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Opinions Please - We have a scenario in which we saw

  1. #1
    Location
    Kansas City, MO
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    Unhappy Opinions Please - We have a scenario in which we saw
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    We have a scenario in which we saw a patient in the office for follow up on L knee pain. At the visit the decision was made to proceed with a scope of the left knee which was scheduled for the following day.

    Then the patient also complained of right knee pain for which she received a steroid inj that same day. W

    We billed the E&M w/25 mod and 20610 on the first day and the scope on the day after. The insurance carrier (Aetna) is denying the E&M as global.

    Do you think we should bill the E&M visit with a diff mod? I am not certain whether the 24 would be more appropriate, or maybe even the 57 since a decision was made that day to do the surgery; maybe a combination of two of these?

  2. #2
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    Long Island/New York
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    Quote Originally Posted by debwoods65 View Post
    We have a scenario in which we saw a patient in the office for follow up on L knee pain. At the visit the decision was made to proceed with a scope of the left knee which was scheduled for the following day.

    Then the patient also complained of right knee pain for which she received a steroid inj that same day. W

    We billed the E&M w/25 mod and 20610 on the first day and the scope on the day after. The insurance carrier (Aetna) is denying the E&M as global.

    Do you think we should bill the E&M visit with a diff mod? I am not certain whether the 24 would be more appropriate, or maybe even the 57 since a decision was made that day to do the surgery; maybe a combination of two of these?
    sounds like E/M w/57 modifier. Did they pay on 20610?

  3. #3
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    Kansas City, MO
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    Thanks, they did pay for 20610.

  4. #4
    Location
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    Quote Originally Posted by debwoods65 View Post
    Thanks, they did pay for 20610.
    Global period of 90 days is really 92. That includes day-of and day-before as they feel docs go over a pre-op (questions, pre-op CBC, etc.) and not a usual E/M before a major procedure.

    So if your doc did an E/M wheras in this session decided to do the surgery the following day then you would need the 57 mod (decision for surgery) to release the E/M payment. Good luck!
    Keith

  5. #5
    Location
    Greeley, Colorado
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    You will probably need mod -25 also because of the injection on the same day. 992XX -57 -25
    Lisa Bledsoe, CPC, CPMA

  6. #6
    Default opinions
    You will need to use modifiers 57,25 on the EM, since the surgery is the next day and a 25 since an injection was performed at the same time. This will protect your EM and get it paid.
    Good luck,
    Lynn

  7. Default
    I agree with Lynn...that is exactly how you need to bill the E&M 57,25.

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