Modifier 25 And Modifier 59 With Examples


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Course Description

CPT and HCPCS modifiers are critical to accurate coding and reimbursement for facility and professional services and procedures. Modifiers impact the outpatient hospital prospective payment system payments as well as the physician fee schedule.

There is a lot of confusion over how to correctly apply some of the modifiers. Audits by CMS and other payers have resulted in identifying a high number of errors in using modifiers 59 and 25. Applying either of these modifiers incorrectly can result in fines and not applying them when they are appropriate will result in underpayments to the practice or hospital.

This webinar will cover details that will explain when and how to consistently apply modifiers 25 and 59. The speaker will also discuss when another modifier may be more appropriate. The speaker will demonstrate how to review the CMS National Correct Coding Initiative (NCCI) edits to help determine if modifier 59 is appropriate or if the code should have a different modifier or no modifier at all.

Extensive examples will be provided with detailed explanations which will help the participants learn how to accurately apply these modifiers with confidence and efficiency.

Areas Covered In The Session:

  • Detailed explanation with examples of when modifier 25 should be assigned and when another modifier may be more appropriate and when an evaluation and management service would not qualify for reimbursement using modifier 25 and why
  • Detailed explanation with examples of when modifier 59 should be assigned and when another modifier may be more appropriate or when no modifier should be assigned and how each situation impacts reimbursement
  • Understanding how to determine from CMS’s National Correct Coding Initiative (NCCI) edit tables, when modifier 59 is appropriate
  • Case studies will cover a variety of scenarios with detailed explanations of correct use of these modifiers
  • Review resources available through CMS in addition to the NCCI edit tables

Learning Objectives:

  • Abstract information from the medical record to determine whether or not an evaluation and management (E&M) service meets the criteria for reimbursement (indicated by appending modifier 25 to the E&M code) on the same day by the same physician as another service or procedure was performed.
  • Appropriately link ICD-10-CM diagnosis codes to both the separately identifiable E&M service and to the code for the other service or procedure to further support the medical necessity of both an E&M service and another service or procedure
  • Abstract information from the medical record to determine whether or not a procedure meets the criteria for full reimbursement (indicated by appending modifier 59 to the lesser procedure(s)) as separate and distinct from another procedure performed on the same day by the same physician.
  • Appropriately link the most specific ICD-10-CM codes to the two or more procedure codes to further support medical necessity of performing more than one distinct procedural service
  • Look up the tables on the NCCI edits to verify if the use of modifier 59 is appropriate
  • Correctly append the correct modifier (59, 25, another more appropriate modifier or no modifier) to several case studies and learn the logic that supports this process.
  • Look up other CMS resources useful in determining correct modifier use
  • Appropriately query the physician when documentation isn’t specific enough to determine if modifier 25 or 59 is appropriate

Who Should Attend:

  • Physician
  • Outpatient Hospital
  • Medical Coders
  • Billing Specialists
  • Practice Managers
  • Hospital Staff Responsible for Auditing Claims

Meet The Presenter:

Brandy Ziesemer,  RHIA, CCS, ICD-10-CM/PCS Trainer is the health information program manager and professor with Lake-Sumter State College. She is a Registered Health Information Administrator and a Certified Coder Specialist. She was an AHIMA-approved ICD-10-CM & PCS Trainer from August 2011 through June 2017. She is also a member of: the American Health Information Management Association and the Florida Health Information Management Association (AHIMA/FHIMA), the Health Information Management Systems Society (HIMSS) and of the Professional Association of Healthcare Office Managers (PAHCOM).

Brandy was the FHIMA ICD-10 Task Force Leader from July 2013-June 2015. The focus of the taskforce included ICD-10-CM/PCS training (basic and “All Hands on Deck), physician outreach and education in Florida, and acting as a liaison between CMS along with their training partner, Noblis, FHIMA, PAHCOM and AAPC to offer free training to clinicians and their staff.

Over the past year, Brandy has presented three “Food for Thought” sessions for practice managers affiliated with Florida Hospital Waterman. Topics included: MACRA/MIPS; Documentation Improvement to increase the accuracy and specificity of ICD-10-CM code selection; and mastering the correct use of CPT/HCPCS modifiers.

Brandy has co-authored a CPT coding book, contributed to a health informatics book and written a text on Medical Office Management and Technology. She is also the editor of PAHCOM’s six Practice Management Manuals and an advisor to PAHCOM’s education staff.
Brandy has been awarded 3 service awards through FHIMA: Educator of the Year; Literary Award and in 2015, Distinguished Services Award.

Prior to joining the LSSC faculty in 1997, she had extensive experience working with managed care organizations in California and New Jersey, and consulting in physician practice management in Florida. She and her husband moved to Florida from Northern California in 1993.

Snippet Of The Webinar:

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