Wiki modifier question for pain mgmt

[elisaarb]

Patient is seen for evaluation 99213 presents with multiple problems Dx: 724.2 729.5 and 726.10. The MD performs an injection for shoulder pain 20610 during same visit. What is the correct modifier for this procedure? Is it 99213-25 or 20610-59? Thanx

 

[MARY K]

Modifier question for pain mangmnt

As long as decision for injection was made during visit modifier 25 will be fine. Assign modifier rt or lt to injection code.thelma cpc

 

[dwaldman]

59 modifier is used when there is code pair of non E/M services to denote that the procedures are separate or independent from each other (ie separate site)

According to the NCCI policy manual, here is the stance on visits on the same day a procedure is performed

https://www.cms.gov/NationalCorrectCodInitEd/

If a procedure has a global period of 000 or 010 days, it is defined as a minor surgical procedure. The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an
E&M service. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25.
The E&M service and minor surgical procedure do not require different diagnoses. If a minor surgical procedure is performed on a new patient, the same rules for reporting E&M services apply. The fact that the patient is “new” to the provider is not sufficient alone to justify reporting an E&M service on the same date of service as a minor surgical procedure. NCCI does contain some edits based on these principles, but the Medicare Carriers (A/B MACs processing practitioner service claims) have separate edits. Neither the NCCI nor Carriers (A/B MACs processing practitioner service claims) have all possible edits based on these principles.

 

[hgolfos]

I agree with dwaldman, and would add my rule of thumb when considering E/M on the same date of service. Ask yourself if the E/M service goes beyond what is needed to clear the patient for the procedure. If the answer is yes, you can bill with a 25 mod. If not, don't bill the E/M. One example of a billable scenario may be management of high risk medications or perscribing other treatments for the patient's pain. Another example would be when the physician addresses a completely separate problem.