Orthopedic Coding Alert

Question: Our payer is denying a claim involving an E/M and a fine needle aspiration (FNA) of a bone lesion with modifier 59 for an improper modifier. Is my modifier use 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 an E/M service reported with a minor procedure, such as an FNA of a bone lesion. You should consider procedures with a 0- or 10-day global period as minor procedures -- FNA code 10021 (Fine needle aspiration; without imaging guidance) has 0 global days.

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, an E/M is not payable unless it is a significant, separately identifiable service.

In other words: If your physician captures minimal history, performs a limited exam, and documents low medical decision making (MDM), all of which are associated with doing the fine needle aspiration (FNA), the E/M does not qualify for a 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. Remember, you-ll use modifier 57 only when the procedure has a 90-day global period.