With a 12-lead EKG with EP study, only add modifier 59 if the patient’s condition warrants an EKG and only if ordered at a separate time

Q.

When performing a 12-lead EKG with an EP study, do you agree that we should report the CPT^® code 93005 but not modify it with modifier 59?  Do other hospitals override the edit instead of using the Level II modifier GZ?  If the entire claim is denied due to the GZ modifier being on the claim, what action should we take?  Should we reach out to our payor guidance?

A.

If you put the GZ modifier on just the EKG CPT code, the entire claim should not be denied. If the entire claim is being denied, then it is best to not report the EKG code in that case, and you should contact your MAC to see why the whole claim is being denied. 

You definitely should not use modifier 59 on the EKG code if it was completed to check the results of the study/procedure. Only add modifier 59 if the patient’s condition warrants an EKG (separate medical necessity), and usually only if ordered at a separate time.

The modifier and full description are:

GZ   Item or service expected to be denied as not reasonable and necessary