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modifier 25 and 59

Jenny Posted Thu 29th of March, 2012 15:17:39 PM

Please help, any input is very appreciated
Do I need to use modifier 25 when patient comes to the office for E/M and lab (cbc and venipuncture) on the same day?
Another the question is for radiology, do i need to use modifier 59 if the patient has 3 procedures on the same day, same doctor. Example a CT of abdomen,a pet scan and a chet x-ray?

Thank you in advance

SuperCoder Answered Thu 29th of March, 2012 16:11:49 PM

•If the only service provided is a laboratory test (eg, urinalysis, blood sugar) or obtaining a blood specimen, only the laboratory test or venipuncture or capillary stick is reported. It is not appropriate to report a minimal level office or outpatient evaluation and management (E/M) visit (nurse visit, code 99211) in these cases.

•Some payers may require that modifier 25 be appended to the E/M code if laboratory tests are reported on the same day of service.

•Some payers, particularly Medicaid and some Early Periodic Screening, Diagnosis, and Treatment programs, bundle laboratory tests with E/M visits. Know what the requirements are for reporting these services.
For More info please refer http://coding.aap.org/content.aspx?aid=11457

Among the modifiers most often used by radiologists are -51 (Multiple procedures) and -59 (Distinct procedural service), which are also easy to confuse. Modifier -51 is used when multiple services are performed and communicates that the codes submitted are not being added to the claim in error. For instance, -51 should be appended when multiple CT or radiographic services are provided to the same patient on the same date of service, especially if the same CPT code is used more than once on the claim. When used in compliance with Correct Coding Initiative (CCI) rules, the -51 modifier should prevent the rejection of the second and/or subsequent procedures as duplicates or included services. Under other clinical circumstances modifier -59 would be used. Often called the “modifier of last resort,” modifier -59 is usually appended to the component code when the CCI attaches an indicator of “1″ to a specific code pair, which means a modifier may be appended to bypass the edit.

Modifier -51 might be used, for instance, when a patient has three single-view chest x-rays on the same date of service and the coder wants to ensure that the last two codes are not rejected as duplicate submissions. Modifier -59 might be used when a four-view knee film is obtained and a fracture is diagnosed. After reduction and casting, a two-view knee series is performed. The two-view series is bundled into the four-view series by the CCI edit. However, the radiology practice would use -59 with the second study to ensure payment
In your case none of the procedures bundle with each other so no use of 59 modifier.

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