To obtain fair and just reimbursements for visits, procedures conducted followed by tests, etc, all medical practices need to ensure that certain best practices are always followed. One of the best practices that any healthcare facility, even if it be a specialty, should ensure that their coders and billers are up to date with the newest CPT and HCPCS codes.
Current Procedural Terminology (CPT) codes are terms that medical coders use when reporting procedures and services. There are thousands of CPT codes that can be used to describe certain processes, but these do evolve and change as per CMS rules & regulations. One example is that of CPT Category III codes, which are altered every 6 months. The frequency of these updates means that it is critical that a medical coder has the most recent knowledge. If they don't, they won't be able to communicate effectively. Failure to learn the new codes can lead to delays and a risk to patients and hospital welfare
Code modifiers help further describe a procedure code without changing the definition of the code. Modifiers can be found in the CPT (Current Procedural Terminology) and HCPCS (HCFA Common Procedural Coding System) code books. A modifier provides the means by which the reporting provider can indicate that a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code. Modifiers answer questions such as: which one, how many, what kind and when. More than one modifier can be attached to a procedure code when applicable. Not all modifiers can be used with all procedure codes. Modifiers do not ensure reimbursement. Some modifiers increase or decrease reimbursement; others are only informational.
However, it should be noted that Modifiers are not intended to be used to report services that are "similar" or "closely related" to a procedure code. If there is no code or combination of codes or modifier(s) to accurately report the service that was performed, written documentation and the use of unlisted code closest to the section which resembles the type of service provided can be employed to report the service
Let's look at 3 Modifiers critical to healthcare centers:
Modifier 25 is considered valid on Evaluation and Management (E/M) procedure codes only (based on modifier definition). But, Modifier 25 is not considered valid when appended to surgical codes medicine procedures, diagnostic tests and procedures, etc. and the line item will be denied as an invalid modifier combination. E/M service codes submitted with modifier 25 appended will be considered separately reimbursable when only certain criteria are applicable which are essential for ant coder to be aware of. Note: The submission of modifier -25 appended to a procedure code indicates that documentation is available in the patient's records which will support the distinct, significant, and separately identifiable Nature of the evaluation and management service submitted with modifier -25, and that these records will be provided in a timely manner for review upon request.
Modifier 59 may not be part of every multi- gastrointestinal endoscopy (EGD) claim. To determine if the gastroenterologist merits more than one upper gastrointestinal endoscopy (EGD) CPT code for the same patient during the same encounter, one should look for biopsy details and such procedures as polyp removal and band ligation in the op notes. Many coders would likely have to attach modifier 59 to 43239. But, for some commercial payers in some states, you may have to attach modifier 59 and modifier 51 (Multiple procedures) to get this combination paid.
You should apply modifier 59 only when CMS or CPT normally bundle the procedures, but you need to indicate that the physician performed those procedures at separate (and thus non-bundled) locations. It is imperative that one verifies with the Correct Coding Initiative (CCI) and other carriers before adding modifier 59 Also, one should be cautious when employing modifier 59, as this is one of the most misused modifiers. If this modifier is not used appropriately, the claim will be denied. The best way to figure out if modifier 59 is the correct modifier is to see if the CMS National Correct Coding Initiative (NCCI) contains an edit that prohibits the two procedure codes from being billed together. If NCCI unbundles the codes, but your services were provided on distinctly different sites, then modifier 59 is appropriate. In the event that a more descriptive modifier is available, it should be used in preference to modifier 59.
Modifier 79 is used to bill an unrelated procedure or service by the same physician during the postoperative period of a previous surgical procedure, as per the Current Procedure Terminology (CPT)® manual.
When a patient has surgery performed, there is a postoperative period -- a period after the surgery has been performed when additional surgical care related to the initial surgery is considered already covered (and paid for) by the allowance provided for the initial surgery. This postoperative period can be zero or 10 days (minor surgical procedure) OR 90 days (major surgical procedure). (Note that some surgeries are considered so minor that they have a zero (0) day postoperative period, usually a very quick outpatient procedure.)
Modifier 79 should be used when a surgical procedure is:
• Performed during the postoperative period, where the original surgery had a global period of 10 or 90 days.
• Performed by the same physician or physician of the same specialty within the same group, and
• Unrelated to the original surgical procedure Note: When the 79 modifier is used, a new postoperative period for the second surgical procedure begins. Additionally, the remainder of the postoperative period of the original surgery is still applicable.
-79 Unrelated Procedures or Service by the Same Physician during the Postoperative Period: The physician may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. This circumstance may be reported by using the modifier '- 79' or by using the separate five digit modifier 09979.
Thus, keeping in mind these 3 critical codes when documenting illness to see that the claims management process runs smoothly and thus receive a fair reimbursement.