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Thread: -59 Modifier/-25 Modifier/ Edit Help

  1. #1

    Default -59 Modifier/-25 Modifier/ Edit Help

    AAPC: Back to School
    Please help if you can, we are a cardiology group so we often have office visits and diagnostic testing in our office billed on the same day. Since CMS edits have gotten stronger we are finding that when we bill a stress test or echo in office, or doctor reads stress portion of nuclear test in the hospital Medicare is coming back saying the tests are bundled from my visits. I have some people in my billiing dept. that have never taken a coding class and just do not know the clinical side of charges. They only see what is denied and what we can do to get paid. Unfortunately I feel I am battling with them because they want to slap -59 on procedures or tests, or -25 on office or hospital visit because once we do that it goes through Navicure edits. I feel it is unfortunate that we cannot be paid but I am afraid I am processing incorrectly if I am adding these modifiers without just cause. I am a CPC coder with several years of experience and am very confused as to what is acceptable and what is not. When you call Medicare they will say in a situation of bundling: modifier is acceptable for this procedure, so I think to myself are they saying add the modifier? If anyone has information or an opinion, please help! I just feel awful arguing my case daily and would like more information to present to my coworkers. Thank you!! Gail

  2. #2
    Join Date
    Apr 2007

    Default documentation

    Generally, what does the documentation support? If there is inadequate documentation, use of modifiers certainly becomes very difficult. If there is good documentation, then the documentation should direct you to the correct modifier? Even if a code editor indicates that use of a modifier will result in reimbursement, paperwork still has to demonstrate that use of the modifier is appropriate.

    I know this doesn't provide a clear answer. But it seems that many coding issues start with the quality of the documentation.

    What about coding policies? Do you have any policies regarding consistent and accurate coding practices? If coding policies are developed and put in place, they would be a resource to rely on without having to "arguing your case" on a daily basis.

    Just some thoughts

  3. #3
    Join Date
    Apr 2007
    Bay City Michigan

    Default Modifiers 25 and 59

    I am also from a Cardiology Group in Michigan. Recently we have been getting denials stating echos read in the hospital are included in the subsequent day charge. We are told it is a McKesson edit and is correct - Medicare, Blue Cross, etc. We are required to add the 25 modifier or 59 modifier on one of them. The problem is we usually bill our echos with 26 modifier before we bill our subsequent days (as we wait for notes to bill). Blue Cross does not like the 25 on the E & M and denies the subsequent day, if the echo was already billed and paid. I was always under the understanding a diagnostic test such as an echo was not included with an E & M, as doctor is seeing the patient face to face and managing other problems also. What changed and caused this edit? I can not find any new information from Medicare on this. This obviously is a new edit and is causing lots of problems with us. Anyone also having this problem?

  4. #4


    This is exactly what is happening to us. We are billing the hospital visit and echo lets say, then insurance pays the echo and I am struggling to make sure we have notes to show seperate E&M visit to allow us to add the -25. Our office has begun scheduling office visits and testing on seperate days to avoid the denials.

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