Appropriate Modifier Usage: Coding and Documentation to Get Reimbursed the First Time

The modifier, a two-digit code additional to the CPT codes, can be a powerful tool to ensure providers get paid for services that are not normally performed together or which may be in addition to the primary service provided. In order to bill for services in the same CCI code pair under the Healthcare Common Procedure Coding System, a provider may in some circumstances use a modifier on the claim to bypass the edit and get reimbursed for the services performed, according to the HHS Office of the Inspector General (OIG). Thirty-five modifiers can be used to bypass the CCI edits.

Modifier 59: A Continued Compliance Hot Spot

Two major modifiers, modifier 59, used to indicate that a provider performed a distinct procedure for a beneficiary on the same day as another procedure, and modifier 25, used to bill for additional E/M services which are significant and separately identifiable, have been focused on in detail by the OIG as high-risk modifiers.

In a March 2017 report, for example, the OIG concluded that a nationwide review showed hospitals generally fail to comply with Medicare requirements for billing outpatient right heart catheterizations and heart biopsies provided during the same patient encounter. Inappropriate use of modifier 59 thus resulted in estimated overpayments of $7.6 million over approximately two years. Inappropriate usage and inadequate documentation are issues that not only plague modifier 59, but lead to reduced and rejected payments across all modifier coding.

Improper Modifier Use: The Consequences

Medical carriers won’t pay for E/M service – a physician-patient interaction that must be medically reasonable and necessary – when reported with a procedure having a global fee period without a modifier appended to the E/M service. CMS doesn’t normally allow additional payments for separate E/M services performed by a provider on the same day as a procedure. According to the OIG, modifier 25 can be attached to a claim if a provider performs a separate E/M service on the same day as a procedure that is significant, separately identifiable, and above and beyond the usual preoperative and postoperative care associated with the procedure.

However, even when providers use the appropriate modifier, receiving reimbursement will continue to be a challenge without the correct documentation to support the services performed. Payers routinely deny claims that include modifier 25, but when these denied or bundled claims are appealed, proper documentation may work in the provider’s favor and result in the insurer paying for the services. However, in other cases, providers may receive reimbursement the first time, only to be required to pay it back later. Sloppy usage of modifiers can thus lead to unnecessary claims denials, which further leads to time wasted in following up on the reasons behind those denials and lost revenue. The OIG also conducts investigations into claims that incorrectly code for modifiers.

Out of the thirty-five modifiers available, physicians and their coders must be able to distinguish between the different types of modifiers and identify the correct modifier to apply in a particular situation. Increased government scrutiny and focus on coding compliance has led to an environment of reduced payments, and suspended and rejected claims. Providers must be able to ensure correct coding and compliance so that they can be paid for services the first time.

Ensure Correct Modifier Coding and Documentation the First Time

In an audio conference hosted by AudioEducator, “Appropriate Modifier Usage for Correct Coding and Reimbursement: Clearing Up the Confusion” with coding expert Elin Baklid-Kunz, MBA, CHC, CPC, CPMA, CCS, she reviews actual visit examples and discusses whether an office visit with joint injection is also payable. Elin also discusses what modifiers can be used for E/M services during the global period and provides documentation tips to reduce the number of suspended or rejected claims. Her sample cases and appeal letters can help coding and billing specialists, practice managers, HIM directors, compliance officers, case managers and physicians use the appropriate modifier for correct coding and reimbursement.

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