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Medicaid & modifiers

  1. #1
    Default Medicaid & modifiers
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    We have a situation in an ER setting where a patient was seen in December for a laceration repair, and then was injured again in January in a different body location that had nothing to do with the first injury. They were seen by a different physician. We billed the claim as usual with a modifier 25 on the E/M level and the repair code.

    A division of Medicaid is denying this as we did not "bill the subsequent surgery with the appropriate modifier to indicate that the service was seperate but preformed in the postoperative period of another procedure." We cannot use 79 as it was a different physician. We have sent the records for both visits.

    We are at a loss as to what modifier they want. Anybody out there have an idea?

    Also, what modifier do you use for Medicaid when a patient is seen multiple times in the ER in one day?

    All input is appreciated!

  2. #2
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    Quote Originally Posted by pherald View Post
    We have a situation in an ER setting where a patient was seen in December for a laceration repair, and then was injured again in January in a different body location that had nothing to do with the first injury. They were seen by a different physician. We billed the claim as usual with a modifier 25 on the E/M level and the repair code.

    A division of Medicaid is denying this as we did not "bill the subsequent surgery with the appropriate modifier to indicate that the service was seperate but preformed in the postoperative period of another procedure." We cannot use 79 as it was a different physician. We have sent the records for both visits.

    We are at a loss as to what modifier they want. Anybody out there have an idea?

    Also, what modifier do you use for Medicaid when a patient is seen multiple times in the ER in one day?

    All input is appreciated!
    I have a stupid question...
    You only put the 25 on the E/M, right?
    If so, your appeal should be approved, since it wasn't the same doctor. I'd fight that one. The denial is describing the 79 modifier, for sure.

    And as for your second question, see modifier 27, if you're billing as the facility, and 25 if you're billing as the physician, as long as they were seen by the same provider.

  3. #3
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    Yes, the 25 is only on the E/M level.
    Thanks for your input, we figured we were right, but they still deny, deny, deny!!!

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