No-Fear Pediatrics Coding: Learn the Correct Use of Modifiers 25 & 59

Pro tip: First check whether the service qualifies as E/M

Let’s face it: You work in a fast-paced environment where codes are added, deleted, and revised on a regular basis. You’re preparing to implement the new ICD-10-CM codes on October 1, 2018 and the new CPT® codes on January 1, 2019. What you need are quick and easy guidance to selecting the right code and modifier quickly.

Pediatrics modifiers are a special thorn in coders’ sides. During her presentation “Modifiers and How to Do an Audit,” medical records consultant Donelle Holle walks you through the when, how, and why of correct modifier usage. The webinar, just one of three session Holle is presenting during AudioEducator’s 2019 Coding Updates Virtual Boot Camp, cuts to the heart of the matter so these tricky modifiers slow you down no more. Plus, she clues you into how to perform a pediatrics audit and how to appeal a denial so you capture all the reimbursement you deserve.

Pediatrics Modifiers 25 and 59: Not Interchangeable

Two particularly challenging modifiers are -25 and -59. Their definitions are similar but not interchangeable. Here’s a quick breakdown of differences between the two:

  • 25: reports a significant, separately identifiable evaluation and management (E/M) service done by the same physician on the same day
  • 59: reports a different procedural service

As you can see, modifier 25 is specifically for reporting another E/M service, whereas -59 is not so specific. Other key differences include:

  • Modifier 59 should be used only as a “last resort modifier.” That means that if there’s another modifier you can use, you should use that other modifier.
  • For -25, you may need to prove that an additional E/M service that went above and beyond the planned procedure was performed because of the patient’s condition on the day of the procedure. To save yourself compliance headaches, it’s a good idea to include this documentation regardless.
  • Modifier 25 should be appended only to E/M codes found in the CPT® manual, whereas -59 should never be appended to those same E/M CPT® codes.

To E/M or not: Save yourself time and headaches by remembering that the first thing to look for—after determining that you can use a modifier—is whether or not the additional service falls under E/M. If it does, use -25; otherwise, use -59 if no other modifier is appropriate.

Good Modifier Usage: Case Studies

To help clarify when you can use which modifier, here are a couple of examples:

Case 1: A 7 year-old child shows up to the pediatrician’s office for a sick visit. During examination, the pediatrician determines that an antibiotic injection (96372) is necessary. To properly code for this visit, you would first use E/M code 99214 (outpatient office visit), appending -25, and then 96372. You append -25 to 99214 since it is E/M, and not to 96372, a non-E/M service.

Watch out for changes: Up until now, outpatient visits have been broken up into five levels, with 99214 being Level 4. However, if the proposed rule from the Centers for Medicare & Medicaid Services (CMS) goes through, the payment system would see some changes. Be sure to read up on this proposed rule, as the changes, if approved, would take effect January 1, 2019.

Case 2: A physician bills for a language delay screening (developmental screening), which falls under code 96110. If this code is paired with an E/M service, you should append -25 to the E/M code. However, if for whatever reason you are unable to do so—say, for example, because of the payer’s rules—you could append -59 to 96110.

Bye-bye to 96111: Code 96110, mentioned above, is still around, but the next one on the list, 96111, will  be no more as of January 1, 2019, due to CPT® edits.

Gear Up for Worry-free Modifier Coding

Key Takeaway: Because modifiers affect your reimbursement, payers are closely scrutinizing your pediatrics claims. That’s especially true for claims with -59 on them, as many coders (unintentionally!) misuse this modifier. Claims denials and pediatrics audits are scary, but only if you don’t have the right knowledge to combat and prevent them. Tighten your knowledge of correct modifier usage today, as it could make or break your practice’s reimbursement levels.

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