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June 5, 2018 @ 11:19 AM Reply  |  Email Friend   |  |Print  |  Top

I have a question can modifier 59 be used on code 90471 when billing an OV 99213 w mod 25? but also a wellness was done and modifier 33 was used for code 99397, now code 90471 was submitted without modifier but an immunization was also given so in that case the claim was submitted without mod 59. The claim denied payment for the wellness code 99397 so I appeal it but this time that's when I used mod 59 to code 90471 but the insurance still denied code 99397. and the insurance had already paid for code 90471 and with the appeal just by adding mod 59 to 9047 the insurance paid .71 cents more. I don't know if 59 should go w/99397?

September 2, 2018 @ 6:04 PM Reply  |  Email Friend   |  |Print  |  Top

When you are billing for a well check with vaccines and sick services in the same day you need to put a 25 modifier on the well office visit line and on the sick office visit line. (99397-25 and 99212-25) However, insurance companies will only reimburse additionally on a 99212 regardless of how much additional time was spent. Therefore, if the patient comes in for a well visit and is sick and needs additional services to include diagnostic tests it may be best to see the patient for the sick visit and reschedule for a well check. Modifier 59 should not be needed. Also procedure code 90471 would be incorrect to bill unless this is a nurse only visit. You need to use procedure code 90460 for vaccine administration with a total number of vaccines given in the quantity. If any of the vaccines have multiple components, then a 90461 also needs to be added with quantity of additional components. I will add that if the patient has any form of Medicaid, you must submit the well services separate from the sick visit. If the patient has a commercial plan then all the services can be submitted altogether.

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