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Using Modifiers

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I've discovered that the majority of our denials come in response to modifier codes — specifically, modifiers -22, -57, and -59 — and are from the private insurers much more than Medicare. Any tips on how to proceed? Do we drop the use of modifiers for private payers due to the amount of time spent appealing?

Question: I've discovered that the majority of our denials come in response to modifier codes - specifically, modifiers -22, -57, and -59 - and are from the private insurers much more than Medicare. Any tips on how to proceed? Do we drop the use of modifiers for private payers due to the amount of time spent appealing?

Answer: It is very common to receive denials for these modifiers. Sadly, many carriers do not recognize them, unless the practice appeals them.

I would analyze resources by modifier. You'll need to do this analysis based on how much money is at stake and how many resources are expended to get that money. If you can send out a generic appeal letter to get the -22s paid, for example, it's worth your time. That said, be sure to establish boundaries for your staff. For example:

  • Appeal once over the phone for all denials.
  • Send a written appeal for denials over $25.
  • Send two written appeals for denials over $100.
  • Solicit physician involvement for claims over $500.

Figure out your own guidelines based on your experience and practice needs.

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