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karmzack -> Re: use of modifiers with billing (January 5, 2006 11:55:00 AM)
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I've used -50 but in my system (military) we don't get credit for bilateral procedures. I've never used -59. I would never use -25 because we don't 'bill' off of E&M codes only the CPT codes, the only E&M code we use is 99499. Hopefully someone that works in a similar enironment as you chimes in.
50 Bilateral procedure - Unless otherwise identified in the listings, bilateral procedures that are performed at the same operative session should be identified by adding the modifier -50 to the appropriate five digit code.
59 Distinct Procedural Service - Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier '-59' is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician. However, when another already established modifier is appropriate it should be used rather than modifier '-59' only if no more descriptive modifier is available, and the use of modifier '-59' best explains the circumstances, should modifier '-59' be used.
Billing for both individual (one-on-one) and group services provided to the same patient in the same day is allowed, provided the CMS and coding rules for one-on-one and group therapy are both met, and that the group therapy session be clearly distinct or independent from other services and billed using a -59 modifier.
The group therapy CPT code (97150) and the direct one-on-one 15-minute CPT code for therapeutic exercises (97110), are a mutually exclusive CCI code pair: 97150 is the column one code, 97110 is the column two code, and the -59 modifier is permitted to be used.
This requires the group therapy and the one-on-one exercise therapy to occur in different sessions, separate encounters, or different timeframes – occurring sequentially, not concurrently - that are distinct or independent from each other.
The therapist would bill for both group therapy and therapeutic exercises, appending the -59 modifier to the column two code, 97110. Without the -59 modifier, payment would be made for the column one group therapy CPT Code, 97150. The CCI edits are based upon interpretation of coding rules
25 Significant, separately identifiable - Evaluation and Management service by the same physician on the same day as the procedure or other service. The physician may need to indicate that on the day a procedure or service was performed, the patient's condition required a significant, separately identifiable E&M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. The E&M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E&M services on the same date. This circumstance may be reported by adding the modifier -25 to the appropriate level of E&M service.
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