Six tips to getting paid for CPT modifiers

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CPT modifiers help payers understand all of the distinct services and procedures physicians perform. As the scope of practice for today’s internists continues to expand, these modifiers are also increasingly required to ensure accurate payment, says Toni Elhoms, CCS, CRC, CPC, director of coding and compliance at RT Welter & Associates Inc., a healthcare consulting company in Arvada, Colo. 

For example, say an internist performs an annual wellness exam and addresses a skin lesion during the same visit. If the physician doesn’t append modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the evaluation and management (E/M) service for the lesion, most payers will disregard the E/M service and only pay for the annual wellness exam, says Elhoms. 

Appending a modifier when it isn’t warranted can also be costly. For example, an internist owns their own radiology equipment. If they append modifier -26 (professional component only) to each radiology service, they actually miss out on revenue, depending on the service, says Elhoms. For example, when appending modifier -26 to the CPT code for chest x-ray, single view (71045), physicians could lose approximately $13 for every test performed.

Elhoms cites the case of an internal medicine practice with its own radiology equipment that saw an immediate 60 percent increase in reimbursement simply by removing this modifier from the radiology CPT codes it reported. 

On the other hand, when a physician incorrectly appends a modifier and subsequently receives payment, they could be subject to a post-payment audit. “I’ve seen so many recoupments regarding inappropriate use of modifier -25 that have put private practice physicians out of business,” says Elhoms. “There’s a false sense of security when it’s paid. Recoupment requests can come out of nowhere.”

Elhoms knows of one family medicine practice that couldn’t recover from a $250,000 recoupment after a payer audited the practice’s use of modifier -25 on E/M office visit codes when providers rendered osteopathic manipulation treatment (OMT) during the same encounter.

The payer alleged that the documentation didn’t support a significant and separately identifiable service, and the payer felt the OMT was part of the typical work associated with the E/M code and shouldn’t have been paid separately, she says. 

Is there anything physicians can do to collect the payment they deserve while also avoiding compliance risk? Here are six tips experts recommend:

1/ Know your payer policies. 

Just because one payer accepts a modifier doesn’t mean all will, says Michael Miscoe,   JD, founding partner of Miscoe Health Law LLC in Central City, Pa. For example, one payer might accept modifier -25 in all instances consistent with the CPT definition of “significant, separately identifiable” while another might not permit it at all for certain services (e.g. when a physician reports an E/M code in addition to a code for a pain management injection). 

Take the time to identify the modifiers each payer does-and doesn’t-recognize. “Check each payer’s medical policies for service-specific as well as general policies regarding separate reporting,” says Miscoe. 

2/ Hire a certified coder. 

“Ideally, you would have at least one person in-house who can assist with modifiers and be proactive about monitoring denials and providing education,” says Elhoms. Another option: Keep a trusted compliance consultant on stand-by as questions arise, she adds.

3/ Focus on clinical documentation. 

For example, when physicians report modifier -25, their documentation must support the history, exam, and medical decision-making for two separate services, says Elhoms. 

Think of each service as a separate encounter even though they’re rendered during the same visit, she adds. For modifier -59 (distinct procedural service), documentation must support a different session, 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 individual.  

4/ Take a closer look at your billing system. 

Does your vendor incorporate National Correct Coding Initiative (NCCI) edits and update these edits quarterly? If so, are you certain that each payer has adopted those edits in its reimbursement policies? Do templates or billing automation encourage modifiers when they aren’t warranted or omit modifiers that are required? 

5/ Append each modifier to the correct code. 

For example, modifier -59 should accompany a procedure or service code but not an office visit E/M code. Always refer to the NCCI procedure-to-procedure edits or specific payer bundling rules when determining what procedure or service code should include this modifier.

Example: When reporting an excisional biopsy and lesion destruction, append modifier -59 to the code for the lesion destruction. When removing an intrauterine device  and inserting a Nexplanon during an office visit, append modifier -59 to the code for the IU removal. Modifier -25, on the other hand, is always appended to an E/M office visit code when supported by the circumstances of the encounter, says Elhoms. 

6/ Know what to do if you run into payment problems. 

Consider the following advice:

• Balance bill the patient. While most payer contracts don’t permit this, a physician who is not under contract with a commercial payer may have the option to do so if all other state statutory advance notice requirements are met. Physicians are not permitted to balance bill patients with Medicare, and some states are enacting statutes to limit exposure of patients to either non-covered service costs or disallowed amounts for services that are covered, says Miscoe. 

• Fight the denial. If the payer hasn’t published a policy on modifier usage, physicians may be able to successfully appeal the denial by citing standard industry guidance (e.g., CPT definitions of various modifiers, the NCCI Policy Manual for Medicare Services, or even medical policies of other major commercial payers), says Miscoe.

• Negotiate your payer contracts. Ask payers to accept modifiers in all or certain circumstances, says Elhoms. 

Taking proactive steps to ensure compliant use of modifiers pays dividends in the long run, says Elhoms.