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Report the injection code with modifier 59 and modifiers to indicate left thumb and right thumb as appropriate.

Department of Health and Human Services. Two separate diagnoses should be reported on the claim. Disclaimer Accurate coding is the responsibility of the provider. American Medical Association; She mentions that she has recently had the same pain on her left hand. To avoid overuse or misuse of modifier 25 and reduce the risk of an audit and repayment demand by payors, the ACS offers the following recommendations: A patient arrives at your office complaining of bright red blood from the rectum.

A woman arrives at your office for a repeat injection of steroid at the base of her right thumb to relieve arthritis pain and swelling.

Modifier 25 under fire: Are you using it correctly?

Use of Modifier Office of the Inspector General. Before performing the biopsy on her arm, you take a history related to her complaint of leg swelling with pain and examine the patient, including palpating the lower abdomen and assessing the lower extremities for varicosities and phlebitis.

Only one diagnosis should be reported. You counsel her to wear compression stockings and elevate her legs and schedule a follow-up to determine if conservative therapy is helpful.

This summary is intended only to serve as a resource to assist in the billing process. Accessed September 9, You then perform a diagnostic anoscopy.

Your medical decision making is aided by the anoscopy findings but is based on the history and physical exam. A woman arrives at your office with a suspicious lesion on her arm.