Wiki use of Mod 57 and 25

[Lubovic]

All on the same day : Patient came in through ED, referred to Colorectal 99221 -57, -AI; had 44320 Colostomy (major surgery 090); and 45300 -51 Proctosigmoidoscopy (minor diagnostic procedure 000).
The EM that did not pay, denied as bundled; other two did pay as coded.
Mod-57 should cover the EM 99221 and the 44320, Mod -51 covers the 45300. Can I or should I, in addition, add Mod -25 to stress the EM was necessary? I thought the -57 was sufficient to indicate the justification for EM necessity therefor the need for surgery?
Can't understand how it was denied bundled. Any help is appreciated !

 

[mk2001]

I have had to use both the 25 and 57 modifier on an E/M before.

 

[Lubovic]

Thank you. I've read many notes suggesting one or the other or both, but not many positive outcomes.

 

[jnnfrrr23]

The answer would depend upon:
1) Patient's insurance plan (check member benefit, plan contract, regulations)
2) Claim form submitted (UB or HCFA)
3) Bill type; inpatient or outpatient
4) Admission and discharge date, discharge status
5) Facility setting, credentialing

Keep in mind the CMS 72-hour rule. Without all of the details, I can't answer definitively, although these factors can affect bundling.

 

[Lubovic]

The answer would depend upon:
1) Patient's insurance plan (check member benefit, plan contract, regulations) - Medicare
2) Claim form submitted (UB or HCFA) - HCFA
3) Bill type; inpatient or outpatient - IP
4) Admission and discharge date, discharge status - admitted IP, services performed during same event, discharged.
5) Facility setting, credentialing - all in order

Keep in mind the CMS 72-hour rule. - Does not apply, not DRG.
Without all of the details, I can't answer definitively, although these factors can affect bundling.

I'm only billing for the MD provider. We had some info from the transfering facilicyt but still had to perform the E/M in order to get enough information to determine to perform the surgery.

 

[Lubovic]

I have had to use both the 25 and 57 modifier on an E/M before.

Commercial, Medicare or Medicaid ?

 

[mk2001]

Commercial, Medicare or Medicaid ?

BCBS and I believe I have to Medicare also.