Category: Medicare

As we implement additional correct coding guideline edits this fall, we want to highlight some important reminders regarding our expectations concerning modifier use. We understand that the billing of patient treatment has some important nuances that make billing complex at times. This article is one of several you’ll find in upcoming newsletters. 


Things to remember

  • Review the “CPT Surgical Package Definition” found in the current year’s CPT Professional Edition. Use modifiers such as 25 and 59 only when the services are not included in the surgical package.


  • Review, the current year’s CPT Professional Edition Appendix A - Modifiers. Pay attention to the appropriate use of modifiers 25, 57 and 59


  • Use modifier 25 with evaluation and management codes. Modifier 25 should be used when performing E/M services “above and beyond” or “separate and significant” from any procedures performed the same day.   


  • Review Level II HCPCS modifiers. When appropriate, assign anatomical modifiers to identify different areas of the body that were treated. Proper application of the anatomical modifiers helps ensure the highest level of specificity on the claim.


  • Use modifier 59 to indicate that a procedure or service was distinct or independent of other “non E/M services” performed on the same date of service. The modifier 59, represents services not normally performed together but may be reported together under the circumstances.


If you feel that you have received an inappropriate denial after applying a modifier appropriately, please follow the normal claims dispute process and include medical records that support the usage of the modifiers when submitting claims for consideration.

Featured In:
November 2019 Anthem Maine Provider News