Modifiers?

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clubdeac

clubdeac

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Are these modifiers still being used in private practice? And if so how are they getting paid

-59 (for a distinct separate procedure). I use this when I do an epidural and they want a knee injection too. Does it pay 100% of both codes?

-25 (add on procedure to a clinic visit) I do this when I see them for back pain and they want a joint injection too. Again does it pay 100% of both codes?

-50 (bilateral modifier) I assume everyone gets paid 1 1/2 times the usual code. Correct?
 
I'm in private practice and regularly use all 3 modifiers.

-25 - I work with some surgeons that send a new patient specifically for an epidural steroid injection so I use an E/M code with the 25 modifier to perform the ESI at the first visit.

- 59 - sometimes I perform SI joint injection with a piriformis muscle injection at the same time. I typically use the 59 modifier for this when I add on the trigger point code for the piriformis muscle. Not all insurances reimburse 100% for both codes.

- 50 - Correct. 1.5x reimbursement typically.
 
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No_Pain_No_Gain said:
I'm in private practice and regularly use all 3 modifiers.

-25 - I work with some surgeons that send a new patient specifically for an epidural steroid injection so I use an E/M code with the 25 modifier to perform the ESI at the first visit.

- 59 - sometimes I perform SI joint injection with a piriformis muscle injection at the same time. I typically use the 59 modifier for this when I add on the trigger point code for the piriformis muscle. Not all insurances reimburse 100% for both codes.

- 50 - Correct. 1.5x reimbursement typically.
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Agree with the above, watch out for applying -25. Overuse will trigger an audit (just like everything I guess) ie don't inject 50% of your patients on their first visit. I think they way above poster uses it is the way that will mostly likely keep you out of trouble.
 
59 almost never 100%

better off bringing back
 
You've correctly suspected that the -50 modifier is a scam to reduce reimbursement.

I use -25 for trigger points. I'll often do those as part of an initial visit, especially with neck/shoulder symptoms. For subsequent visits I usually just bill the 20553, although they pay for crap.

Also don't forget the -53 modifier for aborted procedures.
 
drrosenrosen said:
You've correctly suspected that the -50 modifier is a scam to reduce reimbursement.

I use -25 for trigger points. I'll often do those as part of an initial visit, especially with neck/shoulder symptoms. For subsequent visits I usually just bill the 20553, although they pay for crap.

Also don't forget the -53 modifier for aborted procedures.
Click to expand...

Also don't forget the -53 modifier for aborted procedures.

what does this pay generally?
 
So just found out the hospital employed job I'm looking at does not pay 1.5x wRVUs for using the -50 modifier. Instead they pay nothing extra for bilaterals. Anyone else see this? Sounds like complete bull**** to me
 
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you can just bring them back the next day for the other side. not that i advocate for this, but that is how you would get around it. you shouldnt do the extra side "for free".

i do bilateral TFESIs all the time

this would mean bringing a patient in for 6 separate injection visits to complete a bilateral L3, L4 and L5 RF. not to mention the office visits.
 
Well, technically....

The ASIPP fee schedules do not have columns for bilateral procedures... you can add on, for more than that one level, but bilateral is not considered add on. It’s still same level...
 
The codes 64635 and 64636 wouldn't be affected by the -50 modifier described. You may need 2 sessions for a bilateral, but not 6
SSdoc33 said:
you can just bring them back the next day for the other side. not that i advocate for this, but that is how you would get around it. you shouldnt do the extra side "for free".

i do bilateral TFESIs all the time

this would mean bringing a patient in for 6 separate injection visits to complete a bilateral L3, L4 and L5 RF. not to mention the office visits.
Click to expand...
 
cowboydoc said:
The codes 64635 and 64636 wouldn't be affected by the -50 modifier described. You may need 2 sessions for a bilateral, but not 6
Click to expand...

6 sessions if 2 right mbb then rf
Then 2 left mbb then rf
 
geauxg8rs said:
6 sessions if 2 right mbb then rf
Then 2 left mbb then rf
Click to expand...

correct.

i do a bilateral L5 TFESI on all my LOL with severe L4-5 central stenosis. this "policy" will have a big effect on your practice, and you should have a game plan to deal with it
 
I'll just have to make sure my unilateral TFESIs are medial enough to get good anterior epidural inflow/ingress
 
Is it ok to perform a f/u visit and a in office procedure at the same visit and bill for both. Or is it better to bring them in separately for the in office procedure?
 
Ducttape said:
It’s not about the money.



Or so - apparently - only I say...
Click to expand...

this is about better patient care

a TFESI it s a better injection than an ILESI, and a bilateral TFESI for central stenosis works much better IMHO.

care should not be dictated by how this particular hospital likes to set up their charges.
 
EruditeDoc said:
Is it ok to perform a f/u visit and a in office procedure at the same visit and bill for both. Or is it better to bring them in separately for the in office procedure?
Click to expand...

"better" is a judgement call.

we used to have a poster on this board who thought that it was never OK to bill an E/M the same time you bill an injection.

i do it from time to time, but i try to keep my office visits for office visits and my injection s for injections. it doesnt always work out that way -- if i get a direct referral for an injection or i need to change the injection, or a f/u patient comes back directly for an injection, etc.
 
you have to make sure that the office visit is for something other than getting consent for the procedure. it has to be different. technically, if you only talk about their pain and do an injection specifically for that pain, then the discussion is not separate and you shouldn't bill for both fu and procedure...

I purposely will use 2 different ICD-10 codes to make sure it is clear (for example Z79.899 long term use other high risk medications for a TCA + M96.1 postlaminectomy syndrome).

there can be a reduction in overall $$ if you do them together, but it might be more time efficient for you to do both at the same time, and patients love this because there is only 1 copay. so its almost a crapshoot.
 
So a question for the more senior docs out there, is it legal for a hospital not to pay you for a modifier? Like to not pay you for a bilateral procedure when you use a -50 modifier. I mean the hospital's sure getting paid for both sides
 
clubdeac said:
So a question for the more senior docs out there, is it legal for a hospital not to pay you for a modifier? Like to not pay you for a bilateral procedure when you use a -50 modifier. I mean the hospital's sure getting paid for both sides
Click to expand...
Think it depends on the language of your contract....maybe legal but sure is shady
 
if you wont be getting paid for bilateral procedures -- dont do bilateral procedures. the hospital will have to deal with the fallout from it. we dont do pro-bono work. or at least we shouldnt.
 
What makes you think the hospital is getting paid for both sides?

Review your ASIPP fee schedules.

There is no ASC or HOPD payment for ALL add-on codes.
 
Ducttape said:
What makes you think the hospital is getting paid for both sides?

Review your ASIPP fee schedules.

There is no ASC or HOPD payment for ALL add-on codes.
Click to expand...
ASIPP fee schedule doesn't mean much in this situation as it doesn't show rates for (50) modifier for professional fees in any schedules.
Our ASC gets paid for bilateral fees and I think for the most part HOPD do as well
 
clubdeac said:
So a question for the more senior docs out there, is it legal for a hospital not to pay you for a modifier? Like to not pay you for a bilateral procedure when you use a -50 modifier. I mean the hospital's sure getting paid for both sides
Click to expand...

If you're hospital employed then you probably get paid by wRVU's and if modifiers have no wRVU's associated with them then you won't get 'paid' for them.
Physician Fee Schedule Search
 
In my experience, this is payer dependent.

This is an odd conversation to having at this point. The contract should specify if there is an exception to the wrvu specifics.
 
I will do 99213-25 and 20553 fairly frequently, or occasionally 99204-25 and 20553. I rarely bill the modifier except for TPIs, since from a wRVU standpoint, a 0.83 TPI alone is a negative revenue situation (wRVU/visit <1). If they really just come in for trigger points every couple of months, and we're not discussing two separate issues, I just suck it up and don't bill an E&M, since I don't feel that I can justify it. I also use -25 modifier for E&M and pump/stim programming or fills (baclofen pumps).
 
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drrosenrosen said:
I will do 99213-26 and 20553 fairly frequently, or occasionally 99204-26 and 20553. I rarely bill the modifier except for TPIs, since from a wRVU standpoint, a 0.83 TPI alone is a negative revenue situation (wRVU/visit <1). If they really just come in for trigger points every couple of months, and we're not discussing two separate issues, I just suck it up and don't bill an E&M, since I don't feel that I can justify it. I also use -26 modifier for E&M and pump/stim programming or fills (baclofen pumps).
Click to expand...


U mean -25?
 
I just noticed my hospital billers changed a bilateral MBB modifier on me from -50 and added -51 and -59. Is that appropriate? Has anyone seen that before?
 
thanks for that link. I still don't think they should be switching my bilateral lumbar MBBs from a -50 to a -51 and -59 based on that info.
 
Sometimes have a surgeon refer patient with hot radic requesting same day new new patient visit with ESI. Does the -25 modifier discount payment on either the 99204 or 64483? Or does the modifiers allow for full reimbursement on both?

And is the modifiers applied to the visit or procedure or both? 99204-25, 64483-25?
 
Someone told me it's important (ie. so you don't get audited) to have a good number of 99203 mixed in with your 99204. What % of your patients are 99204 vs. 99203. When I look at the criteria for what qualifies for each, I feel like the vast majority are 99204 but don't want to get audited.

Is it more important this "good ratio" apply to federal payors? Do commerical insurances "audit"?


Sam question for 99214 vs. 99213. What's a good and normal ratio for these that you guys typically see?
 
paintrain said:
Someone told me it's important (ie. so you don't get audited) to have a good number of 99203 mixed in with your 99204.
Click to expand...

A new patient visit means I’m taking a careful history of present illness, reviewing past failed measures, doing a physical exam, reviewing images and medications tried previously and deciding what medication, physical therapy and procedure they need or ordering further work up. To me that’s never a 99203. They are referred to a specialist for a reason. Haven’t been audited for this in the 3 years I’ve practiced.

Most of my follow ups are 99213 because I consider the decision making process easier. I will choose 99214 if there is a new area they want treated or I haven’t seen them in several months after their last problem was “fixed.” I justify this with my skills as a specialist being employed more deeply again to work up why they are here.
 
paintrain said:
Sometimes have a surgeon refer patient with hot radic requesting same day new new patient visit with ESI. Does the -25 modifier discount payment on either the 99204 or 64483? Or does the modifiers allow for full reimbursement on both?

And is the modifiers applied to the visit or procedure or both? 99204-25, 64483-25?
Click to expand...


Applied to Visit
 
paintrain said:
Sometimes have a surgeon refer patient with hot radic requesting same day new new patient visit with ESI. Does the -25 modifier discount payment on either the 99204 or 64483? Or does the modifiers allow for full reimbursement on both?

And is the modifiers applied to the visit or procedure or both? 99204-25, 64483-25?
Click to expand...
from my understanding, that would be no. he is there for the radic and the ESI is treatment for the radic, not a separate and distinct problem or treatment.
 
When you use the -25 modifier on the e&m and then do those tfesi/ilesi, what insurance is this? Do these modifiers only work for Medicare or private as well? No Pre-determination needed for private if you use the modifier and perform in an office procedure suite?
 
I'm in dermatology but a lot of similar stuff applies regarding modifier 59 and 25 (though not the bilateral modifier 50 since skin is one organ). The payer matters in terms of the modifiers. In Michigan it is acceptable to bill new patients under an E&M and 25 for minor procedures I would typically do like intralesional injections, biopsies, etc even if only one assessment (though I like to address multiple diagnoses on the first visit to avoid an audit as one doesn't want to be an outlier for this type of thing). As long as in dermatology and other specialties use a lot of 25 modifiers the insurers (see BCBC/Anthem and their recent attempt to reduce reimbursement for 25 modifiers) they will look for ways to reduce pay. For procedures that take longer than 5 minutes (my typical excisions and repairs) I wouldn't be doing those in the first visit as it's considered bundled with the procedure and I need to verify what a referring physician has done. (This doesn't typically match how some mohs surgeons do the procedure the same day as the first visit. Most of the time their evaluation and consent is bundled in the procedure).

For follow up visits in general I'm not billing a lot of 25 modifiers unless I'm assessing problems other than the minor procedure and properly documenting an exam necessitating the E&M bill separately. For major procedures again I don't typically also bill an E&M due to risk of rejection and for time.
 
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