Health Information Management

A simple review of the rules can help coders avoid costly modifier mistakes

JustCoding News: Outpatient, February 10, 2010

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Although modifiers can sometimes be an afterthought for coders, inaccurate reporting of modifiers has the potential to put the brakes on payment for claims or have serious financial consequences if auditors uncover compliance problems.

“I think the challenge is two-fold,” says Susan E. Garrison, CHCA, PCS, FCS, CPC, CPC-H, CCS-P, CHC, CPAR, executive vice president of healthcare consulting services at Med Law Advisors in Atlanta. For starters, coders need to understand the rules for appending modifiers, and to make matters worse, sometimes staff members other than coders who are not familiar with coding guidelines are responsible for assigning modifiers.

Coders need to understand the rules for appending modifiers, but they aren’t the only ones. For example, chargemaster descriptions drive the coding for certain hospital outpatient services, meaning that someone in an ancillary department (i.e., not HIM) might be responsible for assigning modifiers. So make sure whoever is doing the coding is aware of the coding guidelines, Garrison says.

Consider the following example, which illustrates a case where knowing the rules affects reimbursement: A patient comes in to the ED with chest pain, and the physician orders a troponin lab test at the initial encounter and then also again later that same day to gauge whether the patient’s condition has improved. It would be appropriate to bill for two lab tests and append modifier -91 (Repeat clinical diagnostic laboratory test). However a staff member might mistakenly charge only once for the services because he or she overlooks the fact that these were two separately medically necessary services, Garrison says.

When facilities have departments other than HIM responsible for billing for services, they may need to look at this from an operational standpoint and may need to audit modifier assignment, Garrisons says. For example, when a patient has different lab services on the same date of service but at different times, the lab department might bill for those charges but may not conduct an assessment to see whether a modifier is necessary.

Let’s take a closer look at some common modifier mistakes related to physician practice coding.

Modifier -59

Coders continue to struggle with understanding appropriate unbundling and knowing when to append modifier -59 (Distinct procedural service). In terms of confusion, modifier -59 seems to cause the lion’s share because it is so challenging to use correctly, Garrison says.
Sometimes the challenge reporting this modifier stems from a lack of knowledge about the unbundling rules or National Correct Coding Initiative (NCCI) edits. Other times it’s due to insufficient physician documentation.

In certain circumstances, coders may unbundle procedures and report them separately with a modifier -59 to indicate a different session or different site, says Sharon Bolarakis, CPC, CPC-I, CPMA, a coding and compliance consultant for EthosPartners Healthcare Management Group.

For example, consider a procedure for the shoulder, which is comprised of three areas or compartments:

  • Subacromial 
  • Acromion clavicular
  • Glenohumeral

A surgeon performs a procedure in the subacromial compartment and bills that procedure. If the physician addresses another problem in the glenohumeral, it is appropriate to report modifier -59 and unbundle these procedures.

However, if the physician performs a repair in the subacromial compartment and also performs a debridement in that same area, it is inappropriate to unbundle the procedures and report modifier -59 because the debridement took place in the same area as the repair, Bolarakis explains.

“You have to go to the NCCI edits, and you have to look at each code you’re going to bill to see whether the NCCI edits tell you that it is mutually exclusive or acceptable under certain circumstances to unbundle and report a modifier -59,” Bolarakis says.

It’s tricky because an encoder may tell a coder that two CPT® codes bundle together, and it might tell them that they can potentially bypass this edit with a modifier, but it won’t tell the coder whether actually using that modifier is appropriate, says Garrison, adding that some coders neglect to look at the logic behind the bundling edits.

“Especially for modifier -59, it’s challenging because there’s a great deal of information on the bundling edit, and people can go and review the edit but it’s still somewhat subjective determining whether documentation supports using it,” Garrison says. “Know the guidelines so that you have the tools to make that subjective decision.”

For example, when a physician performs a cholecystectomy (i.e., gallbladder removal), he or she does so through an incision of the abdomen (i.e., laparotomy). Although there is a laparotomy code, this is part of the gall bladder removal, meaning a modifier -59 is not appropriate in this case.

Also, if at the point of incision for the gall bladder removal the physician determines that a hernia is present, coding guidelines state that this hernia repair is an incidental repair and you should not code it. However, if the physician performs an inguinal hernia repair, then you can report codes for both the gall bladder removal and the hernia repair.

“But you need to know the NCCI guidelines to know that,” Garrison says.

Modifier -57

When coding for procedures, sometimes there’s confusion about whether to append a modifier to the surgery code or the evaluation and management (E/M) code.

“I think coders are a little confused about the rules for when to use certain modifiers,” Bolarakis says. “For example, modifiers -57 and -25 will never go on the surgery code—you always report them with the E/M visit.”

For example, a patient trips and falls and hurts his or her ankle, so the patient goes to an urgent care center to find out whether the patient fractured his or her ankle. The physician performs an E/M service and after ordering x-rays determines there is a fracture. The physician performs a procedure for which a closed fracture care code would be appropriate. For this case, you would append modifier -57 (Decision for surgery) to the E/M code.

Coders sometimes incorrectly report modifier -57 with the closed fracture code, Bolarakis says. “If you do this, it will get denied,” she says. “This modifier indicates to the payer that a procedure with a 90-day global period will follow this E/M visit.”

Modifier -25

Similarly, be careful when appending modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) for procedures that have a 10-day global period.

In the past, inaccurate information proliferated throughout the coding community that coders should use modifier -25 when the physician makes a decision for minor surgery (i.e., a procedure with a 10-day global period).

“That’s saying that it’s okay to use modifier -25 when the physician makes any decision for minor surgery, but often the E/M service is already included in the code for the minor procedure,” Bolarakis explains.

But it’s not always necessary to bill for an E/M visit involving a minor procedure, as the following example illustrates:

A patient comes in for knee pain, which is a new problem. After performing an E/M service, the physician decides to try to treat the patient’s knee pain with an injection. The physician determines by way of the E/M service to administer an injection. Therefore it would be appropriate for you to report both the injection and the E/M visit with a modifier -25, Bolarakis says.

However, when the patient returns in two weeks and attests to the effectiveness of the treatment and the physician administers another injection, it’s appropriate to bill only for the injection for this encounter—not the E/M visit nor any modifier.

“The most common mistake I see is that sometimes the documentation doesn’t support the use of this modifier,” Garrison says.

For example, when a patient comes in every month for an epidural injection, the likelihood is that providers should not bill for a separate E/M service each visit, Garrison explains. However, if the physician is evaluating the patient’s pain and ruling out different causes and treatments and decides to try an epidural injection to see if that helps address the patient’s pain, providers may append modifier -25 to the E/M code as long as the documentation supports it, she says.

Modifier -24

Coders also often misuse modifier -24 (Unrelated evaluation and management service by the same physician during a postoperative period).

When patients come to the office after a surgery, many times physicians will administer postoperative injections to address pain due to the surgical procedure. Because this injection is related to postoperative care, it is incorrect to report modifier -24 for these kinds of cases, Bolarakis says.

Append modifier -24 only to indicate an unrelated service. For example, a patient who had surgery on the right knee is still in the global period, and he or she steps out of the shower and twists the left ankle. This patient goes to the physician’s office to have their ankle evaluated, so for this encounter it would be appropriate to append modifier -24 with the E/M code, Bolarakis says.

“Keep in mind that the physician documentation needs to support the reporting for this separate E/M service,” she adds. “Make sure that the physician documents the key components of this service and that they are clearly separate from the service provided or the postoperative follow-up.”

Modifier -58

In the description for modifier -58 (Staged or related procedure or service by the same physician during the postoperative period) in Appendix A of the CPT Manual, the guidance states the following:

It may be necessary to indicate that the performance of a procedure or service during the postoperative period was: a.) planned or anticipated (staged); b.) more extensive than the original procedure; or c.) for therapy following a surgical procedure.

Bolarakis notes that coders sometimes overlook important distinctions included in the description, such as “by the same physician” and “more extensive than the original procedure.”

For example, a patient comes in with an infected hip prosthetic. The physician examining the patient is not the same physician who performed the original surgery to place the hip prosthetic. This physician performs a procedure (the physician’s first with this patient) to remove the infected prosthetic. After several weeks when the infection has cleared, the physician will then insert a new hip, which is a more extensive procedure.

For this case, Bolarakis recounts that a coder mistakenly appended modifier -78 (Unplanned return to the operative/procedure room for a related procedure during the postoperative period). This is incorrect because this physician was not the surgeon who originally placed the hip prosthetic. Instead, the coder should have reported modifier -58 to indicate the more extensive procedure of inserting a new hip (i.e., a planned, related procedure) after removing the infected prosthetic. Inappropriately using modifier -78 instead of modifier -58 will result in lost revenue to the surgeon.

Modifier -50

Rules for reporting modifier -50 (Bilateral procedure) are typically carrier-specific.

Some payers want providers to report modifier -50 to indicate a bilateral procedure, whereas other payers want providers to append modifiers -LT (Left side) and/or -RT (Right side).

Another reporting method involves reporting modifier -50 on one line with two units. But another payer may want you to report modifier -50 on two lines with one unit.

Providers can avoid denials just by understanding the specific reporting methods each payer prefers.

Editor’s note: Interested in learning more about how to report modifiers? Sheryl Spohn, RHIA, CHC, and Sarah L. Goodman, MBA, CPC-H, CCP, FCS, will identify common mistakes and explain how to appropriately append modifiers for compliant coding during the February 23 audio conference, “Advanced Hospital-Based Modifier Clinic: Identify Risks and Ensure Accurate Reimbursement.”

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