Don’t get tripped up on medical claims billing modifiers

Billing medical claims are a continual source of frustration for many chiropractors, and claims billing modifiers are no exception. Modifier confusion can cause your claims to be denied or even result in accusations of fraud.

To clarify how modifiers work, here’s a short primer. Keep in mind that it’s essential to do your own research and find out how modifiers are relevant to your own claims.

Modifiers for unusual claims

Modifiers help you indicate on your claims that something was unusual or additional. It provides other information that you then detail in your documentation.

For instance, the 25 modifier is added to the E/M code to indicate a unique and separate evaluation from the chiropractic adjustment or other treatment occurring that day. Modifier 59 and its subsets can be added to show a separate service, such as massage therapy, happening that day.

Each modifier has its own rules and methodology for applying it. Unfortunately, mistakes happen. Misuse of modifiers, though, can have big consequences for your practice, so learn how to use them or avoid them if you’re not sure.

Modifier 25

If you’re billing E/M twice during the same day, you must add the 25 modifier. According to the American Chiropractic Association (ACA), some good reasons to use this modifier include:

• A new condition or injury in a current patient
• A new patient at your practice
• A re-evaluation to change treatment plans

Generally, then, a separate E/M is required “above and beyond the usual pre-service and post-service work associated with the procedure.” This is for work performed on the same body region.

Modifier 59 and subsets

You only need to use modifier 59 if you’re billing for a service such as massage therapy, manual therapy or neuromuscular re-education that occurs during the same patient encounter as chiropractic manipulation.

The other service must also be performed at a different time, on a different region and using a different technique.

Consequences for modifier misuse

Used incorrectly, modifiers can be costly.

As the ACA previously reported, Blue Cross Blue Shield (BCBS) plans in some states sometimes choose to automatically deny any billing medical claim containing one of these modifiers after concerns over modifier fraud grew. In these cases, the ACA recommended that chiropractors appeal as long as they knew they were using modifiers correctly.

The Office of Inspector General (OIG) recommends taking steps to keep your own billing in compliance with Medicare and Medicaid standards. Being intentional about coding and using modifiers correctly can help protect your practice against accidental misuse and fraudulent practices.

Chiropractic medical claims can be denied, but even if they aren’t immediately denied, you could be held liable for compliance later. Audits may reveal your compliance weaknesses — a self- or internal audit may be just what your practice needs to help you find gaps in your compliance activities.

Get compliant

If billing and coding have you down, it’s important to make a plan that can help your practice get back on track again.

Here are a few ideas that may make compliance easier:

• Compliance training: Seek out online resources on compliance, take a class, participate in a workshop or check out a webinar to learn the basics. Compliance consulting is readily available and there’s abundant coverage online that can help you learn more.

• Outsourcing: A clearinghouse can make it easier to make sure your compliance information is complete. You could also hire a billing and coding specialist if you’re tired of coding yourself.

• Internal staffing: Adding a chiropractic assistant who can help with your billing and medical claims coding may be a worthwhile personnel investment.

• Compliance policies: Do you have your own internal policies guiding your compliance practices? If not, then consider taking steps to protect your practice with the right policies and procedures.

• Self-audits: Checking your practice for compliance regularly can help you identify gaps and prevent problems before they occur.

By getting and staying compliant, you protect your practice and your patients.

Sources:

1. Talcott, T. “Chiropractic is back in the Medicare crosshairs again.” Chiropractic Economics. Published: November 2016. Accessed: April 2019. Retrieved from: https://www.chiroeco.com/medicare-and-chiropractic/
2. CMS. “Billing and coding guidelines for chiropractic services.” CMS.gov. Published: May 2014. Updated: February 2018. Accessed: April 2019. Retrieved from: https://downloads.cms.gov/medicare-coverage-database/lcd_attachments/34585_31/Billing_and_Coding_Guidelines_L34585.pdf