Forum - Questions & Answers

Oct 28th, 2015 - medhari15 3 

Please suggest valid modifier for CPT® code 25600

CPT® code 25600 denied by Gateway health plan stating "The procedure code is inconsistent with the modifier used or a required modifier is missing".
We haven't reported the services with any modifier and the claim was billed together with the CPT® codes "99203, 25" modifier and "Q4012".
Can anyone please suggest me a valid modifier for the CPT® code 25600 for reimbursement. Thank you so much for your time!!

Oct 28th, 2015 -

re: Please suggest valid modifier for CPT® code 25600

I think you need modifier 57 on the office visit since the procedure you performed is considered a surgical procdure. Modifier 57 is used as "decision for surgery" which was made during the office visit

Oct 28th, 2015 - medhari15 3 

re: Please suggest valid modifier for CPT® code 25600

Thank you so much for response. Here the CPT® code 99203 got paid and only the CPT® code 25600 denied for missing modifier. Kindly advise me. Thank you!!

Oct 28th, 2015 -

re: Please suggest valid modifier for CPT® code 25600

Your Welcome, and just an FYI....In ortho anytime a patient is seeing the provider for a FX and he makes the decision during the o/v to set the FX you should use the modifier 57:)

Oct 28th, 2015 - petunia 195 

re: Please suggest valid modifier for CPT® code 25600

CPT® code 25600 denied because it is a 90 day global code. You will need to ask the carrier to correct and add modifier 57 to the 99203 that has already paid in order for them to process 25600. They are denying the 25600 because you have not given them the decision for surgery modifier on the E/M

Oct 29th, 2015 - Sthourot 2 

re: Please suggest valid modifier for CPT® code 25600

Upon researching your request, I have found that Modifier 25 or 57 is one that may be used. However, Also keep something in mind, CPT® code 25600 has a 90 day global period. So it includes the work associated with the day the fracture is diagnosed and all follow-up evaluation and management (E&M) services for the next 90 days. 99024 would also be used for the global service.

Hope this helps.

Oct 29th, 2015 -

re: Please suggest valid modifier for CPT® code 25600

Modifier 57 would be the more correct modifier to use as the physician at the time of service decided to perform a surgical procedure that has a 90 day global. The prevailing industry standard is to use modifier 25 w/an E&M level is used for a minor procedure that has a 10 day global and a modifier 57 w/E&M level that has a 90 day global. also modifier 57 is use to dientify when the decision for any major surgery is made.



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