Results 1 to 7 of 7

Coding 25 and 57 modifiers question

  1. #1
    Default Coding 25 and 57 modifiers question
    Medical Coding Books
    Question regarding how to code 25 and 57 modifiers

    I admitted a medicare patient (day 1) with rectal prolapse. scheduled for flexible sigmoidoscopy.

    Day 2 patient undergoes flex sig and I decide to repair the rectal prolapse on day 3.

    Which days get the 25 and 57 modifiers?

    I think day 1 gets billed as admission only.

    day 2 gets billed as E & M with 25 modifier for the flex sig.

    If I make the decision for surgery on day 2 do I bill both the 25 and 57 modifiers then?

    If I don't add the 57 on day 2 does that E & M get denied?

    Thanks

  2. #2
    Default
    Quote Originally Posted by colorectal surgeon View Post
    Question regarding how to code 25 and 57 modifiers

    I admitted a medicare patient (day 1) with rectal prolapse. scheduled for flexible sigmoidoscopy.

    Day 2 patient undergoes flex sig and I decide to repair the rectal prolapse on day 3.

    Which days get the 25 and 57 modifiers?

    I think day 1 gets billed as admission only.

    day 2 gets billed as E & M with 25 modifier for the flex sig.

    If I make the decision for surgery on day 2 do I bill both the 25 and 57 modifiers then?

    If I don't add the 57 on day 2 does that E & M get denied?

    Thanks
    You would need both modifiers on the E/M - you also want to make sure your primary Dx is rectal prolapse, since that's the condition that prompted the service. Your E/M will probably deny without both modifiers. (To be clear: you can only get reimbursed for the E/M if it's unrelated to the procedure you're performing that day. If it had just been a pre-op clearance, you couldn't have reported it. It's only billable because you evaluated a new/distinct problem.) You may also consider adding a 58 modifier to your procedures, since they are related to one another. Hope that helps!

  3. #3
    Default
    Actually I was thinking about coding the flex sig as v72.83 other specified preoperative exam?

    So even though I admitted this patient for the prolapse, I can't get paid for the E & M unless it's unrelated to the sigmoidoscopy?

    I thought CMS had said you didn't need two different icd 9 codes when a 25 modifier is used? I do try and use two different codes when possible as it seems to make for a cleaner claim?

  4. #4
    Default
    Quote Originally Posted by colorectal surgeon View Post
    Actually I was thinking about coding the flex sig as v72.83 other specified preoperative exam?

    So even though I admitted this patient for the prolapse, I can't get paid for the E & M unless it's unrelated to the sigmoidoscopy?

    I thought CMS had said you didn't need two different icd 9 codes when a 25 modifier is used? I do try and use two different codes when possible as it seems to make for a cleaner claim?
    You don't have to have a different diagnosis, but you do have a to have a significant, separately identifiable E/M, and it can't be part of the global surgical package (which a pre-op clearance is) Taking a look at what you did:

    I admitted a medicare patient (day 1) with rectal prolapse. scheduled for flexible sigmoidoscopy. This is you decision for surgery for the flex sig.

    Day 2 patient undergoes flex sig and I decide to repair the rectal prolapse on day 3. Here, you made a decision to repair the rectal prolapse, so any E/M that you did that day would have to be related to that decison for surgery, otherwise, it's not significant/separately identifiable from the flex sig pre-op and post-op services.

    The only way you can have a separate E/M that's for the same condition as a surgery on the same day as the surgery, is if the condition whcih prompted the surgery has a sudden, acute exacerbation - the patient's overall condition has to change (and require re-evaluation). Does that make a little more sense?

  5. #5
    Default
    Thanks. That does make a little more sense. What confused me is that the flex sig (45330) has a global of 0 days so I didn't think to put the 25 modifier on the initial visit where the decision for 45330 was made.

  6. #6
    Default
    Quote Originally Posted by colorectal surgeon View Post
    Thanks. That does make a little more sense. What confused me is that the flex sig (45330) has a global of 0 days so I didn't think to put the 25 modifier on the initial visit where the decision for 45330 was made.
    According to CPT guidelines, the surgical package includes "Subsequent to the decision for surgery, one related E/M encounter the on the date immediately prior to or on the date of the procedure." That applies to everything in the surgery section of the CPT codes, whether there's a post-op global period or not. In order to distinguish between the E/M that's included with the flex sig, and a distinct E/M relating to the second procedure, you have to have the 25 modifier on the E/M.

  7. #7

Similar Threads

  1. Question about Modifiers 54 and 55
    By Swardjohnson in forum Modifiers
    Replies: 0
    Last Post: 06-20-2012, 12:58 PM
  2. Question about Modifiers.
    By spharrel in forum E/M
    Replies: 3
    Last Post: 10-26-2011, 09:34 AM
  3. Modifiers Question
    By spharrel in forum Medical Coding General Discussion
    Replies: 3
    Last Post: 10-25-2011, 05:09 PM
  4. modifiers question
    By boozaarn in forum Medical Coding General Discussion
    Replies: 1
    Last Post: 02-14-2011, 07:52 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?

Login

Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.