Use modifiers 59 & 25 carefully

I billed a re-examination (99213-25) and an adjustment (98940) on the same visit. The insurance company denied the re-examination. When I called to find out why, the insurance representative said that they are “watching” the use of the 25 modifier very closely and would like to see my notes. Did I do something wrong?

I’m not sure if you did anything wrong without reviewing the patient file, however, you should be careful when billing modifiers 25 and 59. If you rely on the 25 and 59 modifiers for payment, be ready for an audit.

Two reports from the Office of Inspector General (OIG) of the Dept. of Health and Human Services found that each of these modifiers was used incorrectly nearly 40 percent of the time.

MODIFIER 25 DEFINITION

Modifier 25 indicates a significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service.

A provider may need 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 respective 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 the modifier 25 to the appropriate level of E/M service.

MODIFIER 59 DEFINITION

Modifier 59 is defined as a distinct procedural service. Under certain circumstances, a provider may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier 59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances.

This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician.

However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should this modifier be used.

Marty Kotlar, DC, CHCC, is the president of Target Coding (www.TargetCoding.com). Target Coding, in conjunction with Foot Levelers, Inc., is offering continuing-education seminars on CPT coding and documentation. He can be reached at 800-270-7044, through his Web site, or by e-mail at drkotlar@targetcoding.com.