Avoid the Top 10 CPT® Modifier Mistakes – Part 3

Posted on 15 Jan, 2019 |comments_icon 0|By Bruce Pegg

Previously, we looked at six of our top 10 CPT® modifiers that create confusion and problems in coding and billing for medical services and procedures. In this last post, we present the top four misused CPT® code modifiers. See if you agree with us!

4) Modifier 57

How it’s misused: Modifier 57 (Decision for surgery) seems easy to use on the surface: simply attach the modifier to an evaluation and management (E/M) service when your Medicare provider decides that a patient needs surgery that day or the day after.

In reality, before you append 57 to an E/M, you’ll need to pay careful attention to the kind of surgery your provider has decided upon. And if your provider has planned that surgery in advance, appending 57 will get you into all sorts of trouble.

How you should use it: Modifier 57 is designed to alert payers that your provider has performed additional work during an E/M service that has led to her decision. Knowing that is the key to using the modifier correctly, as the extra degree of work points to a decision for major surgery. So, you will need to look at the associated surgery’s global period before you decide on the appropriate modifier: if it’s 90 days, then 57 is the right choice. Anything else, and you’ll append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service).

Example: A urologist sees a patient in the hospital for a consultation and decides he needs to perform a transurethral resection of the prostate (TURP), represented by code 52601 (Transurethral electrosurgical resection of prostate, including control of postoperative bleeding, complete [vasectomy, meatotomy, cystourethroscopy, urethral calibration and/or dilation, and internal urethrotomy are included]), which carries a 90-day global period. If the TURP is performed that same day or the following day, you would modify the E/M hospital visit with modifier 57 to ensure payment of the E/M service on the same day.

3) Modifier 24

How it’s misused: A careful reading of this modifier’s descriptor is a big clue as to how it is misused. If you append modifier 24 (Unrelated evaluation and management service by the same physician or other qualified healthcare professional during a postoperative period) to anything other than an E/M service, and if your provider is evaluating and managing a condition that is related to the reason for a surgery during that surgery’s global period, then you have incorrectly applied it.

How you should use it: As with all modifier use, documentation is vital. You will need to make sure that your physician is not treating complications from the condition or the surgery that the patient has undergone before, which often means recording a very different diagnosis for the E/M before appending 24.

Example: A patient comes into the office for a follow-up visit three days after your provider has performed 17000 (Destruction [eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement], premalignant lesions [eg, actinic keratoses]; first lesion) on a patient’s wartWhile in the office, the patient complains of stomach pain, and the physician diagnoses a urinary tract infection (UTI) during a level-two established patient visit. Because the UTI is a completely new and unrelated condition that has occurred during 17000’s 10-day postoperative period, you would code 99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: a problem focused history; a problem focused examination; straightforward medical decision making), attaching modifier 24 to avoid denial since the E/M service happened during the global period.

2) Modifier 25

How it’s misused: Of all the modifiers, none is more used, and none more abused, than modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service). Again, a close reading of the descriptor identifies some of the pitfalls you can encounter when using it. If the procedure or other service is not on the same day, if the E/M service is not significant or separate from the procedure, and if the same physician or qualified healthcare provider (QHP) did not perform both the E/M service and the procedure (or if either service was performed by someone other than a physician or QHP), then you have incorrectly applied the modifier.

Also, as we noted earlier, you should only use modifier 25 on E/M services performed in conjunction with minor procedures that have a 0- or 10-day global period. You’ll use modifier 57 (Decision for surgery) for procedures with a 90-day global period.

How you should use it: Look closely at your provider’s documentation. If, in addition to a procedure or service, you can separate out a history, exam, and/or medical decision making (MDM) that add up to a specific E/M level, then you likely have a case for appending the modifier to the E/M service in question. And note that you don’t necessarily have to have a separate diagnosis to justify the E/M.

Example: A patient comes in for a weekly allergy injection and proceeds to spend 15 minutes with the physician regarding a sinus issue. The physician documents expanded problem focused history and exam, and medical decision making of low complexity for the patient’s sinus condition, in addition to the injection. You would code 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: An expanded problem focused history; An expanded problem focused examination; Medical decision making of low complexity …) as well as a code such as 95117 (Professional services for allergen immunotherapy not including provision of allergenic extracts; 2 or more injections), appending 25 to the E/M service.

1) Modifier 59

How it’s misused: Known as the “unbundling modifier,” 59 (Distinct procedural service) is our number one misused modifier simply because it is used so often in coding separate procedures and certain services that are usually not reported together. Modifier 59 is used a lot to unbundle and override National Correct Coding Institute (NCCI) edit pairs. Under NCCI, CMS has deemed that a particular pair of CPT® or HCPCS codes should not be reported together because the service described in a second code (the column two code) is regarded as being a part of, or overlapping with, the service described in the main, or column one, code. For some NCCI bundles, you can use a modifier, such as 59, to unbundle the codes, however.

If you try to use 59 to unbundle and override NCCI edit pairs that have a modifier indicator of 0, meaning that “there are no circumstances in which both procedures of the PTP code pair should be paid for the same beneficiary on the same day by the same provider,” according to CMS, you’re misusing 59.

Note that even if the edit pairs can be unbundled when appropriate (having a modifier indicator of 1), sometimes more specific modifiers may apply, such as modifiers for specific anatomical sites (RT, LT, E1-E4, FA, F1-F9, TA, T1-T9, LC, LD, RC, LM, or RI for example), or modifiers XE (Separate encounter), XS (Separate structure), XP (Separate practitioner), and XU (Unusual non-overlapping service).

Finally, coders often incorrectly use modifier 59 when one of the services involved is an E/M service (which requires you to append modifier 25).

How you should use it: Simply put, if your provider performs two different procedures or surgeries that are not normally performed together, on different anatomical sites, different organ systems, different lesions, different injuries, and during different sessions, and you can find no better modifier to unbundle the services, you can likely use modifier 59.

Example: An ob-gyn performs 58301 (Removal of intrauterine device (IUD)) and 57500 (Biopsy of cervix, single or multiple, or local excision of lesion, with or without fulguration (separate procedure)) to remove a large Nabothian cyst on the cervix that is causing pain during intercourse. You would report 58301 and 57500-59.

Contributing Editors: Leigh DeLozier, Kristin J Webb-Hollering, Brett Rosenberg, Suzanne Burmeister

Learn More

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Bruce Pegg
Editor, Newsletters

An experienced teacher and published author, Bruce is TCI’s new voice of primary care, delivering advice and insights every month for coders in the fields of family, internal, and pediatric medicine through Primary Care Coding Alert and Pediatric Coding Alert. Additionally, he is the current editor of E/M Coding Alert. Bruce has a Bachelor of Arts degree from Loughborough University in England and a Master of Arts degree from The College at Brockport, State University of New York. He recently became a Certified Professional Coder (CPC®), credentialed through AAPC.

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