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Modifiers Explained

Modifiers Explained

Melody Irvine couldn’t believe her eyes. A large, established orthopedic practice was submitting claim after claim for E&M visits by its physicians following orthopedic procedures. Payers of all stripes denied the claims because of “unbundling,” attempting to charge for a service already included in the payer’s global period for surgeries and procedures.

The insurance companies never waivered in their denials, but what amazed Irvine even more was that neither did the orthopedists. They continued submitting claim after claim with no chance of getting payment.

“I asked the head of the billing department why she was trying to unbundle those services and what did the CCI edits say about it,” says Irvine, a certified coder and owner of Career Coders, LLC. “This person, who had been in the billing field for 20 years, asked me, ‘What’s a CCI edit?’”

If you don’t know about the National Correct Coding Initiative (NCCI), and you’re not sure if anyone in your billing department does either, then read on. Even if you feel well versed in Current Procedural Terminology (CPT) coding, you may be missing valuable coding opportunities that produce revenue. Often, getting the revenue you truly deserve will require using a code modifier when appropriate.

Modifiers are simple two-character designators that signal a change in how the code for the procedure or service should be applied for the claim. Used correctly, modifiers add accuracy and detail to the record of the encounter. Misused, they can cause denials, payer audits, and worse — investigations, refunds, and fines.

“Modifiers are there so the payer knows that something in how the code was used has been altered in some way,” Irvine says. “Perhaps the physician only did the post-operative portion of the surgery, or maybe they had to do more than one procedure, or an unrelated procedure on the same day with the same patient.”

Going back to Irvine’s orthopedic client, the practice was either trying to get paid for services the payer felt it already had paid for, or the physicians were indeed performing services that were unrelated to the global period’s services. Without the use of a modifier, there’s no way for the payer to tell.

What Irvine and other experts most often see when checking up on their clients’ coding, is that many just forget to use modifiers that are justified. The result is missed revenue that physicians deserve. Here’s a quick primer on how and when to use some of the most frequently misused, underused, or misunderstood CPT modifiers.

Modifier 25

Raemarie Jimenez, director of education for the American Academy of Professional Coders (AAPC), the national coding training and certifying organization, says physicians seem to have the biggest problems with modifiers that affect reimbursement. These modifiers allow a service to be paid when it might otherwise be denied by a payer.

One example is modifier 25. It is designed to obtain payment for an E&M service performed by a physician on the same day the physician provided another procedure or service to the same patient.

“One of the biggest things that always goes wrong is the physician appending it to the procedure instead of the E&M code,” Jimenez says.

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