Correct use of modifiers and their importance

Sending a clean and accurate claim is critical. Billing in incorrect units is a frequent problem I have encountered in so many offices.

Rather than billing out the service or medication with the correct units (lets say 3 units of some code),  coders will list out 3 separate lines of services instead of the procedure code and then specify 3 units. Doing it correctly means that it does not get rejected as a duplicate that way.

As a concrete example, let us say that the patient has received 25 mg of HCPCS code J8700 TEMOZOLMIDE, ORAL, 5 MG. Quite often on claim forms that have been denied as duplicates I have found the reason to be that each line was entered separately. For proper reimbursements it should be as follows:

Code Description Units Each Price Total Price
J8700 TEMOZOLMIDE, ORAL, 5 MG 5 $1.00 $5.00

Below you will also find another example of why putting the correct modifiers is critical to maximizing payments and how to bill out multiple procedures for the same date same surgery correctly and why the format is so important.

The following example illustrates the standard reimbursement rule for multiple procedures. Four surgical procedures are shown. When performed during the same operative session and billed with modifier -51, the reimbursement is determined as follows:

Procedure/Modifier Full-Fee Rate Reimbursement Formula
41150/-AG $ 973.19 100% of full fee rate
38720/-51 $707.37 50% of full fee rate
15120/-51 $409.53 50% of full fee rate
31600/-51 $201.04 50% of full fee rate

Please realize that I placed the reimbursement fee to show how multiples are reimbursed. A lot of billers just enter the codes and forget to note that they should be billed out with primary and most expensive first and then in declining monetary order. Insurance companies are not kind and just reduce the payment for this claim. If 38720 was billed as primary and 41150 as secondary the practice would have lost $265.82 just for this one situation. Multiply this by a few hundred episodes for the year and the practice would have lost thousands.

Probably, the modifier that should be used most often is modifer 25. Modifier 25 denotes the evaluation and management service is separately identified from any procedures performed or rendered on the same day. Many practices are still not correctly using this modifier, but they do not realize it is a problem, since they do not charge for an office visit, if they are doing a procedure on the same day, an extreme loss of money for the office. A lot of times patients come in for one thing and another DX is found and procedure is done, but because of the procedure no one bills for the reason patient came to the office. If you do a procedure in your office for a different reason than the office visit, then you should be charging for the office visit AND the procedure, and making sure you pay attention to 2 (two) things:

  • Modifier 25 is on the Office Visit, and
  • You use a different ICD9 code for each service

Please note I am not telling you to bill improperly, but properly in a way that supports the notes in the patients charts.

You can find modifiers at the following link:  https://www.highmarkmedicareservices.com/refman/chapter-20.html#3

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