The Coding Sleuth 18
by Tara Conklin
The Mystery of the Maddening Modifiers - Part I
Merriam - Webster’s Dictionary defines the word “modifier” as a word or phrase that makes specific the meaning of another word or phrase. To show longevity of this definition Webster’s Dictionary of 1828 defines “modifier” as “He or that which modifies”. It’s safe to say the word hasn’t changed much since its inception.
When applying this to the medical coding world we do have to change it (or for lack of a better word, modify it) to apply to “numbers” because, well, that’s what we have … number modifiers.
There are many modifiers to choose from too. Some, the most commonly used (and widely accepted) are listed on the front cover of our CPT manuals, (nope, open it up and look on the inside.. see they’re right there). Others are listed on the front and back covers or the HCPSC manual. These are their own animal all together and we’ll deal with those another time. What we want to look at is the CPT modifiers since we use them all the time and as we all know they can be quite confusing.
* When are they appropriate?
* How do you use them?
* What order do you put them in when you need more than one?
* What’s the difference between them?
For some coders these answers are clear as crystal. But for many others these are complex questions. So why don’t we put on our sleuthing caps and unmask the mystery of the maddening modifiers?
The proper understanding is important to both coder and biller alike. Why you ask? Simple. If the coder doesn’t know how to use them and in what application, they might not file their codes correctly, or paint a clear picture of the services performed. Likewise, when a biller gets a denial or even a payment of a claim without understanding the modifiers, they may not understand the reason for denial, or even if a payment received was correct based on the modifiers billed. All too often I’ve seen billers accept the allowed amount payment, write off the remaining balance (because that’s what the EOB told them to do) and not realize the procedure was billed bilaterally and the insurance company only paid for one side. Trust me - they do this purposefully, counting on the fact that most billers won’t catch their… ehem… error. We all know the insurance companies like to play games with our claims. If we are going to beat them at their own game we all need to wisen up.
In order to simplify our understanding we will group modifiers by what services they apply to. In this issue of the Coding Sleuth we will concentrate on E&M modifiers. Something to keep in mind when dealing with many modifiers is they are usually added to a charge that is being bundled (or normally included) in another service on the same day. Remember, modifiers paint a clear picture of what services were performed and under what circumstances.
The Office Encounter
There are several modifiers that get tacked on to the E&M codes when the services provided deem their use necessary. Remember all of these modifiers get applied to E&M codes only, never procedure codes.
-25 The most common ones we use are what I like to call our “pre-procedure” modifiers.
M-25 reports “a significant, separately identifiable Evaluation and Management Service by the Same Physicians on the Same Day of the procedure or other service.”
This has two meanings, really. The first applies when the physician has performed the necessary components required to bill and E&M (history, exam and medical decision making) in addition to other services in which the E&M would normally be considered part of. It doesn’t necessarily apply only to procedures but under some circumstances two E&M services may be performed on the same day for unrelated reason, “unrelated” being the key word here. Say a patient has an office visit in the morning for a checkup on their diabetes. The physician bills the appropriate E&M for an established patient. However, later in that day the same patient goes to the ER complaining of chest pain and the same physician admits them. He will also bill an admit code but in order for both E&M services on the same day to get paid and be established as valid services, modifier 25 would need to be appended to the admit code. This is also applicable when both E&M and critical care are performed on the same day.
The most common use of modifier -25 occurs when a valid E&M and a procedure are both done on the same day, and sometimes within 24 hours of each other depending on the circumstances. 25 is also used as a “decision for surgery” but for minor procedures. What constitutes a minor procedure? Well, technically anything that carries a global period of less than 10 days, including those without a global period. The reason for this distinction is modifier 57, which we will talk about in a minute applies to major procedures and in most procedures the “preoperative” evaluation workup is included in the procedure. For an E&M to be separately billable on the same day as a procedure we need to show the physician needed to take a history of the problem, examine the patient and finally decide to perform the procedure on the same day. The decision for surgery was made, but in this case the procedure was minor for all accounts.
-57 We mentioned modifier 57 a moment ago is used to report an E&M service on the same day as a major procedure when the E&M service resulted in the physicians’ decision to perform the actual procedure. As opposed to minor procedures which carry a pre and post operative period of 10 days or less, a major procedure is one which carries a pre and postoperative period of 11 days or more; 90 days is the norm. The tricky thing is the global periods we are all familiar with are only laid out in the Correct Coding Initiative (CCI) which only applies to Medicare claims. The trouble arises when private payers require these modifiers to accept a claim, but turn around and don’t follow the CCI guidelines. Yes, my friend, this is what we call a “double standard” and the big insurers live by them… or more appropriately bank on them.
Now that we have acquainted ourselves with two modifiers used before a procedure is done let’s take a look at a few we might encounter during the postoperative period.
-24 We know procedures that carry a global period normally have either 10 or 90 days after the procedure in which all “normal and related care” is included in the price of the procedure and not billable separately. During this time period the patient may visit the same physician for a service unrelated to the procedure. The physicians may need to indicate the E&M provided was not related to the procedure and therefore separately billable. He easily accomplishes this by appending modifier -24 “unrelated E&M service by the same physicians during a postoperative period.”
Now, as we know it is very common for the patient to come in for a scheduled follow-up visit and while they have the undivided attention of their physician, they bring up some new complaint. Or perhaps the physician may care for something else during the same encounter. Don’t let this confuse you. First, don’t miscount the time and effort he put forth following up on the unrelated problem and just throw the baby out with bathwater (don’t chock the whole visit up as non-billable simply because it was scheduled as a global follow-up). He performed two distinct services during this encounter, both of which should be clearly explained on the claim form and most importantly in the documentation. Get your physicians in the habit of making clear demarcation points in his dictation or the medical record when performing different services on the same day, especially E&M. When applicable, the three key components (history, exam and medical decision making) should be clearly defined for each billable E&M code.
In the instance where you have both a global postoperative visit on the same day as an unrelated E&M service, both procedures should be billed on the claim form. 99024 with a 0 charge is used to report the follow-up visit, and the appropriate E&M code for the unrelated care is reported with modifier 24. A key piece of this puzzle is to make sure you apply the appropriate diagnosis codes to each service. Without a clear linkage between diagnosis and service, you can be sure a denial is coming down the pike.
Since these are the three modifiers that apply to evaluation and management services, and to avoid this article turning a newsletter into a short novel, we’ll only cover these three modifiers here.
There is, however, one important aspect of these three modifiers to take note of. Notice in the descriptors of each modifier they state “by the SAME physician…” The reason these apply to the same physician performing a service either on the same day as another or during a global period, is because the rules governing the procedures or services only apply to the same physicians. For example, if another physician performs the surgery on the same day as the first physician made the decision for the procedure, then there is no coding conflict. The CCI edits and these modifiers cancel each other out. They simply aren’t needed. Both physicians are billing their own separate service. You will see this apply with other modifiers we will be talking about in future issues.
Lastly, keep in mind, all physicians working under the same Tax ID in the same group or specialty fall under the umbrella of these modifiers. If Doctor A performs the procedure but his partner Doctor B performs an unrelated service during the postoperative period, Doctor B would need to append the appropriate modifier mentioned in this article to his service.
Coders and Billers alike should be educated and knowledgeable on coding and modifiers. Coders need to submit a clean claim and billers need to understand what they are looking at when reading EOBs and be able to discern if payment or denial is valid based on the codes and the modifiers billed. Insurance companies take great pleasure in twisting and even changing the codes we bill to suit their needs. Unless coding and billing personnel are rowing the same boat, inevitably the insurance companies will quite easily plunder away the physician's hard earned dollars.
Until next time, Knowledge is Power!
--Tara