Claim Tips

Date Issued: 1/1/2010

Coding
Correctly coding your claims is one way to improve your claims processing success rate. EmblemHealth has adopted the "CMS Payment Policies." Click here for the National Correct Coding Initiatives.

Modifiers
One common error we encounter is the incorrect use — or lack — of modifiers. Evaluation and management (E/M) services rendered in conjunction with a surgical procedure are generally included in the global package. There are exceptions when the same physician (or the same physician group practice) performs unrelated E/M services during the global period. The global period assignment is the timeframe that applies to each procedure grouped in certain preoperative, same-day and postoperative services.

  • Use modifier 24 to indicate the E/M is unrelated to the surgery during the postoperative period for a procedure that has either a 10- or 90- day global assignment.
  • Use modifier 25 to indicate a significant, separately identifiable E/M on the day of a procedure or service that has a 0- or 10-day global assignment. The E/M service rendered has to be above and beyond the usual preoperative and postoperative care related to the procedure performed. The E/M can also be unrelated to the condition that prompted the procedure performed.
  • Use modifier 57 to report an E/M service that results in a decision for surgery that has a 90-day global assignment.

Modifiers 24, 25 and 57 can only be appended to the E/M CPT procedure codes. Modifier exceptions may not apply to certain Correct Coding Initiative (CCI) claims rules. Appropriate documentation of the E/M services must be made available in the event of a review for claims using these modifiers.