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Modifier 25 or 59

  1. #1
    Default Modifier 25 or 59
    Medical Coding Books
    When billing an office visit (99213) along with a B12 injection (96372 & J3420) which modifier would you use and where? I say -25 to the OV, Blue Shield McKesson claims edits say attach modifier 59 to the 96372. Thanks

  2. Default
    wow I agree with you. The mod 25 should be used on the ov because an injection is a procedure. I am, of course, assuming that the ov is separately identifiable from the procedure. I, personally, think the 59 on the ONLY procedure is insane. Just my thoughts

  3. #3
    Default Modifier 25-59
    I agree also. Modifier 25 is the correct modifier on the office visit. You don't need the 59.:d

  4. Default

    Here no need to give 25 modifier to E/M as global concept dose not apply can check in NCCI edits for this information.

  5. #5
    Sumter, SC
    Here in SC, we don't apply the 25 Modifier to the E&M code if the nurse gives the injection. Of course if the provider is giving the injection, then the 25 modifier would apply.

  6. #6
    Columbia, MO
    CMS stated in July of 06 that in office injections should be billed with a 25 on the ov even if administered by the nurse. you may not charge a 99211 to give the injection. this is only if you have a physician encounter with an injection.

    Debra A. Mitchell, MSPH, CPC-H

  7. Angry
    Is anyone still running in to this and how are you getting paid by Blue Shield? I spent many emails back and forth in debate with Blue Shield rep. They will not state I "should bill with mod 59 on 96372" but pretty much suggested that was how I'd get paid. This completely goes against ALL coding guidelines and does not even make sense. We are Urgent Care and our E/M's are seperately identifiable and we bill 99213-25 and 96372 with drug. That to me is the CORRECT coding. Not 99213 and 96372-59. They would not budge and I'm leary of coding the wrong way just to get paid. We are having the same issue with strapping codes such as 29530 and 29540 (which CPT states should be billed with a seperate E/M when appropriate). They will not pay stating it is included in the E/M. Any info on this from anyone dealing with Blue Shield is appreciated.

  8. #8
    Hi Jenny, I would definitely be leary of the -59. We are currently having that same debate in our office right now and the billing department wants us to just slap the -59 on the injection codes so they can bypass the edits and we (the coders) are refusing to do it. It is fraud to code to get paid, so I'm sure your supervisors will understand if you are not comfortable doing that, and if they don't, explain it to them. As far as Blue Shield, I'm not sure what to say other than keep trying. RAC is all over the -59 modifier abuse problem right now and you would have to be crazy to send up a red flag.

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