Author Topic: Modifier  (Read 1130 times)

dfranklin

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Modifier
« on: December 17, 2009, 04:42:20 AM »
How do you know when you should really be using modifier 25, 51, 52 or 59? 

Steve Verno CMBS, CEMCS

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Re: Modifier
« Reply #1 on: December 17, 2009, 05:25:49 AM »
When the circumstances described in the descriptor call for them to be used

Example.  An office visit is an office visit is an office visit.  I go see Dr Jeckyl for a back ache, I am examined, referred to a specialist or sent home with instructions and/or meds.  This is a normal office visit.

BUT, this time I go because I have my back pain and behind closed doors, I say, Doc, I also have this chest pain not associated with a known injury.  I have a history of heart attacks. The doctor doesnt know if I am having a heart attack.  SO, he does an EKG.  The EKG is an extra procedure not normally performed in an office visit (The insurance company nurse will argue wih you about this), so the doctor bills the office visit AND the EKG.  The main reason for the visit was my back pain but I announced the chest pain as an additional problem, hence doing an extra procedure to rule out anything serious.  Modifier 25 is used to designate that the office visit was the main reason for the visit.  The EKG (Page 4 of the CPT), a diagnostic test, not included with an E/M is also being billed.  The back pain and chest pain support the level of E/M. Modifier 25 says the office visit was the main reason for the visit.  The chest pain supports the EKG. 
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