Pediatric Coding Alert

Opt for -59 with multiple procedures and avoid denials

Are you having trouble deciding when to use modifier -25 and/or modifier -59? It's not that difficult - that is, if you know these rules.

When time-consuming issues and procedures arise during preventive exams and sick visits, modifier -25 helps physicians get paid for performed services, says Timothy Richer, MD, FAAP, pediatrician at Richer & Martin & Timm in Milwaukee. "But how can I distinguish between modifiers -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) and -59 (Distinct procedural service)?"

Coding experts offer the following guidelines to help you select the appropriate modifier(s) and improve reimbursement for procedures.

1. Append Modifier -59 to Surgical Codes

Unlike modifier -25, which applies to a significant, separately identifiable E/M service, you should consider using modifier -59 when the pediatrician performs more than one distinct procedure (non-E/M) on the same day, says Kevin Perryman, practice administrator at Primary Pediatric Medical Association in Seguin, Texas. "Append modifier -59 to surgical procedures, such as wart removal (17000-17111), cerumen removal (69210), laceration repair (12001-12057) and incision and drainage (I&D) of abscess (10060)," he says.

Because lab tests are not surgeries, don't use modifier    -59 for lab tests. For instance, if a pediatrician orders a complete blood count (85025-85027) and urinalysis (81001-81003) at an office visit (99201-99215) for a child with fever of unknown origin (780.6), you should not use modifier -59, Perryman says. "Multiple lab tests at office visits are normal and do not require a modifier," he adds.

2. Use Modifier -25, Not -59, for First Procedure

"Use modifier -25 to identify a different E/M service from one procedure," says Victoria S. Jackson, administrator at Southern Orange County Pediatric Association in Lake Forest, Calif.
Suppose an established patient comes in with otitis externa (380.10, Acute otitis externa, unspecified) along with impacted cerumen (380.4). The pediatrician performs a history, examination and medical decision-making (99212-99215, Office or other outpatient visit for the E/M of an established patient ...) and also removes the impacted earwax (69210, Removal of impacted cerumen). To inform the insurer that the pediatrician performed a separate, significantly identifiable E/M service from the cerumen removal (69210), use modifier -25 on 99212-99215, Jackson says.

CPT doesn't require separate diagnoses to report a same-day E/M and procedure. But using different ICD9 Codes on office visit/procedure claims will bolster your case that the E/M service is a separate, significantly identifiable E/M service from the procedure. For instance, in the cerumen-removal example, make sure to link 380.10 to 99212-99215-25 and 380.4 to 69210.

3. Identify the Second Procedure as Distinct

When your pediatrician performs two procedures at the same encounter, you may need to use modifier -59 to identify the second procedure as a distinct procedural service from the first procedure, Jackson says. If the pediatrician in the previous otitis externa/wax removal example also drains a cyst on the child's hand, append modifier -59 to the code for I&D of abscess (10060*, Incision and drainage of abscess [e.g., carbuncle ... cyst, furuncle, or paronychia]; simple or single). "Modifier -59 identifies the I&D (10060) as a distinct procedural service from the cerumen removal (69210)," she says.