Ob-Gyn Coding Alert
Prove Separate Service Before Billing E/M in Global
Question: Our payer is denying a claim involving an E/M and an FNA for an improper modifier. Is modifier 59 appropriate? California Subscriber Answer: Most payers, including Medicare carriers, require modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) on minor procedures. You should consider procedures with a zero- or 10-day global period as minor procedures. Caution: Don't just put a modifier on your E/M visit code to get paid. Make sure your E/M is a significant, separately identifiable service from the minor E/M service that payers associate with the procedure. CPT considers minor procedures to have a very small E/M already included with the procedure. Therefore, insurers won't pay an E/M unless it is a significant, separately identifiable service. And Medicare will not pay an E/M separately on the same date of service as a procedure if the purpose of the E/M was for the ob-gyn to decide to do the procedure. -The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E/M service. However, a significant and separately identifiable E/M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25,- according to the National Correct Coding Initiative Policy Manual,Chapter 1. In other words: If your physician captures minimal history, performs a limited exam, and documents low medical decision making (MDM), all of which is associated with doing the fine needle aspiration (FNA), the E/M does not qualify for modifier 25. Therefore, you should consider the E/M included in the procedure and you should not separately code for it. Alternative: Some payers may prefer modifier 57 (Decision for surgery) for E/M services during the global period of any procedure, so check with your payer and get this instruction in writing to keep with your compliance materials.
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