Issue 13 - September 2004

CPT code modifiers: Necessary — and good— for your bottom line
By Marty Kotlar, DC

Do you really need to use CPT code modifiers? Do they actually help you get paid the right amount? The answers are definitely “yes” and “yes.”

Actually, federally funded programs, such as Medicare, require the use of modifiers and if you don’t use them properly, you can be fined and penalized.

Your billing staff needs to be aware of all the most common modifiers that are used in the chiropractic setting. A missing or incorrect modifier can result in:

• A loss of a just a few dollars to possibly thousands of dollars;

• Overpayment for services;

• Denial of claims. Missing or incorrect coding modifiers are one of the most common reasons that claims are denied. For example: In Texas, incorrect or missing modifiers are the second most common reason why Medicare claims are denied.

WHAT IS A MODIFIER?
Think of a modifier as a communication tool that tells the insurance company that something is different about a particular encounter with the patient. Something is different — but not different enough for the service or procedure to change its definition or code.

Modifiers consequently allow special consideration for payment. For example: If you conduct an exam that is more difficult than usual and consequently took more time than normal, use Modifier -22 attached to the E&M (evaluation and management) code.

Using the modifier code — along with good documentation — is the only way you’ll get consideration for additional payment for your service.

Another common example: If you interpret x-rays that you did not order, use modifier -26. This signals to the payer that the claim should be paid in a different way from a “normal” radiographic service.

COMMON MODIFIERS
Place modifiers in box 24D of the CMS-1500 claim form. Here is a list of the most frequently used modifiers used by chiropractic and MD-DC-PT offices:

• -25. This modifier is used for a significant, separately identifiable E&M service by the same physician on the same day of the procedure or other therapeutic service. E&M services may be reported separately from chiropractic manipulative treatment by using modifier -25, if and only if the patient’s condition requires a significant, separately identifiable E&M service, above and beyond the usual pre-service and post-service work associated with the chiropractic manipulative treatment and/or modalities/rehab.

The E&M service may be caused or prompted by the same symptoms or condition for which the chiropractic manipulative treatment was provided. As such, different diagnoses are not required for the reporting of chiropractic manipulative treatment and E&M service on the same date.

• -26. This modifier is a professional component: Certain procedures are a combination of a physician component and a technical component. When the physician component is reported separately, the service may be identified by adding the modifier -26 to the usual procedure number. All diagnostic testing with a technical and professional component done in an outpatient or inpatient setting must reflect modifier -26. For example: 72040-26 shows the chiropractor read cervical x-rays, two or three views.

• -TC. This modifier indicates a technical component: Under certain circumstances, a charge may be made for the technical component of a diagnostic test only. Under those circumstances, the technical component charge is identified by adding modifier -TC to the usual procedure number.

For example: 72100-TC indicates actually taking lumbosacral x-rays, two or three views.

• -51. This modifier is used to show multiple procedures: Use it when you perform multiple procedures, other than E&M services, in the same session.

• -52. This modifier indicates reduced services: Under certain circumstances a service or procedure is partially reduced or eliminated at the physician’s direction. Under these circumstances, the provided service can be identified by its usual procedure number and the addition of modifier -52, signifying that the service is reduced. This gives you a means to report reduced services without disturbing the identification of the basic service.

• -59. This is used to show a distinct procedural service: Under certain circumstances the physician may need to indicate that a procedure or service was distinct or separate from other services performed on the same day. Modifier -59 is used to identify procedures/ services that are not normally reported together, but are appropriate under the circumstances.

Note: I urge caution when using modifier -59 and suggest you check to see if another modifier isn’t more appropriate.

When you use modifier -59, be certain you can explain (in a potential audit) why it was necessary to do both services for the same patient on the same day and why the services were distinct from one another.

Also remember that anatomical or bilateral modifiers may be more appropriate to use than modifier -59. CMS says in program memo A-00-35 (www.partbnews.com/htm/A-00-35.htm), “In those instances where an anatomic or the bilateral modifier is not more appropriate, modifier -59 may be appropriate. On the first line the code is reported without the modifier. On subsequent lines, the code is reported with modifier 59 and the unit of service is equal to one.”

Marty Kotlar, DC, CHCC, is the president of Target Coding Inc. He is certified in healthcare compliance and has been helping chiropractors get better reimbursements from insurance companies since 1992. He can be reached at 800-270-7044, through his Web site, www.TargetCoding.com or by e-mail at drkotlar@targetcoding.com.