Master these commonly misused modifiers for improved compliance and revenue.
Despite the thousands of CPT® codes in the codebook (some 10,000 as of 2016,) you still won’t find a code to perfectly fit every possible circumstance. That’s when you need to know how to use CMS billing modifiers to ensure you’re properly reimbursed for your work.
Modifiers communicate important information about a procedure’s specifics, and details directly affecting how much you will be paid. But they frequently lead to coding and billing mistakes. And these mistakes can cost you not only money but also time and energy spent correcting them.
Because we care about increased healthcare provider efficiency and productivity at MDCodePro, we want to point out some modifiers practitioners commonly find problematic. By reviewing our short list of CPT® modifier definitions and examples, you can avoid some of the pitfalls tripping other providers up.
A Brief Guide to Billing with Frequently Misused CMS Modifiers
Modifier 25
Modifier 25 appears to be one of the most commonly misused CMS billing modifiers. Just last year (2017,), CMS flagged potential Modifier 25 misuse as a problem, noting 19% of codes for 0-day global services (services whose valuation already includes routine E/M) were billed with Modifier 25 over half the time. This misuse suggests Modifier 25 may still be causing as many problems as it did in 2005, when a notable OIG report found a full 35% of claims using it failed to meet Medicare requirements, resulting in $538 million of improper reimbursement.
The CPT® manual defines Modifier 25 as “Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service.”
This definition means not every additional service a provider decides to perform on the same day as another procedure warrants the modifier. A service must be “above and beyond” what is normally required in the other procedure’s pre- or post-operative services, as the Bulletin of the American College of Surgeons (ACS) states. For example, coding consultant Emily Hill points out Modifier 25 sometimes properly distinguishes E/M service from an actual injection or drug administration, but “some immunization codes include counseling the patient.”
“A knowledgeable individual, looking at the available documentation,” writes the AAPC’s John Verhovshek for Physicians Practice, “should be able to identify the important E&M components of history, exam, and medical decision-making (MDM,) apart from any other procedures or services performed on the same day.”
To avoid misusing Modifier 25, make sure your documentation supports the service as significant, medically necessary, and separately identifiable; and that the same provider (including different physicians in the same group practice) performed the service. Append Modifier 25 only to E/M codes, not procedure codes. And consider using Modifier 25 instead of Modifier 59; as CMS emphasizes, Modifier 59 “should not be appended to an E/M service.”
Modifier 24
Modifier 24 identifies an “[u]nrelated E/M service by the same physician during a post-operative period.”
“Unrelated” is the key. Your documentation must show you performed the medically necessary service solely to treat the underlying condition, and not as a part of routine post-operative care included in the surgical package. Medicare does not allow separate billing for post-op medical and surgical complications unless they require another trip to the OR, as coding expert Betsy Nicoletti writes for Physicians Practice.
Emily Hill writes Modifier 24 is “often overlooked” and suggests practices keep “an easily accessible list of the global periods for office-based procedures [to help them] remember whether a modifier is required.” (You might consider keeping a list of relevant CPT® modifiers and their definitions close by, as well.)
Be certain you don’t confuse Modifier 24 with Modifier 79. The former describes unrelated E/M services; the latter, an unrelated, non-E/M service or procedure.
Modifier 57
Modifier 57, “Decision for Surgery,” is appropriately applied to an E/M service not included in the surgical package, but an initial consultation or evaluation in which the physician determines a major surgical procedure (one with a 90-day global period) is necessary.
Providers sometimes mistakenly apply Modifier 57 when Modifier 25, discussed above, is the proper choice. Modifier 25 is appropriate for minor procedures—John Verhovshek offers “many injections, minor integumentary repairs, and endoscopic procedures” as examples—while Modifier 57 should be reserved for major ones.
Nor should Modifier 57 be used when decisions for elective surgeries are made, as such decisions “typically are made at a previous outpatient encounter,” as billing and coding expert Carol Pohlig writes for The Hospitalist. But Modifier 57 should sometimes be used with Modifier 24, when the E/M service leading to the decision for surgery occurs in post-op period of another, unrelated procedure.
When you use Modifier 57, be certain the documentation in the patient’s record supports your decision for surgery itself, not simply your pre-operative clearance of the patient for surgery.
Modifier 26, TC, PC
Some procedures present complicated coding questions because they contain both a professional component, or “PC” (supervision, interpretation, and reporting) and a technical component, or “TC” (the costs of the equipment, supplies, and technical support necessary for the procedure, as well as practice and malpractice expenses.) For example, diagnostic tests and radiology procedures generally involve both PC and TC.
If a single physician or practice performs both parts of a two-component procedure (for example, a doctor at an independent clinic orders and reviews an X-ray taken on-site,) a single, global CPT® code will suffice. But in many cases, separate payments for PC and TC are in order, as when a physician interprets a test administered at another facility.
Modifier TC claims reimbursement for a service’s technical component only. But, somewhat confusingly, the modifier for professional component only is Modifier 26; Modifier PC indicates the wrong surgery was performed on a patient.
Remember: Some CPT® codes are standalone codes, indicating professional-component and technical-component only services. Don’t use Modifier 26 with the former group or Modifier TC with the latter.
Develop Stronger Documentation for Better Coding with MDCodePro
The “inaccurate reporting of modifiers has the potential to put the brakes on payment for claims,” according to JustCoding News: Outpatient, “or have serious financial consequences if auditors uncover compliance problems.”
As is often the case in medical coding, one of the best ways you can guard against mistakes in using CMS billing modifiers is to ensure your documentation is as accurate and comprehensive as possible. And one of the best ways you can achieve that goal is by making MDCodePro a part of your practice.
Our coding methodology, validated by numerous audits, offers you a streamlined understanding of CMS billing regulations as well as an easy-to-use approach to documentation that supports the most accurate, compliant, and optimalcode for each office or inpatient visit. And our intuitive, step-by-step code generator gives you an even greater advantage, finding the optimal code for every patient encounter based on the information you provide.
Find out more about how MDCodePro can make your practice even more efficient and productive. Request further information by filling out this online form.
The post Costly Mistakes to Avoid When Using CMS Billing Modifiers appeared first on MDCodePro.
source https://mdcodepro.com/blog/cms-billing-modifiers/
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