Modifiers

Modifiers- Get to know them

Here are some of the modifiers that family physicians are likely to use most.

Modifier -25, “Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service,” may be the most important for family doctors. The classic use of this modifier is for an annual preventive-medicine encounter during which the patient says, “Oh, by the way, ...” As a result, you address the “by the way” ailment and perform the preventive service. In this case, you may submit codes for both a preventive service (such as 99396) and a regular office visit (such as 99213) by attaching -25 to the office-visit code. This tells the third-party payer that you did perform two significant, separately identifiable E/M services for the same patient on the same date, and it should keep the payer from bundling the services.

Use modifier -21, “Prolonged Evaluation and Management Services,” when an E/M service takes more time than is usually required for the highest level of service within a given E/M category. For example, you see an established patient with multiple, concurrent problems, spending more than 90 minutes in assessment and counseling with the patient and family. You feel the examination and medical decision making easily qualify the service as a 99215. But in this case, because the service was prolonged (according to CPT, the typical time for a 99215 is 40 minutes) “or otherwise greater than that usually required for the highest level” code in its category, you could append -21 to the 99215 and get credit for the extra time.

Modifier -59, “Distinct Procedural Service,” is similar to modifier -25, but it's applicable to procedural, rather than E/M, services. Attach -59 to a code to indicate that a procedural service is distinct or independent from other services performed the same day, particularly when the services or procedures aren't normally reported together but are appropriate under the circumstances.

For example, you incise and drain two abscesses — one simple and one complicated — for one patient. If you bill for these services using the appropriate CPT codes (10060 and 10061), it may appear as though you're coding twice for the same service. However, by appending -59 to one of the codes, you clarify that the services were distinct and that both should be reimbursed.

Here are several other situations in which modifiers can help you get paid appropriately for what you do:

Don't stop now

Of course, these are only a handful of the modifiers you'll find in CPT. Appendix A includes a number of others that may be relevant to your practice and are worth reviewing.

You should also know that the two-digit modifiers aren't the only type available. If an insurer's system won't accept the two-digit variety, you may use five-digit modifiers in addition to the E/M or procedure codes you're reporting. The convention for five-digit modifiers is 099XX, where “XX” is the two-digit version of the modifier. For example, rather than attaching -25 to a CPT code, you could submit 09925 as well as the code for the service.

You probably won't be surprised to learn that not all third-party payers recognize modifiers. But in claims to those payers that do, modifiers can be valuable tools to help you get paid appropriately for your work.

Information taken from: https://www.aafp.org/fpm/1999/0500/p18.html#

Modifiers: Keys to reimbursement

Modifiers can be the difference between full reimbursement and reduced reimbursement – or denial. While some payers differ in their use of modifiers, taking the time to learn the rules will pay off. In the last five years, payers have increased their recognition of modifiers when processing claims, which makes it even more important to learn them and use them correctly.

Modifier 25. Anytime you provide more than one service at a single encounter, you must consider whether a modifier is needed. According to CPT, modifier 25 is used to report a “significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service.” In some cases when an injection or drug administration code is reported, modifier 25 is required to distinguish the E/M service from the actual injection. However, some immunization codes include counseling the patient, so to use modifier 25, you would have to provide an E/M service for another indication. When you provide a preventive medicine service (codes 99381 to 99397) and spend significant additional work addressing a problem, modifier 25 is again required. Remember, the modifier must be appended to the E/M code and the services must be clearly documented. For more on modifier 25, read “Understanding When to Use Modifier 25,” FPM, October 2004.

Modifier 59. Modifier 59 is used for “distinct procedural services” that wouldn't otherwise appear to be distinct – that is, procedures and services that are not normally reported together, but are appropriately reported under the circumstances. According to CPT, this may represent “a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician.” Medicare recognizes the modifier to indicate that two or more procedures are performed at different anatomic sites or different patient encounters.

For example, if you perform a destruction of a premalignant lesion (code 17000) on the same day you biopsy another lesion (code 11100), you will need to append modifier 59 to CPT code 11100 to indicate that the services were performed at different anatomic sites. The first step to determining whether modifier 59 is needed is to refer to Medicare's Correct Coding Initiative(CCI). The CCI lists code combinations that are generally not reimbursed separately. Private payers often use the CCI as a guide for their own bundling policies. When reporting CPT codes with the designation “separate procedure” in conjunction with other procedure codes, be aware that these codes are often considered components of other services. If the procedures are distinct, then modifier 59 is required.

Modifier 24. This modifier is often overlooked. CPT suggests using it with an “unrelated evaluation and management service by the same physician during a postoperative period.” For example, an excision of a benign lesion (codes 11400 to 11471) has a 10-day global surgical period. So if a patient returns to the office within 10 days of the excision for an unrelated condition, you will need to append modifier 24 to the E/M service to get paid for the visit. It is helpful to maintain an easily accessible list of the global periods for office-based procedures so you can remember whether a modifier is required. You can find global periods in the Federal Register (see the far-right column starting on page 12 of the pdf).

Modifier 53. Another forgotten modifier is modifier 53 for “discontinued procedure.” It is used when the physician elects to terminate a surgical or diagnostic procedure because of extenuating circumstances or a threat to the well-being of the patient. It is not used for elective cancellation or cancellations that occur before surgical prep or induction of anesthesia. For example, modifier 53 could be appropriately appended to code 58100 when an endometrial biopsy cannot be performed without risking uterine perforation or other complications. The purpose of the modifier is to obtain some payment for the work and practice expense associated with the attempted procedure as well as to preserve the opportunity to report the code again later.

You should consider including the most common modifiers on your superbill or in your EHR and plan to conduct periodic quality checks to make certain modifiers are being reported correctly.

Information taken from: https://www.aafp.org/fpm/2011/0300/p31.html