Medical Billing Coding - Training Primer - Modifiers, cpt, codes
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Thread Topic: Training Primer - Modifiers
Topic Originator: Steve
Post Date May 16, 2011 @ 3:49 PM
Training Primer - Modifiers

May 16, 2011 @ 3:49 PM Reply  |  Email Friend   |  |Print  |  Top

Modifiers can be tricky and they can be easy to use.  

Without coding training, using modifiers is tricky because you dont know which one to use or why you are using it.

Modifiers are located in Appendix A of the CPT manual, and to select the proper modifier for the situation requires reading the modifier descriptor.  

For example, I had a non trained person tell me it is permissable to use modifier 59 with an office visit.  I knew why they said this.  Modifier 59 is universally used by some to bypass an insurance company's electronic bundling edits and the claim is put through the insurance company's claims processing software.  The insurance company sets up the edits based on (a) NCCI or their own internal coding edits.  It is designed to keep out the claims incorrectly coded so that they arent paid.  But, some people who may be paid a percentage of what they recoup, dont make money when a claim is denied, so they want claims paid, so when they send a claim that has been denied for coding bundling, they learn to use modifier 59 to bypass the bundling denial and voila, a check is received, and now they can invoice the doctor for the paid claim.  

If you look at the descriptor for modifier 59, you see that it states the following:
Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures or services, other than E/M services, that are not normally reported together but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or 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. However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available and the use of modifier 59 best explains the circumstances should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25.

Looking at the modifier descriptor tells you that you cant use modifier 59 with an office visit.  You have to use modifier 25, so next, you look at the descriptor for modifier 25 to see if it fits the scenario for the visit.  Modifiers tells us that something happened during the visit or the procedure that was out of the norm that usually happens during a regular visit.  An example is you go to Walmart to buy some towels.  Driving to Walmart usually takes you 15 minutes.  But, during this trip, you had a flat tire and their computer was down so you couldnt use your credit card, you had to use cash.  Two things happened that were out of the norm for a trip to buy towels.  You can add to this with, instead of white towels, all they had were yellow towels and you bought a book on how to play Lords of Ka-a.  The flat tire required a modifier, the use of cash is different modifier, no white towels is another different modifier and last, buying a book is another modifier.  Under normal circumstances, going to buy white towels requires no modifier.  

Again, before you use a modifier, you need to read the documentation as to what happened during the visit.  look to see why the patient came to the doctor and what happened or didnt happen during the visit or procedure.  Example:

Mary came to the doctor for back pain.  The doctor find an infected cyst on her back causing the pain.  He incises the cyst.   Under normal circumstances, the doctor would code the office visit because examining and evaluating the back pain is what would have happened during a normal visit.  BUT, what is out of the norm is an infected cyst.  The doctor can bill the appropriate office visit as a significant and separate evaluation and management because the patient came in to be treated and examined for back pain.  The doctor uses the appropriate modifier of 25 to show that the office visit is significant and separate from the I&D.  The patient didnt come in to have the cyst I&D'd.  If the patient came in for an I&D of the cyst, then an office visit (99201-99205 or 99211-99215) wouldnt be significant and separaate from the I&D.  The back pain diagnosis which is what brought the patient to the doctor is what supports the office visit.  The infected cyst diagnosis and back pain supports the I&D of the cyst.  No modifier is needed  with the I&D because there is no other service that was provided in addition to the office visit and I&D.  If, during the visit, the patient has a splinter in her foot which is removed.  The doctor can report the splinter removal using modifier 51 because he performed multiple procedures (I&D and splinter removal)  

Now, during the I&D, the patient fainted and had to be taken to the emergency room, so he didnt complete the I&D, so he reports the discontinued service using modifier 53.  Why did he select modifier 53?  he went to Appendix A and read the descriptor which provided the guidance as to the modifier to use for the situation documented by the doctor.  

Lets say Dr A did bariatric surgery on Mr. Magoo.  Bariatric surgery has a 90 day global period.  30 days after surgery, Mr. Magoo went in to have his G tube removed.  Dr. A should not be billing for this visit as it is within the global surgical period.  He should code the visit as 99024 (no charge office visit), but Dr. A feels he should be paid or his biller is paid a percentage of what they collect, so they bill an office visit, using modifier 59 to bypass the coding edits so a check can be issued.  

Now, lets say Mr. Magoo falls and sustains a sprain of his left arm.  The arm sprain is not part of the original surgery, so the office visit can be reported for payment, BUT, the insurance company will see an office visit during the global period so the claim might be denied. An appropriate modifier to show that the fracture care during the global period which was separate from the bariatric surgery, can be billed so that the fracture care can be paid.  When you read the descriptors for modifiers, you can see that modifier 24 describes this scenario.  

Using some modifiers may need to have a copy of the medical record submitted with the claim to provide foundation to the visit, the procedure, or the scenario behind the use of the modifier.  

Selecting a modifier without medical record review can be dangerous.  For example,  I have CPT XXXXX, YYYYY, ZZZZZ and AAAAA, which modifiers do I use to get these paid?  
While that is a valid question, we must understand we are not in the profession to get anything paid.   While valid CPT codes may be shown, we dont know if they were performed or if they were documented, we dont know any circumstances as to why they were performed at the same visit.  For all we know these codes could possibly be part of a fraud scam taking place by a biller or doctor looking to bill an insurance company to get rich.  A mom and pop unregistered clinic may have set up shop in a strip mall in Miami, Orlando, Binghamton, Johnson City, Lawton, Ayer, or Honolulu and the word is out if you submit XXXXX, YYYYY, ZZZZZ, and AAAAA, you can make several millions of dollars.  To get them paid, a modifier is needed to get past the electronic gatekeeper.  In our profession, we do not and we never support fraud or abuse in any form (Im not saying that true fraud is taking place.  these examples are fictitious to provide an example of possible fraud).  We dont know if the sprocedures are legibly documented as actually being performed.  We dont know if any procedure was performed by the same provider or different providers at different visits. We dont know if the procedures were performed during the global period of another procedure.  We dont know if any procedure was completed or discontinued.  

Coding on a forum can be dangerous. Coding MUST always be done by a trained coder, reading the medical record documentaion.  Any answer provided could be correct and it could be wrong.  Something completely different could have taken place, so by coding using what is presented in a post could open the forum, the forum owners and the person answering to a possible lawsuit, not to mention possible proscecution for contributing to a fraud scenario.  If I said use modifier 51 on AAAAA, 59 on YYYYY, 50 on ZZZZZZ and 77 on XXXXX and the claims are denied, this doesnt stop the original poster and doctor from sueing me for revenue loss.  I highly recommend that someone who doesnt know coding and is using a forum as a means of getting an expert to code for them, to undertake proper coding training.  Forums can never replace good training.  Forums, while helpful, have severe limitations.  Forums should never replace a trained, experienced and certified coder.  Last, forums can never replace opening the coding manual and reading it.

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