Wiki Modifier 25 and/or 57

[Klynch49]

I bill for a plastic surgeon that is called by the ER department regularly. He presents to the ER and does a consult and at times it leads to an emergency surgery. My problem is that we are continually denied the consult reimbursement. After appeal, with documentation, we are still denied. This has been happening mainly by United HC. Does anyone have any experience with this issue?

Thank you

 

[ellzeycoding]

My thoughts, without knowing which codes you are actually billing.... If it is a surgical procedure that has 0 or 10 postop days (i.e., minor procedure), the E/M that leads to the decision is included in the reimbursement for the surgical procedure. This has to do with the NCCI edits that went into effect in January 2013. CMS created it and most carriers now follow it.

The E/M is reimbursed if separately identifiable to the procedure (unrelated to decision to perform the procedure).

This bundled E/M and minor procedure rule is true for both new and established patients.

 

[TThivierge]

Modifier 25 and 57

Hello there!

You did not list which CPT codes you are billing, but I will take a shot at this question. Also can check back of CPT manual for list of modifiers definitions in Appendix A section. The modifier 57 is for surgery decision only but shall need a Z code Z01.818 and a definitive diagnosis from the family doctor on the claim. Do not use the 57 modifier with a surgical CPT code just eval management CPT codes. The modifier 57 can be applied to (BEFORE ACTUAL SURGERY takes place...so if surgery done that day might reject claim). Check with your insurance payer rules to for use of modifier 57 . The modifier 57 involves a way to tell the payer the patient is getting surgery and may need global days for recovery plus as a statistical purposes.

Modifier 25 is a modifier only use on eval management codes not surgical procedure CPT codes.

I hope this info helps you.