How to Make Proper Use of Modifiers in Outpatient Coding

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Outpatient coding refers to assigning the medical codes for the services provided for the patient who is treated in the hospital less than 24 hours. Medicare determines reimbursement of these services on the basis of the Outpatient Prospective Payment System (OPPS). You can buy the best coding material books at huge discounts.

However, the use of modifiers is equally important to ensure reimbursement for outpatient services. Modifiers used in outpatient coding must be appropriate and accurate to the services provided. You can opt for medical coding and billing books where you will find relevant information.

If you don’t apply modifiers then your claim will be flagged for review and you will fail to submit the required documentation. In this way, modifiers can be the source of outpatient coding errors if you don’t give proper attention. Here are some modifiers which are used in outpatient coding and are also mentioned in medical coding books:

  • Modifier 25:-

Modifier 25 is notable and separately identifiable evolution and management service by the same physician or qualified healthcare professional. To be more specific this modifier may be appended to an evolution and management (E/M) service code if:

  • A distinct E/M service is provided on the same day as another at the same or separate encounter.
  • Performed by the same physician or other qualified healthcare professional.
  • Modifier 59:-

Modifier 59 is specified as a Distinct Procedural service and typically used as a modifier of last resort. It is important to indicate a procedure or service was distinct from other non E/M service performed during the same day.

If you are appending this modifier then your clinical documentation support the following:

  • Different Session
  • Different procedure or surgery
  • Separate injury
  • Different site or organ system

One point to note down is that you should not append this modifier.

  • New X modifiers:-

The center of Medicare and Medicaid Services (CMS) introduced new X modifiers on January 1.CMS will accept either modifier 59 or modifier X.

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