Coding Topic : Handling denials with Modifier 24 and 25

 

Modifier 24- Definition Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period: Physician may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure.

An E/M service can be coded with modifier 24 to indicate a visit in the postoperative period that is unrelated to the original procedure (surgery). This modifier is not valid when coded with surgeries or other types of services. It is not appropriate for modifier 24 to be coded with diagnostic tests performed in the postoperative period. These are not part of the global surgical allowance and are always considered separately.
_____________________________________________

How to handle denials on No Fault claims submitted with Modifier 24 and 25

 Telephone Appeal

 Written Appeal-

 If payment is still not made - then arbitrate.

Modifier 24 - Telephone appeals to the insurance carriers are common for such denials and usually effective . Diagnosis codes are often overlooked by the insurance carrier  as well as the modifier when billing is submitted with a modifier 24 .  Explain to the insurance  claim representative what denial was placed on the claim, why the denial is incorrect and request payment reconsideration to be made.  If this doesn't get the payment in , then submit a payment review request in writing, with a copy of the AMA modifier 24 guidelines ,pointing out how the E/M service billed is not related to the surgery performed. 
__________________________________________________
Modifier 25- Definition

Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service: It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59.

***Use the same steps as above - Telephone appeal, written appeal and arbitrate if necessary .


Billing and Collections staff should have modifier appeal letters on hand to respond to this type of denial immediately.