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Modifier 59 attached to E/M?

  1. Question Modifier 59 attached to E/M?
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    I am confused. I thought only modifier 59 could be attached to the procedure not the E/M code. We have a code that is being bundled and the Aetna rep said to add the modifier to the procedure and send it back in as a corrected claim. Can the modifier be attached to the procedure?:

  2. #2
    Greeley, Colorado
    Do you have mod -25 on your E/M?
    Mod -59 is ONLY for procedures.
    Lisa Bledsoe, CPC, CPMA

  3. Default
    No, we did not attach the 25 modifier to the office visit.

  4. Default
    Love it when the payers become coders. Adding a -59 seems to be the universal answer. No wonder the use of -59 has become a red flag

    Anyway, any time your provider does an E&M service and a CPT service the same day, you will need to add mod -25 to your E&M code

    But, be sure the documentation for the E&M supports the use of mod -25. There are lots of guidelines that address the correct use for using mod -25. The E&M documentation must clearly support that a significant separate E&M service was performed in addition to the CPT service. So you should review each encounter to see if mod -25 applies

    If a kid falls and cuts his forehead open, comes in, and the physician looks and just closes with 3 stitches, an separate E&M is not supported

    If a kid falls and cuts his forehead open, but also complains of dizziness and a headache, physician evaluates these complaints and closes with 3 stitches, then a separate E&M and mod -25 would most likely be supported. He did a separate evaluation in addition to the stitch repair

  5. Default
    Thank you sbicknell, that is what I thought. Here is the issue we are having.

    A 6 month old child comes in for a well care visit, immunizations and mom is concerned about the childs vision so we perform a 95930 Visual Evoked Potential Screening on the baby and it was found to be abnormal so we referred the parent to an ophthalmologist. The original billing on this was 99391 DX V20.2, 379.99, 382.00, 95930 DX 379.99, A4556, A6411, A4558, 90648, 90723, 90669, 90465, 90466. The original claim did not include a modifier.

    Aetna bundled the 99391 and 95930 and the told us that it would be paid if the 59 modifier was added to 99391. I knew that was not correct so I corrected the claim to have the 59 modifier on the 95930 procedure and it stilled denied.

    I do have other claims that the 25 modifier was added to the 99391, but Aetna bundled that also. I do not understand they were reimbursing for both up until February of this year.

  6. Default
    Since this is something Aetna is doing, I would check with them. Wonder if they changed their payment policy on what they consider as a routine part of a WCC and not paid separately. Odd thou, cause you have a abnormal finding on this eye check.

    Unless someone else has more info, I would start with Aetna and see what their policy is on WCC encounters

    Also, just a note. If a separate problem was identified during a WCC that required significant separate work, you can code an additional E&M for that work. So if documentation supports, you code code the 99291 plus 9921x-25 linking the separate problem to the 9921x-25 code plus any CPT servies perfomed

  7. Default
    Thank you for your help.

  8. Default
    Aetna changed there policy for the VEP 95930. They now consider it experimental, there is only four instances that this would be considered medically necessary. We had to stop doing the VEPs for anyone with Aetna insurance. The policy is on their website.

    Denise Smith CPC, CEMC

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