Corporate Compliance

CMS calls for proper use of modifier - 79

Healthcare Auditing Weekly, February 17, 2009

On February 13, CMS released a transmittal asking contractors to strengthen safeguards that prevent improper payment for claims including modifier -79.

Coders append modifier -79 to indicate the physician performed a procedure or service, during the postoperative period, which was unrelated to the original procedure. CMS established this modifier to simplify the billing process in these cases, according to the transmittal

The OIG initiated an investigation after receiving allegations that a provider was billing for podiatry surgeries that he never performed. An investigation revealed that between 1994 and 2000, the provider billed for surgeries for his patients every five to six days, according to the transmittal, and used modifier -79 to avoid detection.

According to the transmittal, contractors should follow these requirements:

  • Review modifier -79 claims data
  • Take appropriate action if the data warrants any action, such as:
    • Establishing a prepayment edit
    • Developing pre- and post-payment reviews
    • Educating the provider

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