Modifier 57 Alone Should Preclude the Need for 25
Posted on 04. Feb, 2009 by Editor in Hot Coding Topics
Medicare carriers don’t require you to append both modifiers.
Myth: Payers “don’t like” modifier 57 (Decision for surgery), so it’s okay to use modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) instead.
Reality: You should append modifier 57 to an E/M service that occurs on the same day, or on the day before, a major surgical procedure, and which results in the physician’s decision to perform the surgery.Don’t miss Barbara Cobuzzi’s modifier training session just for otolaryngology coders.
Scenario: Suppose your physician performs an E/M service followed by three major procedures. You erroneously append modifiers 25 and 57 to the E/M code.
Correct coding: Medicare payers should accept the claim with modifier 57 appended to the E/M code if the documentation supports it. You shouldn’t have to append both modifiers, says Barbara Cobuzzi, MBA, CENTC, CPC-H, CPC-P, CPC-I, CHCC, with N.J.-based Healthcare Solutions.
Direct from the source: Medicare’s Internet Only Manual, section 40.2, instructs carriers, “Pay for an E/M service on the day of or on the day before a procedure with a 90-day global surgical period if the physician uses CPT modifier 57 to indicate that the service was for the decision to perform the procedure.”
“Since the physician is billing just one E/M service, only one modifier — 25 or 57 — is necessary,” says coding consultant Jay Neal.
“You’ll use modifier 25 if the procedure being done is a minor procedure, meaning it has zero to 10 global days,” Cobuzzi says. “When you use this modifier, you’re telling the payer that the E/M performed entails more than the small E/M included in the minor procedure.”
Modifier 57, however, tells the payer...
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KRISTEN
17. Jun, 2009
MY NAME IS KRISTEN. I WORK FOR A CARDIOLOGIST. WE ARE HAVING TROUBLE BILLING MEDICARE WITH MODIFIERS. WE NEVER SEEM TO GET IT RIGHT, WHAT MODIFIER TO USE WITH EACH CPT CODE. IS THERE SUCH A THING AS A MEDICARE CONSULTANT THAT COMES TO YOUR OFFICE AND TEACHES YOU THE CORRECT WAY TO BILL MEDICARE?
Coding News
18. Jun, 2009
Hi, Kristen: Yeah, modifiers are tricky. There are lots of good consultants you can hire to teach you about billing Medicare, but that could get expensive. If it’s basic information you’re seeking for your office, here are some Medicare billing training options our partners offer that might be cheaper.
A lot of Medicare consultants speak Audioeducator. They are widely respected in coding profession, so our audios are a great way to get instruction from a consultant for a low price. Everyone in your office can just gather around a listen for one price, with opportunity for questions afterwards. Here’s one on Medicare modifiers coming up soon with Betty Johnson. I’ve taken some live classes with her (recently one on coding basics and one on cardiology IVR) she’s very good. Here is the link to that audio: http://www.audioeducator.com/industry_conference.php?id=1509&trk=ITCI1896.
If you want live instruction for yourself and your colleagues, check out this travel-free education opportunity of Part B Medicare coding and billing basics: http://www.codingconferences.com/seminars.htm. PMCC instructors from all over the country teach this, and there might be one coming to your area.
Finally, many of our speakers have their own consulting businesses. If you look through the bios on Audioeducator, you’re likely to find experts whom you can contact directly to work just with your practice.
Good luck! Let me know how it goes for y’all …
Erin Lang Masercola, PhD, CPC