CMS Modifier 25 and 59 Reimbursement Guidelines: Don’t Bottleneck Your Payments

Event Materials (Key Required)

Course Description

Modifier 25 and 59 have a long history of confusion and misused by providers, coders, and auditors. These modifiers are one of the hardest modifiers to determine appropriate use. The term “significant, separately identifiable service” has been very subjective to different interpretations. The American Medical Association (AMA) recently indicated that more than one E/M service on the same day by the same provider may be reported with Modifier 25, leading to further confusion in the coding community. Modifier 25 has been on the payer’s radar for some time and continues to be a problem for payment.

This webinar will describe the nuances related to the usage of modifier 25 and 59 when billing for your level of service and services on the same day as a minor procedure. Using modifier 59 and distinctly documenting the two procedures using the right tools and knowing when it’s requirement and how to appropriately append them. With granular understanding of its usage, will create more opportunities for fluid revenue stream and understanding its usage.

Learning Objectives

• Understanding how and when to use modifier 25 and 59
• Documentation requirements for when modifier 25 and 59 is most appropriate
• What is modifier 59 and what are the purposes?
• Understanding the Procedure-to-Procedure (P2P) files and knowing how to use them when understanding bundled payments or services which are inclusive for services
• Learn the NCCI guidelines on the appropriate use of modifiers
• Be able to apply the correct modifier(s) based on the specific circumstances
• Learn how to properly resolve NCCI edits including a breakdown of modifier 59
• Proper use of modifier 25, especially in the office or outpatient setting

Areas Covered in the Session

• What is CMS’ definition of modifier 25?
• Modifier 25 Updates from AMA from CPT Assistant
• Key considerations for correct reporting of modifier 25 include the following:
• Append only to E/M services
• Requires awareness of usual preoperative and postoperative services
• Inpatient or Observation on the Same Calendar Date of Another Service
• Billing Examples: CMS (Medicare finalized Rule) vs. AMA (CPT Guidelines)
• What is modifier 59, XE, XP, XS, and XU?
• National Correct Coding Initiative (NCCI)
• Understanding and Applying the National Correct Coding Initiative Coding Manual
• What is modifier 59 and the X modifiers?
• The Dilemma: Using Modifiers 59, XE, XP, XS, and XU
• Using XS Modifier
• Using XE Modifier
• Using XU Modifier
• Modifier 25 vs Modifier 59
• Modifier 25 Correct usage
• Modifier 25 Examples
• Modifier 59 and X Modifiers Correct Usage
• Modifier 59 and X modifiers Examples
• Example 1: Column 1 Code/Column 2 Code - 11102/17000
• Example 2: Modifier 59 Column 1 Code/Column 2 Code - 47370/76942
• Example 2: Modifier 59 Column 1 Code/Column 2 Code - 93453/76000
• Key Takeaways

Suggested Attendees

• Physicians and Non-Physician Practitioners
• Qualified Health Care Professionals
• Coders
• Billers
• Auditors
• Nurses
• Practice Managers
• Medical Officers
• Compliance Officers
• Clinic Managers
• Insurance Company Claims Reviewers
• Insurance Payers
• Payment Policymakers
• Denial Resolution Team

About the Presenter

Maya Turner, CPC, CPMA, CPC-I, has nearly 30 years of experience in revenue cycle management, coding compliance and education. Maya’s dynamic teaching style and unparalleled expertise will undoubtedly enrich the learning experience for our participants, ensuring a comprehensive and engaging educational journey. A seasoned certified coder and auditor, boasting of nearly 30 years of experience and subject matter expert to many coding compliance subjects, she especially is sought after for her in depth knowledge base of pro fee multi-specialty practice, primary care, hospitalists, telehealth, inpatient, as well as SNF. She is also a published author having written articles for AAPC and HCCA, and currently is a part of the ACDIS Leadership Council. She’s scheduled to speak at such venues as HealthCon, and HCCA’s Compliance Institute.

She showcases her unmatched three-dimensional thinking in complex subject matters, Maya's success is marked by her clear and well received presentation style, reflecting her profound understanding and expertise. Maya also has a consulting service called Turner Expert Consulting Services, LLC. This venue allows her to assist other entities and provide training and expertise outside of her current employer. It’s with this, bringing her great joy to assist others in any way she can.

Additional Information

System Requirement:

• Internet Speed: Preferably above 1 MBPS
• Headset: Any decent headset and microphone which can be used to hear clearly

For more information, you can reach out to the below contact:

Toll-Free No: 1-302-444-0162

Email: care@skillacquire.com 

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