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Before Requesting a Review on Modifiers, Read This!

Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

Generally, there is uniformity in the use of modifiers between payers. However, this is not always the case; you may see a difference in payer policies and how modifiers are handled. One way to know if a modifier can be used according to CMS rules can be found when using the National Correct Coding Initiative (NCCI).  However, keep in mind the edits do not include every possible code combination, and while most payers follow NCCI edits, some payers have their own rules. In addition, CMS/NCCI does not address services that are excluded from Medicare coverage. See this article for more information on how NCCI edits are used, "Are NCCI Edits and Modifiers Just for Medicare?" If a payer does not follow NCCI edits, you will report the modifier according to the payer policy; if not reported correctly, the payer may deny your claims or rescind the funds if paid improperly.  

CPT Modifiers and Compensation

Some modifiers will directly impact reimbursement. (link is only for an example; other payers may have different rates; we will address this later in this article.) while others are informational only. Be sure always to put the functional modifier (impacts reimbursement) first and the informational modifier second on the appropriate CPT code.   

Not all payers will pay the same amount of reimbursement when using modifiers. 
For example, see DMBAs Surgery Modifier Payment Table; the reimbursement is different from Tufts Health Plans Commercial Modifier tables.  DMBA allows 70% of the plan's fee schedule when reporting Modifier 54 - Surgical care only, and TUFTS allows 80% of the plan's fee schedule using the same modifier. 

CMS- Proper Use of Modifier 59

According to CMS, one of the common misuses of modifier 59 relates to the part of the definition of modifier 59 allowing its use to describe a “different procedure or surgery.” The code descriptors of the 2 codes of a code pair edit describe different procedures, even though they may overlap. Don’t report the 2 codes together if they’re performed at the same anatomic site and same patient encounter because they aren’t considered “separate and distinct. ”Don’t use modifiers 59 or –XU to bypass a PTP edit based on the 2 codes being “different procedures.”

However, if you perform 2 procedures at separate anatomic sites or at separate patient encounters on the same date of service, you may use modifiers 59 or –X{ES} to show that they’re different procedures on that date of service. Also, there may be limited circumstances sometimes identified in the National Correct Coding Initiative Policy Manual for Medicare services when you may report the 2 codes of an edit pair together with modifiers 59 or –X{ES} when performed at the same patient encounter or at the same anatomic site

Example : Column 1 Code/Column 2 Code - 34833/34820
• CPT code - 34833 - Open iliac artery exposure with creation of conduit for delivery of endovascular prosthesis or for establishment of cardiopulmonary bypass, by abdominal or retroperitoneal incision, unilateral (List separately in addition to code for primary procedure)
• CPT code - 34820 - Open iliac artery exposure for delivery of endovascular prosthesis or iliac occlusion during endovascular therapy, by abdominal or retroperitoneal incision, unilateral (List separately in addition to code for primary procedure). 

CPT code 34833 is followed by a CPT Manual instruction that states: “(Do not report 34833 in conjunction with 33364, 33953, 33954, 33959, 33962, 33969, 33984, 34820 when performed on the same side).” Although the CPT code descriptors for 34833 and 34820 describe different procedures, don’t report them together for the same side. Don’t add modifiers 59 or –X{EPSU} to either code to report 2 procedures for the same side of the body. If you performed 2 procedures on different sides of the body, you may report them with modifiers LT and RT as appropriate. However, modifiers 59 or –X{EPSU} are inappropriate if the basis for their use is that the narrative description of the 2 codes is different.

Consider using Modifier 59 if the following circumstances apply:
                   (this list is not all-inclusive - review payer coding rules)  
 Procedure is independent of other non- E/M services performed on the same day 
·         Procedure is performed on anatomically separate sites
·         Mutually exclusive procedures
·         Separate encounters
·          A more extensive procedure was performed
·      Coding guidelines permit using Modifier 59
·         If the procedure can’t be described by a more specific anatomic modifier
·         Don’t use modifiers 59 or –XU to bypass a PTP edit based on the 2 codes being “different procedures."
·         Documentation must always satisfy the criteria required (such as examples above)

See Palmetto GBA for additional CPT Modifier 59 Coding Examples using NCCI edits. 

The difference between Bilateral and LT/RT modifiers

Modifier -50 applies to any bilateral procedure performed on both sides at the same operative session.
The bilateral modifier -50 is restricted to operative sessions only.
Modifier -50 may not be used:
   • To report surgical procedures identified by their terminology as “bilateral” or
   • To report surgical procedures identified by their terminology as “unilateral or bilateral.”
The unit entry to use when modifier -50 is reported is one.

Modifiers -LT or -RT apply to codes that identify procedures that can be performed on paired organs, e.g., ears, eyes, nostrils, kidneys, lungs, and ovaries.
Modifiers -LT and -RT should be used whenever a procedure is performed on only one side. Hospitals use the appropriate -RT or -LT modifier to identify which of the paired organs was operated upon.
These modifiers are required whenever they are appropriate.

Introduction to Modifiers According to WPS

The information below offers usage guidance from the WPS article in the article "
Introduction to Modifiers." 

A clear understanding of Medicare's rules and regulations is necessary in order to assign the modifier correctly. This is particularly true for modifiers 22, 25, 50, 51, 59, 76, and 78. If coded incorrectly and paid, the payment may be rescinded. 

Inappropriate Modifier Usage

The system used by Part B carriers to process claims is called the Multi-Carrier System (MCS). The MCS will deny claims as "unprocessable" for inappropriate modifier use. If the use of a procedure code/modifier combination is inappropriate, you will need to make the necessary corrections and resubmit the claim.

Important Review Facts

  • Adding modifiers 24, 25, 26, 58, 59, 76, 78, or 79 to a denied service continues to be one of the top reasons for requesting a review. 
  • Remember that two different diagnosis codes alone do not justify adding modifier 25
  • Calling to add a modifier just because the service was denied is not appropriate. 
  • Having front-end edits in your individual claim processing system can eliminate a delay in payment for you and unnecessary follow-up work for both WPS GHA and your offices. 
  • Be prepared before calling in for a review. We have experienced providers calling and asking to add a modifier. Then when that modifier did not get the claim paid, they want to try another one. This is inappropriate.

Important Documentation Facts

  • It may be necessary to use the phrase "additional documentation available upon request" in the narrative field of your claim in order to support the modifier used. 
  • It is necessary to indicate you have documentation with modifier 22, critical care, and co-surgery modifiers for the same specialty. 
  • When documentation is requested because of modifier usage, the number one reason for denial is that the documentation is not returned in a timely manner. 

Important Miscellaneous Facts

  • It is only appropriate to report modifiers 24, 25, and 57 on evaluation and management procedure codes. 
  • Never report modifier 76 on a surgical procedure code. 
  • When it is necessary to report the following payment modifiers with another modifier, the payment modifier must be reported in the first modifier field: TC, 26, 52, 53, AA, AD, QK, QW, QY, and QZ.
  • Report modifiers 54 and 55 on the surgery code only. 

We have only addressed a few examples in this article, but we can see how important correct modifier usage is; for more detailed information and other correct coding policies, refer to the "NATIONAL CORRECT CODING INITIATIVE POLICY MANUAL FOR MEDICARE SERVICES."