Do you know about - understanding curative Claim Modifiers - The Modifier -25, -24, -51, -57, -59, -26
Claim Management! Again, for I know. Ready to share new things that are useful. You and your friends.I am writing this report again as a advice from many of my readers on my blog. This report is more ample in a way that scenarios were cited to have a bigger look on the allowable use of some of these leading modifiers.
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In this article, I will be describing the medical claims modifiers - Modifier -25, -24, -51, -57, -59, -26.
Modifier -25, 25: Significant, separately identifiable evaluation and administration service by the same doctor on the same day of the procedure or other service:
This modifier must be appended with an E/M service. This is the modifier you will need to use with the evaluation and administration service done on the same day with other procedure done by the same physician. It has to be above and beyond the usual preoperative and postoperative encounter with the procedure. In fact, by using this modifier, it doesn't have to have a dissimilar determination reported. The most leading thing is that, the E/M level should meet its key components or if it is excellent based on time with the sick person (counseling and coordination). You have to be meticulous in using this modifier. It must meet medical necessity. As you know, there are procedures that already includes all other care and management.
Let's delineate this modifier 25:
A sick person came in for her monthly result up for her lasting back pain. At the same time, sick person was complaining with severe headache. The pain doctor performed bilateral occipital block on the sick person at the time of service. You will append modifier 25 for the E/M code to indicate that both services were rendered on the same day.
You don't use modifier 25 with E/M encounter that resulted to Decision for surgery (we have other modifier for this!)
Modifier -24, 24: Unrelated evaluation and administration service by the same doctor during postoperative period.
As the modifier indicates, this is other modifier that you can only append with an E/M counter. It indicates that the E/M encounter is not associated during the global period.
Let's delineate this modifier 24:
A pain expert performed facet nerve destruction for the patient. during the normal, postoperative global period, the sick person came in to the office with severe knee pain due to fall on ice as evidenced by the patient's subjective information. The pain expert will then report that E/M encounter with the sick person by appending modifier 24 to indicate that encounter is not associated during the postoperative global period.
This modifier, like modifier 25 has no restriction as with the level of E/M code as long as it meets medical necessity, all its components or are time-based.
Modifier -57, 57: Decision for Surgery:
An evaluation and administration service resulted in the preliminary decision to accomplish surgery during the E/M encounter.
Let's delineate this modifier:
An Ob/Gyn sees a sick person who complains with severe abdominal pain. It turned out (through ultra sound, radiology and all other diagnostic testing and documentations), the sick person is having an ectopic pregrancy. The Ob/Gyn performs the laparoscopic surgery on the same day. The E/M encounter will then be reported with modifier 57 which resulted to decision for surgery. The laparoscopic surgery should also be reported as performed on the same day without a modifier.
Modifier -50, 50: Bilateral Procedure
You will append modifier 50 for procedures that are obviously billable as bilateral (or two sides, both sides), performed on the same day, the same operative session, on same anatomical sites, organs (arms, legs, spine).
A Facet Nerve block is unilateral (can be billed as bilateral). When using a modifier 50, make sure you only bill for one unit on the claim form since there is only 1 procedure is performed bilaterally. Though guidelines from other payers may differ. They may wish you to list it twice (line 1 and line 2 on the claim form). You have to be responsible to elaborate this with your payors.
You use this modifier with add-on codes too! Do not use this modifier with procedures which are already described as bilateral procedures.
Modifier -51, 51: multiple Procedures
This modifier is used when reporting multiple procedures performed by the same doctor on the same day. Do not use this modifier for "add-on" codes (see appendix D of the Cpt Code book). Do not use this modifier for codes with "modifier -51 exempt" emblem (see appendix E of the Cpt Code book). Do not use this modifier with an E/M code. This modifier can only be used by the same doctor on the same day who performed the procedure.
Coding tip: List the top reimbursable code (after the main procedure code) based on the fee schedule.
Modifier -59, 59: clear Procedural Service
Description of Modifier -59: Under clear circumstances, the doctor may need to indicate that a procedure or service was clear or independent from other services performed on the same day.
Modifier 59 is used to recognize procedures/services that are not regularly reported together, but are suitable under the circumstances. This may represent a dissimilar session or sick person encounter, dissimilar procedure or surgery, dissimilar site or organ system, cut off incision/excision, cut off lesion, or cut off injury (or area of injury in ample injuries) not commonly encountered or performed on the same day by the same physician. However, when other 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 modifier 59 be used.
Use this modifier only if the other procedure is a separately identifiable procedure code. procedure that is clear and can be described as independent procedure, on cut off anatomical site, lesion, injury site, dissimilar organ system, and dissimilar session. Do not use this modifier for E/M code.
Modifier -26, 26: professional Component
This modifier is used only for the professional component (physician) of a service or a procedure. clear procedures are a composition of both professional and technical component. By using modifier 26, it indicates that procedure being reported as professional component only.
Professional Component versus the Technical Component. By illustration, procedures rendered at a premise such as sick person hospital or Asc, these equipments are facility-owned. The premise will then report the technical component for such service while the doctor will report the professional component for the that procedure. One very good example, the doctor performs Paravertebral Facet Block under Fluoroscopic advice using Cpt code 77003. The doctor will report the fluoro with modifier 26 for his/her professional component. While the premise will report the the same procedure with modifier -Tc for the technical component.
Modifier -Lt or -Rt are used to indicate a Left or Right side or anatomical site. So if the pain expert performed Left Cervical Facet Block, you will append a modifier -Lt to report this procedure.The above modifiers are used to delineate your claims for the services performed on the sick person for suitable payment. Always consult your local careers and third party payors for local determination, policies and guidelines on these modifiers. Finding at the edits is also very important!
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