Wiki 99401 what modifier?

[schanderson]

I am confused and am looking for the correct direction. At our office my physician is billing the office visit code and the 99401 what modifer goes on the 99401? I have seen in other threads to place a 25 on it, but I am confused with that because others are stating to put a 59 on the 99401. My logic says that it would be a modifier 25 on the E/M code and then a 59 on the 99401 ,but this is the world of billing and there is always exceptions to every rule. Guidance and direction would be greatly appreciated thank you.

 

[amyjph]

In my opinion you would append a 25 modifier to the office visit to show it was significant, separately identifiable E/M. That is, IF the documentation supports it, the time of 99401 is documented, it is separate from the E/M, the office visit was not a preventive (e.g. 99395), the payer allows 99401 AND payer guideline doesn't say to use a different modifier such as 59, etc.
99401 lives in the E/M section of the CPT book.

Look at part of the Modifier 59 definition: "Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances." "To report a separate and distinct E/M service with a non-E/M service performed on the same date (refer modifier 25)."
Then part of Modifier 25 definition: " significant, separately identifiable evaluation and management (E/M) service by the same physician or other qualified health care professional on the same day of the procedure or other service."

 

[Fhussain]

Our practice is having an issue now. Whereas before we used to bill 99401 with 99213 all the time we got paid for both without a problem. As of recent they started denying the 99213 and paying only for 99401. When asked one of the billing departments said that it is due to an NCCI edit where 99401 is a column 1 code, 99213 is a column 2 code. Which means that 99213 is included in the 99401. We've been billing them both together for years so I am not sure if this is a new development or if 99401 includes "preventive" in its description and that is conflicting with another e/m code. But now, the same insurance company that told me this is reimbursing me for both 99401/99213. our modifiers are there all the time but I was wondering if anyone has a reliable source that says these cannot be billed together or that it can be with the exception of mod 25.