to take the certified coding class and become certified. Reason: I've done OK but I'm sure I can do better with your expertise until I become certified.
    Lame question: Please forgive me.
    When I charge for an office call 99213 with appropriate diagnosis yadayada and give an injection with modifier 59 they only pay for the injection and not the office call. However if he has a separately identifiable problem and I use modifier 25 then use the CPT code then use 59 for the injection code and use the J code or medication code they pay for the whole ball of wax. I don't get it. How do you get paid for an office call say for abscess of the nose and charge for the office call and get paid for more than the IM Rocephin we charged for using modifier 59? Do I use a different modifier in these cases when he doesn't use mod 25 with another procedure?
    Thank you

  2. #2


    I need to clarify something before I can answer. Are you saying that you are seeing a patient (99213)for one problem (or diagnosis) and then doing a procedure for another problem (or diagnosis)? Or are you saying the E&M was done, the decision made to do something and that something (a procedure) was then done, all on the same day?

    Next I need to know if the outcome of your billing situations are variable based on insurance type:

    Modifier 25 is for a "separately identified service" and is appended to the 99213 when the documentation warrants its use. Not all carriers will recognize this modifier.
    Modifier 59 is a modifier of last resort and other modifiers (such as 25) should be used as applicable first. Not all carriers follow the same CCI edit list so one insurance could pay a combination and another not even with the exact same CPT and ICD9 combinations.

    Could I get more info?

    Jill M. Young, CPC, CEDC, CIMC
    Past Member AAPCCA BOD 2007-2011
    Young Medical Consulting, LLC
    East Lansing, Michigan

  3. #3
    Join Date
    Apr 2007
    Duluth, Minnesota


    I'm not following the question... what code "exactly" are you putting a .59 modifier on, and "why"?
    Donna, CPC, CPC-H

  4. #4
    Join Date
    Apr 2007
    Columbia, MO


    I am with Donna on this, a little confused. First of all you do NOT need two separate dx to use a 25 modifier for the E&M. A 25 modifier is used on the E&M to state the E&M and procedure are significant and separately identifiable. I explain it this way to my students:
    Every procedure has as a natural and inherent component the assessment of the patient necessary to perform the procedure. If the assessment/exam of the patient goes beyond that then your E&M is significant and you must have a separately identifiable procedure note, have a separate paragraph where the physician tells what was done. example, the physician must examine a lesion and describe it in order to excise it, therefore no E&M with the excision, however if he also documents a complete body survey to see if other suspicious areas exisit then the criteria for the 25 has been met and you have only the one dx once the pathology is back. I am not seeing why you are using the 59 modifier if only one procedure is performed.
    As far as some carrier not recognizing the 25, this is not true. All carriers recognize this modifier, some may not have it in their electronic edits, although in this day I cannot see that being the case. However on post audit many found that the documentation did not support the usage iof the 25 so they routinely pay one or the other the E&M or the procedure (generally the one that pays the least), they frankly ae waiting for you to appeal with documentation to support the usage, when you do not then you simple uphold their notion that your docuemntation did not support the modifer.
    I hope this is useful.

    Debra A. Mitchell, MSPH, CPC-H

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