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Modifier question 25, 59, 51

  1. #1
    Default Modifier question 25, 59, 51
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    I have the proper documentation for these services but I'm at a loss for the use of the modifiers; 99215-25 (level V E/M), 85025 (complete CBC) , 36416 (capillary blood collection), 96450-59 (chemo admin-intrathecal), 62270-51 (spinal puncture lumbar). Are the 59 and 51 modifiers required for these services billed on the same day and same encounter?

  2. #2
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    According to CCI edits the 25 on the visit and the 59 on the lumbar puncture are needed but the 51 was not needed. Also make sure your diagnosis are different on the E&M than on the procedures.

  3. #3
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    Could you elaborate in alittle more detail? Why the 51 not needed and why would I need a different dx on the EM?

    thxs

  4. #4
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    “Modifier 25 is a Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service.” It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the E/M service to be reported. The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. Consider the use of modifier 57. For significant, separately identifiable non-E/M services, consider the use of modifier 59.

  5. #5
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    Quote Originally Posted by Tonyj View Post
    I have the proper documentation for these services but I'm at a loss for the use of the modifiers; 99215-25 (level V E/M), 85025 (complete CBC) , 36416 (capillary blood collection), 96450-59 (chemo admin-intrathecal), 62270-51 (spinal puncture lumbar). Are the 59 and 51 modifiers required for these services billed on the same day and same encounter?
    I see you have 96450 and 62270 both coded. Unless the lumbar puncture was separate from (and for another reason) the chemo admin, you can't code 62270. 96450 includes the lumbar puncture.

  6. #6
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    Thanks for the clarifications.

  7. #7
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    Quote Originally Posted by Tonyj View Post
    Could you elaborate in alittle more detail? Why the 51 not needed and why would I need a different dx on the EM?

    thxs
    You would not need to use a different dx code for the E/M and additional procedure because the modifier 25 allows the s/s of the CC may be related to the procedure. Remember, you must meet all medically necessary criteria for the history, exam and MDM of the E/M code to validate both the E/M and the procedure the same day if the dx is related.

  8. #8
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    Thanks Terribrown

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