Why you should tread carefully when using Modifiers -25 and -59 in Urology Billing?

Urology Billing is the process by which healthcare practitioners bill insurance companies for services provided to patients. The Urological Supplies Local Coverage Determination (LCD) provides for the use of modifiers with each submitted HCPCS code to indicate whether the applicable payment criteria are met KX modifier and to provide other information related to coverage and/or liability (GA, GZ, and GY modifiers) when the policy criteria are not met. This article reviews the appropriate use of each modifier through Urology Medical Billing Services.

Proper selection of the correct G modifier requires an assessment of the possible cause for denial. Some criteria are based on statutory requirements. A failure to meet a statutory requirement justifies the use of the GY modifier.

By and large, Medicare uses modifier — 25 on all E/M administrations connected with a minor procedure, which means the evaluation and management, ought to be paid for separately and not bundled with the surgical reimbursement. It might be important to point out that on the day a procedure recognized by a CPT code was performed, the patient’s condition required a critical, independently identifiable E/M administration well beyond the other services provided or past the typical preoperative and postoperative consideration connected with the procedure that was performed. Furthermore; Urology medical billing services implemented a new modifier —25 which implies the surgery will be done on the same day.

So, when should you ‘NOT’ use the Modifier 25?

  • When billing for procedures performed amid a postoperative period if identified with the past surgery
  • When there is only one E/M service performed during office visits (no procedures done)
  • At the point when on any E/M on the day a major procedure is being performed
  • When a patient came in for a scheduled procedure only

What does the – 59 Modifier mean when used in Urology Billing Services?

Modifier – 59 indicates that two services not normally reported separately are appropriately reported separately under the circumstances. For example, if you see an accident victim in the emergency room and the patient requires fracture care on the right arm and some strapping on the left arm, you may need to attach modifier -59 to the strapping code to indicate that it was separate from and should not be bundled with the fracture care, which includes the initial cast, strap or splint. Modifier -59 should be attached to the lesser value of the two services or to the code, regardless of value, that would otherwise be denied or is a component of another, more comprehensive code. This modifier is usually considered a last resort since its descriptor says that it should only be used “if no more descriptive modifier is available, and the use of modifier -59 best explains the circumstances.”

Modifier -59 would be attached to indicate that the biopsy, which is normally bundled with excision of the same lesion, was done on a separate lesion from the one that was excised.

Medical Billers and Coders (MBC) is a leading medical billing company providing complete medical billing and coding services. In case of any assistance needed in urology billing and coding, call us at 888-357-3226 or drop an email at: info@medicalbillersandcoders.com.