Modifiers 25 and 59 have a long history of confusion and misuse by providers, coders, and auditors. These modifiers are one of the hardest modifiers to determine appropriate use. The term “significant, separately identifiable service” has been very subjective to different interpretations. The American Medical Association (AMA) recently indicated that more than one E/M service on the same day by the same provider may be reported with Modifier 25, leading to further confusion in the coding community. Modifier 25 has been on the payer’s radar for some time and continues to be a problem for payment.

This webinar will describe the nuances related to modifier 25 and 59 usages when billing for your service level and services on the same day as a minor procedure. Using modifier 59, distinctly documenting the two methods using the right tools, knowing when it’s required, and how to append them appropriately. A granular understanding of its usage will create more opportunities for a fluid revenue stream and understanding its usage.

Learning Objectives

• Understanding how and when to use modifiers 25 and 59
• Documentation requirements for when modifiers 25 and 59 are most appropriate
• What is modifier 59, and what are the purposes?
• Understanding the Procedure-to-Procedure (P2P) files and knowing how to use them when understanding bundled payments or services that are inclusive of services
• Learn the NCCI guidelines on the appropriate use of modifiers
• Be able to apply the correct modifier(s) based on the specific circumstances
• Learn how to resolve NCCI edits, including a breakdown of modifier 59 properly
• Proper use of modifier 25, especially in the office or outpatient setting

Areas Covered in the Session

• What is CMS’ definition of modifier 25?
• Modifier 25 Updates from AMA from CPT Assistant
• Critical considerations for correct reporting of modifier 25 include the following:
  • Append only to E/M services
  • Requires awareness of usual preoperative and postoperative services
• Inpatient or Observation on the Same Calendar Date of Another Service
• Billing Examples: CMS (Medicare finalized Rule) vs. AMA (CPT Guidelines)
• What is modifier 59, XE, XP, XS, and XU?
• National Correct Coding Initiative (NCCI)
• Understanding and Applying the National Correct Coding Initiative Coding Manual
• What are modifier 59 and the X modifiers?
• The Dilemma: Using Modifiers 59, XE, XP, XS, and XU
• Using XS Modifier
• Using XE Modifier
• Using XU Modifier
• Modifier 25 vs Modifier 59
• Modifier 25 Correct usage
• Modifier 25 Examples
• Modifier 59 and X Modifiers Correct Usage
• Modifier 59 and X modifiers Examples
  • Example 1: Column 1 Code/Column 2 Code – 11102/17000
  • Example 2: Modifier 59 Column 1 Code/Column 2 Code – 47370/76942
  • Example 2: Modifier 59 Column 1 Code/Column 2 Code – 93453/76000
• Key Takeaways

Attendees

• Physicians and Non-Physician Practitioners
• Qualified Health Care Professionals
• Coders
• Billers
• Auditors
• Nurses
• Practice Managers
• Medical Officers
• Compliance Officers
• Clinic Managers
• Insurance Company Claims Reviewers
• Insurance Payers
• Payment Policymakers
• Denial Resolution Team