ED Coding and Reimbursement Alert

Few days pass when professional coders who often code dozens of records in each eight-hour period aren't faced with the prospect of adding modifiers to the services emergency physicians provide. In some cases, the choice of modifiers is clear and the circumstances requiring them undeniable. At other times, however, the coding may be less than clear-cut.
 
"Modifiers have been implemented with a very clear purpose," says Carol Pohlig, BSN, RN, CPC, who works in the department of medicine at the Hospital of the University of Pennsylvania. "They identify circumstances or procedures that vary from the original code description. It alerts the payer that something unusual has taken place. Because modifiers address exceptions and not the rule, the potential for misuse or abuse is significant."
 
To ensure no misuse or abuse takes place, coders must understand the distinctions between modifiers, when they should be applied, and how best to submit modified codes to ensure greatest likelihood of payment.
Two Facts Increase Payment Success
Two foundational truths about modifiers increase reimbursement success, Pohlig says. "To begin with, coders must recognize that not all insurers treat modifiers the same way. Medicare, for instance, recognizes most of the modifiers that appear in the CPT manual. Medicare also relies heavily on Level II HCPCS modifiers. Other insurers recognize none of them. Still others recognize some, but not all. Coders should work closely with payer representatives to understand how that particular insurer approaches modifiers."
 
Secondly, she adds, coders must submit the claims in the most effective manner. "A lot of coders don't realize that claims containing certain modifiers should drop to paper (e.g., modifier -22, Unusual procedural services; modifier -52, Reduced services; modifier -53, Discontinued procedure). Typically these are automatically denied, with a request for more information explaining the circumstances requiring the modifier. Rather than wait for the denial and request for supporting documentation, practices are better off submitting the claim on paper with the progress notes or procedure report already attached."
 
If modified claims are denied after submission of the documentation, Pohlig advises that ED coders request peer review. "Make sure the claim is reviewed by a healthcare practitioner who practices in the same specialty and is familiar with the procedure. They are the only ones who will completely understand the circumstances and the service, thereby increasing the likelihood of ultimately getting paid."
Modifier -25 Poses Problems
The most problematic modifier for emergency department coders is modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), according to Karen Benson, CCS, a coding supervisor for North Shore Medical Center in Salem, Mass. "There are two major issues that arise with the -25 modifier in my experience," [...]