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3 Ways Payers Are Monitoring Your Use of CPT Modifiers

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3 Ways Payers Are Monitoring Your Use of CPT Modifiers

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CPT modifiers

Without CPT modifiers, many coders would struggle to submit accurate claims to payers. Why? Because modifiers allow you to provide insurers with more information about a service or supply, without changing the meaning of the code they’re modifying. In many cases, modifiers can be the difference between a denial and a claim approval.

Coders have a responsibility to use modifiers accurately — and because CPT modifiers are often tied to actual dollars, some payers are scrutinizing them to ensure they aren’t being abused. Check out three ways payers are keeping tabs on your modifier usage.

Checking Modifier 52 on Time-Based Codes

The AMA’s CPT Assistant says not to use modifier 52 on time-based codes — instead, only report the code in question if you hit the midpoint of the time named in the code. If you don’t hit the midpoint, then you shouldn’t report that code at all — and you certainly shouldn’t simply append modifier 52 to the code.

This is backed up by many individual payers, such as Part B MAC Novitas Solutions, which advises practices in its Modifier 52 Fact Sheet, “Do not use on time-based codes.”

Reviewing Multiple Claims for Surgical Patients

Payers are beginning to scrutinize when two claims are submitted for the same patient for the same surgery, particularly when one is submitted by the facility and one is submitted by the surgeon.

If it’s the same operating room, the CPT codes should typically be the same for the surgery. You may have different codes for things along the lines of supplies, implants, or drugs, but in those cases, the hospital or the facility will then report it and the surgeon will not. There could be differences, but in general, the codes should match. If they don’t, the payer will wonder who has the right code and who doesn’t. In addition, if you fail to append CPT modifiers to the claim, expect an audit or denial.

If you’re using the assistant at surgery modifier (80), be ready for payers to review your documentation to ensure the assistant is actively participating in the procedure and isn’t simply holding or passing instruments that a surgical tech or scrub nurse could do.

Evaluating Whether Modifier 25 Describes a Separately Identifiable Service

If you report an E/M code and a procedure together and append modifier 25 to the E/M code, payers will ask a variety of questions to justify the use of the modifier:

  • Was an E/M service performed and documented, separate from the procedure?
  • Does the E/M service stand alone as a billable service?
  • Is there a different diagnosis? And if the diagnosis isn’t actually different, did the documentation indicate pre-service and post-service work above and beyond the components usually included in the procedure?

If you can’t answer these questions appropriately, question whether modifier 25 is the right modifier for your claim. You want to pick up any coding inaccuracies before payers do so you can correct issues involving CPT modifiers before facing denials.

Don’t leave your modifier use to chance — master modifiers with tips from expert Michael Strong, MSHCA, MBA, CPC, CEMC. During his one-hour online training event, Master Coding Modifiers and Uncover Unclaimed Revenue, Michael will give you the modifier strategies you need to collect more pay. Register today!


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