Forum - Questions & Answers

Mar 31st, 2015 - MHYETT 5 

medicare billing ugh

I have a patient that came in for a Pessary, 57160, and polyp was found so polypectomy 57500 was done... any suggestion on getting paid for both?? Would modifier 25 be appropriate, and should it be on the 57160? Thanks for input...in advance.

Mar 31st, 2015 - youngblood 278 

re: medicare billing ugh

Well, here is a weird bit: the Bx is higher value than the pessary fit, but it is the one that bundles. So it should be 57160 and 57500-59.

Mar 31st, 2015 - MHYETT 5 

re: medicare billing ugh

Thank you, that was my 2nd thought.. appreciate the feed back!

Mar 31st, 2015 -

re: medicare billing ugh

First of all modifier 25 should only be used on levels of E&M services not procedures. Please refer to the back of the CPT® book for the correct use of modifiers, you will find a complete description of their correct use. Per the ACOG guidelines you are allowed to bill 57500 with 57160 as long as the correct modifier is used. CMS has adapted new modifiers for modifier 59 to define subsets of modifier 59. If you go to the MLN Matters site for CMS you can find the article explaining the new HCPC's modifiers, XE, XS, XP and XU. it is MLM Matters Number: MM8863, all practices should get in the practice of using the more defentive modifiers. CMS will continue to reconize the 59 modifier, but notes that CPT® intructions state that the modifier 59 should not be used if a more descriptive modifier is available.(you should pull up the article and read it thourghly) also CPT® code 57500 pays 2.26 rvu's and 57160 only pays 1.41 and should be billed as the second procedure with the correct modifier. :)

Mar 31st, 2015 - MHYETT 5 

re: medicare billing ugh

Got it, thank you.

Apr 20th, 2015 - MHYETT 5 

re: medicare billing ugh

I just received my eob from Medicare and they did not pay on the 57500, which was listed first, and then followed by the 57160 with mod. 59. I am hopeful that I misunderstood the advise. Please help. Was I suppose to put the modifier on the 57500?

Apr 20th, 2015 - Mand0984 11 

re: medicare billing ugh

59 should be on 57500 which is listed in column 2 of NCCI edits.



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