Practice Management Alert

Question: If my doctor is charging an E/M and a FNA, is modifier 59 appropriate? Our payer is denying the claim for an improper modifier.

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 significantly, 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 significantly, 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 is associated with doing the fine needle aspiration (FNA), the E/M does not qualify for a 25. Therefore, you should consider the E/M inclusive to 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.