Joined: March 21, 2005
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.
Joined: May 11, 2004
Wow... the Zack Attack in the Army knows billing codes! I didn't think you guys used those codes... although 2 years ago a couple of PTs I met in the Air Force mentioned that they were going to have changes and said the "P" word and mentioned codes so that the military could, I guess, compare their performances with civilian performances and for benchmarking?
Soleman, I think the CMS site has guidance on those modifiers in their medlearn matters area? I don't know. I can't keep the modifiers or CCI edits straight and I don't personally bill. I have heard though that if you use a -59 that your documentation has to reflect that whatever procedures you are modifying with that -59 were definitely distinct, separate services.
Joined: May 11, 2004
Well, Zack, you can say you're in the Army. LOL Maybe it could be a good thing to have the military having to perform some of the idiotic crap - especially if you have to follow Medicare guidelines - maybe THAT would help change things.
This from Rehab Regs.
3. OIG: Physicians and therapists are using modifier 59 incorrectly
The Office of Inspector General (OIG) recently released a report that found that 40% of code pairs billed with modifier 59 in fiscal year 2003 did not meet program requirements, resulting in $59 million in improper payments because Medicare allowed payments for 40% of the code pairs despite not following program requirements. In 15% of the cases, modifier 59 was used inappropriately because the services were not distinct from each other.
The OIG is recommending that the Centers for Medicare & Medicaid Services (CMS) encourage carriers to conduct prepayment and postpayment reviews of the use of modifier 59.
The study consisted of a random sample of 350 code pairs for services that bypassed correct coding initiative edits.
CMS says it will distribute the report to its contractors responsible for identifying improper payments and potential fraud, waste, and abuse, while also issuing an article to provide continuing education to physicians and therapists on how to bill modifier 59 properly.
Joined: March 21, 2005
[QUOTE]you can say you're in the Army [/QUOTE]That was classified!! :cool: [QUOTE]it could be a good thing to have the military having to perform some of the idiotic crap [/QUOTE]Your tax dollars hard at work!! :D