International Classification of Diseases or the ICD-9 system is utilized to code signs, symptoms, injuries, diseases and conditions. The relationship between ICD-9 and Current Procedural Terminology (CPT) is critical, in that the diagnosis supports the medical necessity of the procedures or Evaluation and Management (E&M) service being provided.
The provider’s documentation must be specific, and the diagnosis code selected must be to the highest specificity that the documentation supports. ICD-9 codes may be 3 to 5 digits depending on the level of specificity required.
Abdominal pain – 789.0
Abdominal pain, right upper quadrant – 789.0
A level I modifier is a two digit code that modifies a service or procedure under certain circumstances. Level I modifiers are updated annually by the American Medical Association (AMA). These modifiers add information, change the description of a service or procedure rendered. Appending an appropriate modifier will effect reimbursement of the service.
Some examples of commonly used modifiers would be:
25 – Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure of other service;
57 – Decision for surgery;
59 – Distinct procedural service; and
82 – Assistant Surgeon (when qualified resident surgeon not available)
Are your providers utilizing modifiers correctly, and does their documentation support the use of the modifier?
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