Sunflower State Health Plan Update on NCCI Edits for Modifiers 25 and 59

 

Sunflower State Health Plan’s clinical editing team will review claims submitted with Modifiers 25 and 59. The team will determine if the claim provides enough information to warrant the use of these modifiers. If a claim has denied and you believe the modifiers were billed appropriately for services provided, please follow the processes for Corrected Claims, Requests for Reconsideration or Claim Disputes as outlined in the Sunflower State Health Plan Provider Manual. You must submit supporting medical documentation with your Request for Reconsideration or Claim Dispute.

The 2014 Provider Manual is now available on our website at www.sunflowerstatehealth.com under Provider Resources.


Significant, Separately Identifiable E/M Service by the Same Physician on the Same Day of the Procedure

Modifier “-25” (Significant, separately identifiable Evaluation/Management (E/M) service by the same physician on the same day of the procedure), indicates that the patient’s condition required a significant, separately identifiable E/M service beyond the usual pre-operative and post-operative care associated with the procedure or service.

Providers must document both the medically necessary E/M service and the procedure must be appropriately and sufficiently documented by the physician or qualified non-physician practitioner in the patient’s medical record to support the claim for these services. This documentation should be submitted for reconsideration of a denied claim.


Procedure or Service was Distinct or Independent from Other Services Performed on the Same Day

Modifier -59
: "Distinct Procedural Service: Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier 59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries)not ordinarily encountered or performed on the same day by the same physician. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used."

More information and examples about the use of Modifier 59 can be found at

http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html?redirect=/NationalCorrectCodInitEd/NCCIEP/list.asp