Coding Questions: When and when not to use modifiers
Q: Are code modifiers necessary, and do they really help you get paid faster?
A: The answers are definitely YES and YES! In fact, federally-funded programs like Medicare require the use of modifiers, and if not used properly, a provider can be subject to stiff fines and penalties.
Utilizing correct modifiers is crucial to getting your claims paid for the correct amount. Your billing staff should be aware of the most common modifiers used in the chiropractic setting.
A missing or incorrect modifier can result in a loss of more than $1,000. On the other hand, an incorrect or missing modifier also can result in overpayment for services.
Missing or incorrect coding modifiers are one of the most common reasons claims are denied. In Texas alone, incorrect or missing modifiers are the second most common reason Medicare claims are denied.
Modifiers provide the means by which the reporting provider can indicate a service or procedure has been altered by some specific circumstance but has not changed in its definition or code. Modifiers were designed to provide payers with additional information needed to process a claim.
Think of a modifier as a communication tool that tells the insurance company something is different about that particular encounter with the patient.
The purpose of a modifier is to allow special consideration for payment.
For example: Modifier 22 attached to an E/M code communicates that there was something unusual about the E/M procedure. It either took longer than usual, or was harder than usual. In this instance, the only way youíll get consideration for additional payment is if you use the modifier and have good documentation.
Although modifiers are an important component of proper chiropractic coding, itís easy to get confused about how to use them correctly. In addition, modifiers, just like the CPT codes themselves, are constantly changing.
Itís helpful for chiropractors and their billing staff to have the most recent edition of the CPT book and attend coding workshops regularly. Even when a billing staff member codes the claims, itís still important for the chiropractor to be as familiar as possible with CPT codes and modifiers. The more familiar with modifiers you are, the more you can facilitate proper usage and payment. †
Modifiers are placed in Box 24D of the CMS-1500 claim form. Below is a list of the most frequently used modifiers by chiropractic and MD/DC/PT offices.
Modifier 25: A significant, separately identifiable E/M service by the same
E/M services may be reported separately from chiropractic manipulative treatment using modifier 25, if and only if the patientís condition requires a significant, separately identifiable E/M service, above and beyond the usual pre- 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.
Modifier 52: Reduced services. Under certain circumstances a service or procedure is partially reduced or eliminated at the physicianís direction.
Under these circumstances, the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying the service is reduced.
This provides a means of reporting reduced services without disturbing the identification of the basic service.
Modifier 59: 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 not normally reported together, but are appropriate under the circumstances.
Be careful when billing modifiers 25 and 59. Two Office of Inspector General (OIG) reports revealed that each modifier was used incorrectly nearly 40 percent of the time. Both modifier 25 and 59 are used to alert the payer that a second service should be paid separately, due to special circumstances.
The most common problem the OIG found with the documentation for modifier 59 was that the claims donít specify clearly enough that the two treatments the modifier makes separately billable were performed at separate and distinct times and for a medically necessary reason.
You can clear up some of the confusion by writing down the specific times an action took place.
Be cautious when using modifier 59 and double-check that another modifier isnít more appropriate. Be sure 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.
According to CMS in program memo A-00-35, ďIn 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.Ē
Marty Kotlar, DC, CHCC, CBCS is the President of Target Coding. Target Coding in conjunction with Foot Levelers offers continuing-education seminar on CPT coding and compliance documentation. He can be reached at 800-270-7044, firstname.lastname@example.org, or through www.TargetCoding.com. †