Medical Billing & Coding For Dummies
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Medical Coders have found that certain modifiers are appropriate for surgical or diagnostic procedures. Other modifiers are appropriate for claims submitted for reimbursement of office visits, referred to in the coding world as evaluation and management, or E&M, visits. Here are the modifiers you’re most likely to use:

  • Modifier 25: You use this modifier when a procedure is performed on the same day that an E&M visit occurred. This modifier indicates that the procedure wasn’t related to the E&M visit, and the provider feels that additional reimbursement is warranted.

  • Modifier 51: This modifier indicates that multiple procedures have been submitted on one claim, and the appropriate discount may be applied.

    Most claims processing pay 100 percent of either negotiated rates or fee schedule reimbursement for the first procedure. Then additional procedures are paid at 50 percent of fee schedule, although some commercial payer contracts pay 25 percent of the third (or remaining) procedure(s) on each claim.

    Medicare pays 100 percent and 50 percent, regardless of the number of codes submitted. Other payer contracts may limit the number of procedures paid per encounter.

  • Modifier 59: You use this magic modifier to indicate that a procedure being billed is normally included with another procedure or encounter but warrants separate consideration.

Correct reimbursement may depend upon using the appropriate modifier, and you’re responsible for understanding which modifier to use when. But be careful. If you overuse or incorrectly use them, the provider can get into trouble.

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