1. A—Modifier -25 is defined as a significant, separately identifiable evaluation and management (E/M) service by the same physician or other qualified healthcare professional on the same day of the procedure or other service. It is to be placed on the E/M visit only because it attests to the payer there is documentation to support the medical necessity of billing for an E/M visit and a procedure during the same encounter.
2. C—Both the -50 and the -LT/RT modifiers are acceptable, depending on individual payer policy. Either modifier could be used on a bilateral procedure. The -50 modifier should be placed on the second procedure. The -LT modifier is for the left side of the body, and the -RT modifier is for the right side of the body.
3. C—The modifier -25 would be placed on the E/M visit to attest there was a separate and/or significant reason for the visit besides the procedure. The -59 modifier identifies a distinct, different area of the body. The –XU modifier is for an unusual non-overlapping service. You should verify with your payer which modifier, -59 or -XU, is allowed. The claims would be billed as 99214-25, 96361-XU or -59, 96413, 96415, J1745 x 20, J7050. The infusion was stopped because the patient had an adverse reaction. This is why CPT code 96361 with a modifier is allowed. The modifier indicates this was not just an ordinary use of saline to move the drug along, but was used to flush out the patient’s system. It was coded as a subsequent hydration because the infusion was continued; only one initial code is allowed for each infusion, and the chemotherapy code 96413 has the greatest reimbursement. This is allowable according to CPT coding guidelines.
4. B—The -EJ modifier is to identify subsequent claims for a course of therapy, such as a series of viscosupplementation injections. It is to be placed on the HCPCS code after the initial injection. The –EJ modifier is to be placed in the second area of the modifier fields. The first modifier place is for a pricing modifier (e.g., -25, -LT/RT, -59), and the second modifier place is for informational documentation. The -RT is for the right knee that was injected. Note: The -F2 modifier identifies the left hand, third digit. The -E2 modifier identifies the lower left eyelid. The -76 modifier is for a repeated procedure or service by the same physician or other qualified healthcare professional. The claim was coded as 20610-RT, J7323.
5. A—The modifier -25 is to be placed on the E/M visit. The modifier -RT is to be placed on the procedure to identify which side of the body was injected. Note: The E/M would be coded as 99214-25. The history was comprehensive, the exam was expanded problem focused and the medical decision making was moderate. The procedure CPT code should be 20610-RT; which is an arthrocentesis, aspiration and/or injection, major joint or bursa (e.g., knee); without ultrasound guidance. The lidocaine was not coded as it is considered incident to the procedure. The methylprednisolone sodium succinate should be coded as J2920.
For questions or additional information on coding and documentation guidelines, contact Melesia Tillman, CPC-I, CPC, CRHC, CHA, via email at mtillman@rheumatology.org or call 404-633-3777 x820.