[Music] hello we're ready for our cco student webinar we're on number 68 and there is some questions that had recently come in that we're going to answer from our students uh hello to everybody that's visiting us live we had questions about modifiers that's something that is there's a little bit of a learning curve on modifiers you need to know them for both real world coding of course and testing but what everybody struggles with is well when do we actually use the modifiers and so that's what we're going to talk about tonight now our cco student webinars are a little more casual uh make sure you put in the chat anything that pops up that you want to ask a question about and i may stop and answer it but or we'll save them to the end i've got lots of things that i'm going to show you in reference tonight about the [Music] that resources that you can use the first thing you need to be aware of when you're going to use the modifiers in medical coding is what's the actual purpose of the modifier why do we use them ultimately it just helps tell the story so every time that you have a visit with a provider and a patient it is telling a story the provider is going to do an evaluation in a management of the patient an e m and the patient's going to tell the provider you know what the problem is or what's occurring whether it be positive or negative maybe they're doing better with their diabetes or maybe they're struggling with depression or they're there for refills on their medication or they need their annual wellness visit or it's a you know work physical it doesn't matter it's as soon as they walk in that door there's a story to be told and we translate that documentation into a code set so that we can capture it statistically but also that's how our providers are reimbursed both with the cpt codes and the icd codes the modifiers help tell the rest of the story it lets you know that there's going to be something about that code that we're using that we're translating that's a little bit different so again from the time they walk in the story starts and then all the documentation that occurs where we're putting that into a code set so that it could it can be saved and you know maybe you could think of a modifier as in the story being additional adjectives or the like so when we look at the the use of the modifiers first we need to know the purpose what's the purpose of every single modifier that we see in the cpt manual now there's modifiers in your hexpix manual too but once you understand the way the modifiers in your cpt manual work hixpix is just an extension off of cpt so it will work exactly the same way so know the purpose and then we need to know the type of modifier so the purpose of our modifiers they're going to be for increasing funds right you did more work so therefore we're going to increase the funds or decreasing the funds we intended to get to this point in the scope but we weren't able to due to a mass and so we wouldn't be reimbursed for what the intent was or needed to get a claim paid we have to be able to append the modifier to tell the rest of the story sometimes modifiers are just informational to let you know uh what's happening in the scenario so that you know why we're using two codes back to back when you know why did they come back into the or to do the same procedure that you just did well because they had a complication and we needed to bring them back in and open them up and look at them now let's talk about the types of modifiers that there are we've got global package modifiers what that means is whenever you have a procedure it's going to be either a simple procedure that's going to have a 10-day global package or a a more complex procedure that will have a 90-day global package and so if say you um had cut your your hand and you go in and you have stitches you know the then it's a 10 days er you know everything that they do to put those stitches in and take care of that wound is encompassed in 10 days so if you have problems then you come back and that's all included to take care of that one but if you have say a um hysterectomy okay that's 90 days so every the care that it is happening to the patient that had that procedure done there's a 90-day global uh period for that procedure where everything's encompassed in the care of that one procedure there's bundling or cci edits so that would be wanting to break out something that was bundled together or bundle something together some can only be appended to evaluation and management codes some will just tell numbers in other words we had to use two surgeries two excuse me we had one surgery but we had to have two surgeons to to do this procedure so then the modifier explains that there are some modifiers that are only used for anesthesia and then same for labs and then of course there's always something that we like to call other and usually other is defined by the code set even with e m and modifiers is know we have a definition we have specificity there's just not something to describe it or a code you know to describe it okay if you want more information about modifiers we have a freebies area on the cco.us website and in that freebies area if you go down to the bottom there's cpt modifiers a modifier grid that laureen created and i'm go we're going to talk about it i'm going to show it to you really quick but know that you can go in you can download that yourself it's something free that we give you but this is what it looks like we'll come and reference it again in a little bit notice that the information that i just told you about global packages and e m and anesthesia and lab that's all there in description and i'm going to tell you about those arrows as well but not right now let's talk more about those individual modifiers excuse me modifier 24 that is a very common 24 25 both of those are pretty common modifiers in fact they're modifiers that we usually start teaching on modifier 26 is one of the first ones that that i know i teach this students but let's talk about 24. now let's read the description it's an unrelated evaluation or e m service by the same physician or it could be another qualified care professional during a post-operative period what's the type well what does it do it affects global package and it also is an e m you would only append it to an e m code that's important to know so what does it mean okay so we do an e m and it's during a post-operative period meaning 10 days or 90 days for a reason that's unrelated to the original procedure so you went in you had a hysterectomy there's a 90-day global period for that procedure and you after 20 days you go in and you see the provider and he ends up doing another e m it's in the post-operative period because it's in the 90-day window but it doesn't have anything to do with your your hysterectomy okay then you would append a 24 modifier 24 on there to indicate that hey i did some the provider did something separate from the global period and the hysterectomy you have to do that or when you send that off the codes translated as everything that you do for that patient during that 90 days is related to that hysterectomy unless you tell us otherwise and the modifier 24 would do that for you i got my arrows and after i share a screen it won't work uh okay so when uh when are you going to use a modifier 24 we need to think of each modifier this way now i didn't do that tonight we're not going to look at every single one of the modifiers because if we were to do that we would be here for quite some time sarah asked the question says if a patient has a disease and swoon and can we build an e m and a closure okay first of all sarah a disheasence is an opening of a surgical wound so it would not be a separate e m it would be in the global package because it would be part of the care of say a hysterectomy so the hysterectomy scar usually goes this way sometimes they do it you know up and down but if they go across and let's say again a dishes would be where it opens up and and the suture pops or whatever and it doesn't close and those can be really deep because again they cut you open kind of slayed you in a way and then that pops open but why did it do that because of the suturing or the the sutures of the surgical wound right so it's in the 90 days of the closure so you cannot you cannot bill for that that's a complication related to the procedure that was done that's the same thing as if a person has a cast and they put you know pins or whatever they took care of a fracture and then you go in because the the the cast is rubbing and your arm or whatever has swollen or your skin is being irritated due to the cast and they decide to take the cast off remove the cast and put another one on or decide to splinter or something that's all part of the global package and so it cannot be charged again or as a modifier 24. this look at ways to use modifier 24. now where i got this information was off of find-a-code but find-a-code's source um i went ahead and put in our resource on the very last page of the slide deck so our cco club members they have access to this and again like all club members the perk is that you get the slide deck you get the links you get the transcription as well as the video and continued conversation in the club but uh okay back to modifier 24 if you append a modifier 24 it has to be put on an e m code and it can be an unrelated e m but note here service beginning the day after procedure okay when the e m is performed by the same physician during the 10 or 90 day postoperative period meaning like the example seri sarah had was what if we have a dishes okay well that's part of the post-operative period that's a complication a post-op complication so you wouldn't use a an e m for that okay now what you could use it for is if the patient came in and they're looking and they say oh yeah there's a dishes here we're going to address that right so that that's part of the goal package and then the doctor looks at the patient's abdomen and says well when when did that rash pop up and you say oh i'm not sure i noticed it a day ago well is it did it start when you started the antibiotic i gave you and they say no i've taken that antibiotic before and i've taken the antibiotic several days i just noticed this pop up you know yesterday but i'm allergic to you know um strawberries or or they could say you know what i stepped outside and there was poison ivy or whatever whatever and that's not related to the procedure and the doctor says you know what we need to probably address that because that could affect your wound it's on your abdomen and um so let me go ahead and prescribe for you a steroid and let's keep an eye on that that would be a separate e m it it's the same doctor it's in the post-operative period but it has nothing to do with the procedure that you had okay and so therefore it would append a modifier 2024 to get reimbursed for that on an e m if documentation indicates the service was exclusively for treatment of the underlying condition and not for the post-operative care so what would be the uh the underlying condition well let's go back to our patient that has a hysterectomy okay why did they have a hysterectomy maybe they had adhesions and they had endometriosis okay well they took out the uterus and they may have tried to burn off some of the endometriosis in the abdomen but endometriosis is uh well they don't necessarily know what all it's caused by or whatever but let's say that for some reason uh they he's going to give you an additional treatment or care for endometriosis well that is not part of the procedure of the hysterectomy even though it's the underlying cause of the hysterectomy okay so it's separate that would be acceptable um e m code when the same physician is managing immunosuppressant therapy during the post off operative period of a transplant so whenever a patient gets a transplant they are put on immunosuppressant medication and they'll have to take that for the rest of their life so let's say we have a kidney transplant and then the patient comes in and they are looking at the patient post-transplant that's 90 days but they're not they're not doing anything that hasn't to do with the surgery and the procedure itself or the ckd or whatever in-stage renal disease that caused them to have that what the provider is going to do is manage the medication that's separate they're on long-term use of anti-im immunosuppressant drug therapy and which is like z79.811 or something like that okay so that the e m that he would do for that managing that would be different uh sarah says no problem i'm a derm coder and my providers try to add it because they re-evaluated the care and then had to decide a new treatment plan nope not if it's in the global period right and that's right because they don't understand either they think well this is something new and different no it's a direct result of the procedure and it's in the global package and yeah that would be a classic scenario the only thing that you could caveat to that is let's say they had two different surgeries or procedures done by two separate providers and because they're derm they address not the procedure they did that they're in the global period but what the other provider did and they look and there's a dishes on the other provider or the other procedure they say yeah we can we can treat that that would be an additional e m because it's separate it's something different than what uh what they're doing for their e m we almost need somebody to sit down and think up scenarios right all day long you know you get paid really well to do that let's look at the next one same physician managing chemotherapy during a postdoc period so a patient has a bilateral mastectomy due to breast cancer and um the patients on chemo right so in the 90 days the management if they have any management of the chemo that would not be their the same as the mastectomy procedure and then unrelated critical care so uh the patient has a uh a critical care scenario they throw a pulmonary embolism after a procedure or they get a blood clot right after a procedure that's unrelated critical care that would be appropriate so when do we not use modifier 24 now you have to think this through for every single modifier now why would you use it why would you not use it so if we did an e m for surgical complications or an infection or a dishes that's part of the surgical package don't use it if for things like removing of sutures a cast removal things like that that's all included in that global period surgical package if the surgeon admits a patient to a skilled facility or for a condition related to the surgery so the patient has a hip replacement and they're not up and mobile yet and they need to go to a skilled facility to get therapy because they can't do the therapy at home then again wouldn't be applicable that's all part of the the procedure medical record documentation clearly indicates the e m was unrelated to the surgery you know don't use it unless it's there that's another difficult thing for our providers to understand that they can't just use a modifier to append to the e m and say well that explains it no you have to have it in the documentation to tell why you're going to use modifier 24. mary says what if the patient goes to their pcp for removal of stitches but the pcp did not put them in well remember in the previous said same physician so that would not be the same physician so they could use an e m for that very good mary that's a question that gets asked pretty often but it's that same physician let's see outside the post-op period of the procedure so after the 10 days or after the 90 days then you can or the same day as the procedure so again if you're you would not use it if you're doing something you know on the same day of the procedure you wouldn't use the modifier 24. everything that happens to that patient that day falls under that in that e m code now what would happen if we needed to use more than one e m to tell the whole story then we have an example that's given you have a major surgery you're within the global period and you have an unrelated e m visit um if the provider determines that he needs to do a minor surgery or other procedure it was necessary okay that would mean that one you would end up with a modifier 24 and you'd end up with a modifier 25 why because the e m is unrelated to the original procedure and modifier 24 is going to be appended to the nm service and the modifier 25 is going to identify it as hey i'm doing another procedure and it's separately identifiable okay so that is another reason to use that one now you could actually use modifier 79 possibly to state that it's not related to the major surgery that is one that you have to see which fits better and jane says you cannot use more than five modifiers right on a claim line that's correct yeah there's a there's a rule in there i don't think they've changed that um i assume i've been doing this so long that i was thinking that at one point that they had changed something where you could either they even let you have more or less but most of them it's really hard to come up with five modifiers reasons to use them this one here it's difficult to think of a scenario almost that you would use it but why do they have the you know they talk about it because it does happen and and again the proper use of modifiers makes a huge difference not only in the reimbursement but also for the statistics to state how we use the codes all right let's look at modifier 78 that's unplanned return to the operating procedure room by the same physician now notice i made small other qualified health care professional just don't even read that part that is just it of course we know other qualified health care provisions okay following initial procedure for a related procedure during the post-operative period so again the key is that it's in the post-la postop period and it's related to the procedure now we had a particular we did q a webinars in the past and you can find a lot of those out in clips of those on our youtube channel but we had done one on modifier 78 and what i put in italics here is what jennifer our billing expert had stated i'm going to actually show you that answer sheet that's up in the club for our club members to see the the question that was asking how it was answered but modifier 78 is used for emergencies and sometimes you have complications or problems with a previous surgery and then they have to return or they have they have to make some changes now if that's the case and the example she gave was cardiac catheterization a laser sweet endoscopic suite they can't take place anywhere else right and so that's why you have to go back to that particular area so let me show you the scenario that we talked about because we we used to do these all the time and they're all up no that's the wrong one i apologize let me find it here modifier 78. so this is the answer sheet that um our club members got to see the question had come in i'm getting confused when to use modifier 78 and 79 and she says one of our ep physicians does a loop recorder and then a week or two later the patient needs an ablation does this call for a 79 or 78. she said the code that we use is i48.1 which is i5 0 is heart failure so it's right before that there's uh i can try to remember what i48 is so again she reiterates what 78 is for unrelated or unplanned related procedure and then this is the information that i took that i added to our slide deck but she goes on to give some sources and she said the difference is modifier 79 is unrelated procedure or service by the same physician during the post-operative period whereas 78 is unplanned related procedure so again when you use a 79 it's when you have another procedure that's not anything related to the original condition to the surgery and the example she says a patient with knee surgery falls and breaks the wrist then again that's not related they're still in the global period but it's not related to the original one and who's going to fix it the orthopedist why is the orthopedist going back to the or with the same patient and doing a similar you know something to do with a fracture ah well because um they uh are an orthopedist and they fell you know so you have to have a modifier to explain no this wasn't planned or related and then they go in to explain what a loop recorder is and what cms said uh and some more resources for um for this particular type of procedure so again this is something that we have in our club uh we have a recording of this transcribed what happened and questions that were given to us that we'd go and read research and now we do we don't do them all in one night where we could only do like six questions at a time we just do like three nights a week with this so anyway i wanted you to see that and how we answer those questions so that explains 78 and also gives you some insight on 79. um let's see and we've got links up there to oh i 48 a-fib or flutter thank you sandra yeah i knew i kept thinking i should have this one memorized this is going to be one of those ones that it's like i know i5 0 is heart failure chf uh what's 5 4a it's like it's got to be something to do all right when you've been doing this so long you can't help but have them memorized right so let's go to our next oh sorry let's go to the modifier grid i want to talk about the modifier grid a little more in depth now let's go back to the main page and i don't know let me see i was thinking i could make this all big for you but i guess i can't let's no okay so this modifier grid is something that you can actually print off and a lot of people go ahead and laminate it front and back on one page paper so that they can do it use it as a reference now you can't take this in with you if you're going to test but this will really help you understand the ways the modifiers work both because you have the description what's the purpose and what does it do so let's kind of break those down so i encourage you after this webinar to go to the cco.us site download the free cpt modifier grid and if you're in the club it's already in the club for you and probably a lot of also you'll find a lot of lectures where we talk about modifiers this was brilliant laureen came up with this some time ago and i i tell you it's one of in fact she started this way back when i was teaching in a college in in texas and my students weren't getting e m and i couldn't figure out what i needed to do to explain it i mean obviously i wasn't explaining it well enough to them uh so i that's when i found laureen online and these youtube i said go watch her youtube channels you know watch her videos she explains it so well and so we started you in using that and then we found the modifier grid that she had done it's like okay this is brilliant this is exactly what you need to explain i've never seen anybody explain it any better than what she does so again here is the uh types and the uh abbreviation for what's the type the modifier is used for and then what is the the purpose okay it's going to make if the arrow goes up it means that that modifier is going to have an increase in revenue if the modifier or if the arrow just goes leans off kind of sidewise then it means the claims doesn't get paid unless you use this modifier without it you're going to get a denial and then if it's down the very easily it means reimbursement is going to be lowered and then if it goes lateral from the side to side it you know it's just an informational modifier and everything stays the the money stays the same it's not going to increase or decrease the reimbursement but it needs to be there for informational purposes and then what she did was um she gave the you know which ones are e ms which one's an anesthesia which one's surgery radiology path and lab medicine uh surgery centers and hospitals okay so if it's listed there then you'll know it's pertinent for that modifier now we looked at the first one modifier 24. notice that it has an angled arrow which indicates hey if it's not there the claims not going to get paid it's going to be denied all right and it's only used on e m's and it affects e m in global packages it's a global package modifier now everything we just talked about and explained that we kind of broke that out and explained it now i again i didn't go through all the modifiers because it would take us all night to get through them but this teaches you how to use the modifier grid which is a free tool for you and i really encourage you to use it as well as give it to your providers right anybody that you know that is working in coding any students or your providers to let them help them understand the modifier usage all right let's just kind of glance through some of these others another one that is used for e m but it's also used for medicine notice right here is decision for surgery modifier 57 okay now there's specific guidelines around modifier 57 and um what you need to be aware of is that decision for surgery can only be done at a certain time right and it will not make a change in the reimbursement per se but you're not going to get paid for that decision in surgery if you don't append modifier 57 okay so it's a gp and an e m it's used on e m's and medicine section 58 stager related procedure only global package same arrow but look you'll be using that with surgery radiology medicine and in hospitals and stuff so we're not going to go through every one of these let's skip down to modifier 25 because we also spoke about that it is one that is very commonly used it's a significant separate identifiable e m service so when your patients come in for their annual wellness visits for medicare then and they decide to give them their flu shots modifier 25 will be added to that because the annual wellness visit isn't you're not supposed to have anything wrong with you now this is used on e ms and it's used in hospital and notice that you're not going to get reimbursed without it it's uh has more than one global package e m and the b u n which stands for uh it's bundled bundling professional component you almost are guaranteed to see this on any of the credentialing exams this is probably the most used and tested on modifier all right so modifier 26 professional component this is gonna bundle and it will decrease reimbursement and it's not used on e m and anesthesia but it's pretty much used on everything else except for hospital ancillary surgeries so the example for those that they usually give you is that a patient has an x-ray and they have an x-ray at the x-ray machine does it belong to the provider is it owned by him and his clinic or is it owned by the facility that he works out of and if it's owned by the facility that he works in then he's only giving a professional component he's reading the x-ray so modifier 26 would be applicable right whereas if you went in to your pcp and he owns the clinic he owns all the equipment in there it's his x-ray machine and he pays the technician to take the x-ray and all the electricity that's used in the light bill and he reads it well then you're not going to use a modifier 26 he does more than the professional component for that all right uh let's see we already talked about modifier 25 so let's scroll down to some of these others notice that we have um mandated services that gets a little confusing modifier 32 it's an other right doesn't fall into the other categories but it could be one that you're not going to get paid for it if you don't use the modifier or it may make no changes but it can be appended to almost everything mandated services are things that are like court ordered so a court ordered test for paternity would be what they usually use as an example the easiest one let's look at modifier 50 another very common probably the most common after modifier 26 bilateral procedure it's an other it increases reimbursement and it's used for surgery radiology medicine and hospital well uh it makes sense surgery if we're going to do um bilateral mastectomy right there isn't a code for bilateral mastectomy there's a code for a mastectomy and the different types of mastectomy but if you take both breasts it's a bilateral mastectomy and you have to use a modifier 50 to indicate that both breasts were removed okay reduced services and discontinued services a lot of confusion about that and that's one that i would encourage you to study is reduced services means that hey we didn't um we didn't end up doing what we planned to do discontinued is that we had to stop something happened the anesthesiologist said the patient's not doing well we need to stop the procedure so it was discontinued whereas reduced services were um we were something that's normally done bilaterally and it's not done bilaterally because you don't have the laterality you're missing whatever the other thing is to give it laterality would be an example rosanna says let's see if someone comes in for a wellness visit and they also are being seen for a headache but no x-ray or other services was done for the headache would the patient still need an e m for the headache if they're coming in for a wellness visit where they're not supposed to have anything wrong with them that's what a wellness visit is then yes they would do another e m for the headache if they do anything to treat the headache they don't have to do an x-ray they don't have to do anything they could just do a soap note right why why are you here are we what's the problem i have a headache then they ask them well when did it start how long does it last does anything make it better or worse etc etc you know and then the provider looks in the ears and says no you know it so again yes they would need to do an e m for that additional service because they're there for an annual wellness visit some providers won't do it they will say well you have to make another appointment which is kind of sad especially you have to travel now there was a question on vaccines let me look at that real quick scroll up right before roseanne's and that was elizabeth says i think i missed what you said about the flu vaccines can you repeat that if a patient comes in for their annual wellness visit every if you're on medicare every year you have to have an annual wellness visit and again you're not expected to have anything wrong with you you're just establishing the diagnoses that the patient has and kind of giving you a starting point of the patient's health and care at that moment in time and you want to maintain or get better improve but the that's a great time for the provider to say hey did you get your flu shots yet you know have you had your your your flu shot your pneumonia shot and now they have the um shingles shingle shot so then they will go ahead and do those and that's separate that's that would be a separate identifiable scenario do you use modifier 50 a cpt description say bilateral no you do not jane very good question if they have like if a person goes in and has bilateral knee replacement which they do do sometimes the code states that you know a knee replacement and there's more than one type of knee replacement but if they do both knees that's bilateral knee replacement you would use that code and then modifier 50 to state that it was bilateral let's say they're removing an ovary now when they go in and they take out they do a histo oophophyrectomy it's salpingo a histo salpingo oofuphorectomy that means they're taking out everything histo is this uh is the uterus salpingo is the fallopian tubes and oof and you go oof oof because there's two you have two ovaries um that is bilateral now my mother had that done at a very young age because she had what we were talking about endometriosis really bad and so they because she was younger they took everything out but they left one of her ovaries a piece of her ovaries so it wasn't a uh a a histo salpingo right that they take out two so laterality you know is involved there because if they're going to take them out they usually take both out right so the code for the removal of an ovary you'd have to go look at it but it probably says you know bilateral or sometimes they'll say single or multiple bi or you know with bilateral in there donna says there is a scenario six seven two two one to be followed by uh two two five this second eye why not right and left uh modifiers used here well okay you could use right and left the codes are written for um again statistical we have to remember it's statistical it's not originally to get paid and the reason they make a code is because the scenario happens often and so a code for laterality with the description laterality built into the code description will be used because it's used so often or that scenario like you're talking about and you could use right or left but again rt and lt is used by medicare and so if it's not a medicare patient then you're going to use modifier 50 for laterality or use the two separate codes yeah uh when you code cpt99253 i don't have that code memorized you'll have to tell me what it is or vanessa or i can use the encoder to look it up um let's see we've sarah said this is uh had an increase in denials with uhc they want to see anatomical modes for ears and hands you know i'm not surprised about that with uhc sarah because um last year there was a huge influx in ear codes now i don't know about hand codes but there were um yeah there was a lot of changes where additional ear codes and hearing codes and procedure codes for the ears were added uh in icd and so uh and and thus i in cpt as well so again i'm i'm not really surprised to see that that they're wanting uh anatomical modes for for those type of things yeah okay 99253 i'll look that up real quick because i just happen to have an encoder and then inpatient consultation for new and established patient which requires these three key components now keep in mind that um yeah you ate donna says uhc is a tough customer frequent denials yeah they are uh blue cross blue shield isn't much farther behind uh okay so with this one is an inpatient consult i would look at my notes and again they don't pay a lot of them don't pay for consults but this is an inpatient consult cms has eliminated the use of all inpatient consults so [Music] when you code 99253 what they end up having to do if the payer won't pay for it you use the regular e m codes established patient or new patient but otherwise you just follow those and there you or if you were asking me about modifiers appended to that that is that is classified as a a as an e m uh a console i know modifier 95 is for telehealth videos right yeah it is let's look at modifier 95 and synchronous synchronous telemedicine services rendered via real-time interactive audio or video telecommunication visit yeah so um real-time interaction between physician toilet communication yeah you know there we did uh we had a lot of um education that we did on televisions right at the beginning of the year i'd encourage you to go look at our youtube channel medical coding cert regarding that because there were um you know everybody was trying to get up to speed some of this stuff has been around but we didn't use it very often and then when coveted hit and we all had to use it everybody was scrambling to understand the nuances and then they made changes almost daily for medicare patients so uh yeah i wouldn't i would encourage you to go and look um look at some of those that break those modifiers down and the telehealth very good guys we did good tonight um elizabeth says i'm trying to find the modifier sheet and can't located it there's a link placed in the chat but i'll just show you how to go find it real quick let's just go ahead and do that and sometimes a visual go to cco.us hey we got a cell going on uh freebies and then we break down all the freebies there's the free exams the reports and guides and it's a tool and it's this tool right here there's six tools there and it's the upper right hand quadrant get your modifier decision grid job aid tool and you can click on that you fill out this and then you'll be able to download that okay and then let's see we had a couple more questions do you have an uh do you have to add modifier 25 to cpt 99497 when you have an e m cpt 99497 let me just put it in i am i am not quick with cpt codes icd i have a lot of those memorized but cpt is i don't work in that world as much and so i um would struggle to have those off the top of my head advanced care planning including the explanation discussion of advanced directives and you want to know if you would append modifier 25 i don't think i would um well you could yeah i guess you could it's an e m so if you do a an e m at the same time and do 99497 yeah you could i believe so not 95. you could use gt but 95 probably is um oh and outpatient yeah uh ooh 99253 a lot in vascular um yeah vascular surgeries you're right deborah it's used a lot uh then do you append modifier 20 to an e m visit for 213 uh okay 99213 is a established patient level three and three six four one five i don't have that one to memorize i gotta look at that collection of venus what um you know okay um no probably not uh because isn't it common for like an annual wellness um now collection of venous blood is is not separate it's not above and beyond what you're you're doing and you're treating for that patient i don't think you would do that i could be wrong i'd have to double check with jennifer but i don't think so what does it say here if it says anything about that no because i mean they they have to take blood to to do lab tests oh now if they send it off to lab core um that could be different there is a modifier where you're sending it off to another lab i have to do some more research i know we've talked about it in fact i know we have things in both the club regarding this jennifer's talked about it and probably on our medical coding cert so let me let me defer to that bell because um off the top of my head i i would not want to tell you uh yeah modifier 90 reference lab that's what i'm thinking of too you're right now that you said that reference outside laboratory that's the modifier that you would use passing lab right here thank you guys donna yeah we did not use modifier 25 yeah yeah i i'm going to say i just don't think i think drawing labs is a regular component of even an annual wellness visit because they they'll do your labs to see how uh how you're doing yeah and you can check your ncci edits for that absolutely and in fact you can go in like here and i have ncci edits i have it somewhere in here there it is and then i would say non-facility and then it would tell me the ones that you can and cannot put together yep find a code has just about everything i would ever need uh no bonafire needed okay from uh family okay i'm thinking fm family medicine and i am we didn't use 25 unless injections are in office procedures right injections is different see you're going to give them a flu shot you're going to give them a shot of an antibiotic because they have um cellulitis on their leg you know so they come in for their regular visit and they you end up giving them you know a shot of benadryl or a shot of antibiotic and you send them home with a script okay that's not why they were there right so you would definitely use or they get their flu shot you use modifier 25 to indicate that yep all right guys thank you for joining us i know we covered a lot of content tonight let me just get rid of these screens and get back to our um the end and remember we are here every wednesday night for students then you can our students send in things that they're struggling with or scenarios that we know that it's a good teaching moment that we can share with every fund and we just invite you along you're welcome for the freebies and the q a webinars all of our students get that all the stuff gets loaded in for additional content for our students but your great questions help and some of your insights uh because um some of these things for cpt like i said uh first one to tell you that is not my world to be able to rattle that stuff off the top of my head you throw the icd and now i'm i'm i can hold my own with that but thank you for the i-48 reminding me that that was afib and arrhythmias that i it was on the tip of my tongue so tomorrow we'll be back uh most tuesdays wednesdays and thursdays we'll be here live don't forget to hit the like button for us if you're watching on youtube that really helps us guys so i would appreciate you doing that that lets youtube know that we're um we're a site that is helping people with our content and again don't forget you can share these and hit the little bell so that you know when we're going to come live and if you join the club we let you know uh we'll send you out an email to give you a heads up so again thanks everybody appreciate it do you need more medical certification and business training learn more at www.cco [Music]