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presentation

Medical Billing - Use Proper Modifiers to Reduce Denials

February 19, 2015



Incorrect usage of modifiers can result in revenue loss for a medical practice. If not used appropriately, faulty codes can lead to claims denials, reduced income for practices and compliance issues too. The coding modifiers are revised annually by payer organizations. The guidelines for using modifiers keep changing making it is necessary for the billers and coders to have the recent copy of the CPT book produced by the AMA and AAPC. Since these codes are a critical component of medical coding, billers need to thoroughly know the modifiers in order to reduce the risk of losing revenue.

Avoiding Misuse and Abuse of Modifiers

Medical practices should use the modifier codes only when they are relevant and backed up by specific information within the patient’s record. Here are some of the modifier types:

- this needs to be used in conjunction with modifiers 24 and 25 if practices want to bill for E/M services

  • Modifier 22 - incorrect usage of this code is more likely to trigger an audit and therefore, it should not be used until there is no CPT code describing increased work. It is not recommended to append this modifier to an E/M service
  • Modifier 24 - during a post-op period, practices need to use this modifier correctly in order to get paid for an E/M services. If used incorrectly, practices might face audits
  • Modifier 25 - this may only be appended to an E/M CPT code. There are different guidelines for new as well as established patients that coders need to be aware of
  • Modifier 79
  • Modifier 22 - incorrect usage of this code is more likely to trigger an audit and therefore, it should not be used until there is no CPT code describing increased work. It is not recommended to append this modifier to an E/M service
  • Modifier 24 - during a post-op period, practices need to use this modifier correctly in order to get paid for an E/M services. If used incorrectly, practices might face audits
  • Modifier 25 - this may only be appended to an E/M CPT code. There are different guidelines for new as well as established patients that coders need to be aware of
  • Modifier 79 - this needs to be used in conjunction with modifiers 24 and 25 if practices want to bill for E/M services
  • Modifier 57 - when the E/M results in a decision for important surgical procedures, this modifier replaces modifier 25. This may be used with E/M codes 99201 and 99499
  • Modifier 59 - as per reports, 40% of this modifier usage is incorrect. It should be used only when no other modifiers are available. It is used for identifying services or procedures that are bundled together but are appropriate to be reported separately. Inaccurate use of this modifier can result in incorrect coding and overpayments

This modifier is not appropriate with unlisted codes, and some CPT and HCPSC codes. Misuse and abuse of modifier 59 is a frequent target of payer audits. As per the Comprehensive Error Rate Testing program report, it racked up around $770 million in improper payments in 2013.

Changes in 2015 by CMS

From January 01, 2015, the CMS has started analyzing medical claims for proper use of four new X-modifiers for Medicare claims that can be more appropriate than 59. The providers will have to deal with an increased scrutiny and confusion too due to this change. They will have to use these new codes in the correct manner to avoid risking audits and claims denials. Appropriate usage of the new modifiers will also help providers in capturing full reimbursement.

In order to avoid penalties and technical billing errors, practices need to train their in-house billers in using modifiers. Many providers have started outsourcing their medical billing services to reputed billing agencies. Companies like MedicalBillersandCoders.com ensure error-free usage of modifiers and CPT codes with their expert coding and billing teams. The dedicated AR team ensures a smooth flow of collectibles to boost your revenue by 30%.

 

Category : Best Billing and Coding Practices