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Medicare modifiers

  1. #1
    Default Medicare modifiers
    Medical Coding Books
    We have an issue that keeps coming up where I work and I was wondering if anyone can give me any information or point me to something (from CMS) in writing for this concern: (keeping in mind that we are a rural CAH and we code for both pro and facility in the ER)

    We have a patient that comes into the ER, s/he is seen in one of the clinics on the same day. For medicare, the accounts have to be combined, correct?, which means that both E&M are now on the same account?

    If that is the case, how can you bill for both E&M's for that day, or can you? Do you have to take one of the E&M levels off of the account?

    I realize that there can be many different scenerio's so would the outcome different if the patient was seen for different reasons (different diagnosies)? What if it's the same dx?

    What if the patient was sent from the ER directly from the office and the patient sees whoever is on-call at the hospital (never the clinic physician)? In our system here, the patient would never be seen by the same provider if they had an ER and an office visit the same day.

  2. #2
    Columbia, MO
    Your revenue codes will be different and you will use the 27 modifier for the second and subsequent facility fee. If you are putting your pro fees on the UB then you will use the physician rev code (I can never remember that one something like 981) and I think you just put both physician levels. I have done this before with no problem but it was a while back and I cannot remember if we put any kind of identifier on the UB for the different physician. If you are billing the pro fee on a 1500 then you just put the different POS for each line item and the different rendering NPI.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Hi Deb, and thanks for your quick response. I was hoping you would be out there today! I felt kind of like a tool having to ask that question but I just couldn't seem to find a difinitive answer for that exact scenario anywhere else, and as you know, I very much value your knowledge and input. Unfortunately, I do not do the billing part of it but it is the billing department that is sending me requests for modifiers so I just wanted to make sure I was telling them the right thing. It requires me to have access to the er and the ov encounter and I do not always have the clinic end of it so I have to rely on the er dication summary and t-sheet to see if the visits are related. If they are not, can I still use the -27? I can only do that when the visits are related, right? If I can't use the -27, do I then use the -25?

  4. #4
    Columbia, MO
    the 27 has no relationship to the nature of the visit it just indicates 2nd visit on the same day regardless of revenue center. The 25 is used the same way as for the physician so if there is a procedure in one visit then all E&Ms for the facility must have a 25 attached as well so there may be instances where you need both the 25 and the 27, the 25 goes first.

    Debra A. Mitchell, MSPH, CPC-H

  5. #5
    Oh, ok. I completely unerstand now. Thanks so much!!

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