One of the common reasons medical claims may be denied is for missing modifiers or invalid modifier combinations. Accurate coding of treatment is essential, but it’s also important to ensure you include modifiers when necessary and ensure you’ve used the correct one for the code you’re using.
When your claim is denied, it not only has the potential to delay payment but also could result in non-payment. Misusing medical billing modifiers could also trigger an audit that can lead to hefty fines and audits can go back many years. Medicare audit fines might be as high as $10,000 for each occurrence.
This means every time you bill a modifier on a claim incorrectly, you may have to pay $10,000 for each occurrence. That adds up quickly. In this article, we discussed the most commonly used modifiers 59, 51, 26, and TC and their misuse. You can review your coding guidelines and can crosscheck if you are not making the same mistake.
Misusing Modifier 59
Modifier 59 is considered the most misused modifier by coders. Modifier 59 is defined as a ‘Distinct Procedural Service.’ It is normally used to indicate that two or more procedures were performed during the same visit to different sites on the body. This modifier should also only be used if there is no other, more appropriate modifier to describe the relationship between two procedure codes.
Unfortunately, it is too often applied to prevent a service from being bundled or conjoined with another service on the same claim. It should never be used strictly to prevent a service from being bundled or to bypass the insurance carrier’s edit system. If there is another modifier that more accurately describes the services being billed, it should be used in place of modifier 59.
Misusing Modifier 51
Modifier 51 is defined as multiple surgeries/procedures. Multiple surgeries were performed on the same day, during the same surgical session. This modifier can be misused in several different ways. First, you can incorrectly apply it when a procedure is more accurately described with an add-on code. Also, you should not use it with an evaluation and management (E/M) service.
And finally, you might incorrectly apply it to the wrong procedure, especially if you are billing claims for Medicare. Do not append modifier 51 when two or more physicians each perform distinctly, different, unrelated surgeries on the same day to the same patient.
Confusing between Modifiers 26 and TC
Modifier 26 indicates the professional component (physician’s interpretation or report) of a diagnostic, lab, or pathology service, while modifier TC represents the technical component. It’s very important to know when to bill globally and when to segregate a code into professional and technical components.
Separate payments may be made for the technical and professional components of a procedure if, for example, a facility provides the technical component of a service/procedure, while an individual physician performs the professional component. The physician bills the procedure code for that service with modifier 26 appended, and the facility bills the same procedure code with modifier TC.
If, however, a physician provides both the professional component (supervision, interpretation, report) and the technical component (equipment, supplies, and technical support) of a service, that physician would report the global service, the procedure code without the TC or 26 modifiers. Understanding the appropriate use of modifiers 26 and TC is key to filing clean claims and avoiding denials for duplicate billing.
Medical Billers and Coders (MBC) is a leading outsourcing medical billing company providing complete revenue cycle management services. Our coding experts are well versed with coding guidelines and payer-specific policies to ensure the appropriate use of codes and modifiers.
If you need any assistance in medical coding for your practice or if you are looking for complete revenue cycle solutions, contact us at info@medicalbillersandcoders.com/ 888-357-3226
FAQs:
1. What are modifiers in medical billing?
Modifiers are two-digit codes that provide additional information about a procedure or service performed, helping to clarify billing details.
2. Why are claims denied due to modifiers?
Claims can be denied for missing or incorrectly used modifiers, which can delay payment or lead to non-payment.
3. What is the purpose of Modifier 59?
Modifier 59 indicates a “Distinct Procedural Service,” showing that multiple procedures were performed on different body sites during the same visit.
4. How can I avoid misusing Modifier 51?
Ensure Modifier 51 is applied only when multiple surgeries are performed on the same day and avoid using it with add-on codes or E/M services.
5. When should I use Modifiers 26 and TC?
Use Modifier 26 for the professional component of a service and Modifier TC for the technical component, ensuring to bill globally when both are provided by the same physician.
