Medicare Compliance & Reimbursement

Tip: Learn modifiers’ differentiated roles to boost revenue.

It’s not surprising that modifier misuse remains a fixture on most Medicare claims error lists. These helpful codes add depth to your submissions as well as dollars if they’re used correctly. Regularly reviewing other providers’ mistakes can help you cut down on your claims losses — and perfect your modifier game in the process.

That was the word from Medicare Part B payer CGS Administrators in last month’s webinar “Avoiding Modifier Rejections.” During the session, CGS’ Juan Lumpkin outlined the most important facts to know about commonly used modifiers, and shared information on the most frequent problems he sees when reporting them. Check out a few of his insights below.

Tip 1: Modifiers Are Supplements

“The use of modifiers is an important part of coding and billing for healthcare services,” Lumpkin said. “Modifiers are two-character codes reported with CPT^® and HCPCS [Level II] codes to modify or supplement the description of services rendered based on certain exceptions or circumstances. They do not change the code description, but they simply supplement the description of those codes.”

He continued,“Using them correctly will help make it clear why certain codes that are normally or shouldn’t be billed together are billed together, which helps avoid questions of fraud or abuse from the provider’s perspective.”

Tip 2: Modifiers Frequently Prompt Denials

If you think modifiers aren’t important enough to cause denials among your claims, think again. “The category ‘invalid or incorrect procedure code/modifier combination’ is always among the top 10 claims submission errors,” Lumpkin noted.

Tip 3: Not All Modifiers Are Created Equal

Different types of modifiers are available, he said. Some are payment modifiers, which have a direct impact on how much you’ll collect for the service. For instance, modifier 52 (Reduced services) tells the payer that a service should be reduced, and the documentation you send with it explains how the payer should manually cut the reimbursement for the service.

Other modifiers are informational, showing whether they may meet exceptions that allow you to bypass certain edits. Modifier 59 (Distinct procedural service) is an example of this, he noted.

Tip 4: Not Every Payer Accepts Every Modifier

“Just because the [American Medical Association] AMA creates a modifier or even defines a modifier, does not mean that that modifier applies to Medicare claims,” Lumpkin said. “Those are not just for Medicare claims; other payers use them as well, and [Centers for Medicare & Medicaid Services] CMS dictates whether a particular modifier will apply to Medicare claims.”

To determine whether a modifier applies to your service, refer to the Medicare Physician Fee Schedule (MPFS), which shows whether particular modifiers such as 50 (Bilateral procedure), 62 (Two surgeons), or 66 (Surgical team) might apply to a particular code.

“If you’re ever questioning whether a modifier applies to your situation, I would encourage you to look at the database tool,” he said. Each payer will maintain their own database look-up tools, and you can also refer to the MPFS on the CMS website as well, he noted.

Tip 5: Modifier 95 Caused Many Recent Denials

Data from CGS indicates that modifier 95 (Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system) was by far the modifier responsible for the highest number of rejections within the past few months, Lumpkin said.

Other commonly rejected modifiers include 59, GT (Via interactive audio and video telecommunication systems), 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service), 26 (Professional component), 51 (Multiple procedures), 50 (Bilateral Procedure), RT (Right side), and LT (Left side).

“CPT^® modifier 95 is for telehealth services,” he acknowledged. “I’m sure all of you can agree that there was a lot of confusion early on with telehealth modifiers once the public health emergency (PHE) was announced.”

Although modifier 95 was fairly straightforward prior to the COVID pandemic, it’s become more confusing since the PHE began — and CMS adjusted the rules, he said. If you’re performing services now via telehealth that you used to perform face to face — and the dates of service are on or after March 1, 2020 — you can bill with the place of service equal to what it would have been had the service been furnished in person using modifier 95 through the duration of the PHE, he explained.

Tip 6: Modifier 59 Denotes an Exception to Bundling Edits

Modifier 59, which also rejects frequently due to errors, “is the modifier that’s used mostly to let us know that there are two services done on the same date, which typically cannot be billed on the same date of service; however, this service meets the exception,” Lumpkin said. If you want to find out whether certain codes can be billed separately, check CMS’ online guidance on procedure-to-procedure code pairs, he suggested. If you download this sheet, you’ll see the different code pairs and determine whether they can be billed together on the same date of service with the modifier appended. No matter what, your documentation must support the fact that you’re requesting an exception to the edit.

However, modifier 59 won’t be the only modifier that may apply to your claim when you’re trying to separate edits, he said. “Use modifier 59 when no other modifier would accurately describe the exception,” he advised.

Tip 7: Modifier GT Is No Replacement for Modifier 95

HCPCS Level II modifier GT is one of the original telehealth modifiers and refers to telehealth services specific to critical access hospitals (CAHs). “This is for a telehealth service billed under a CAH Method II, for facility-type billing,” he said. “The data suggest that this modifier was billed to Part B because providers weren’t sure which modifiers to bill early on during the PHE. But this should be used for institutional, or Part A claims,” he mentioned.

Tip 8: Most Procedures Include Evaluation Component

Modifier 25 is also ranked as one of the most commonly rejected modifiers, Lumpkin noted. This modifier “pays for E/M services any time a minor procedure is done on the same date. Typically, when a patient comes in for a minor procedure, the only thing you’re to bill Medicare for is that minor procedure. The fee schedule amount that CMS assigns to minor procedures includes an evaluation component to it already. So under normal circumstances, an additional E/M service is not allowed,” he said.

However, if your documentation demonstrates that you performed a distinct, separately identifiable E/M service along with the procedure, you can append modifier 25 to your E/M code.

Tip 9: Not All Services Allow Modifier 26

You should use modifier 26 to report the professional component only of a global service. “This is used on diagnostic services, such as radiology,” he said. “The professional component is the reading of the results of that test, and the technical component is the performance for that test. If the provider is just billing for the professional component of the test, they can use modifier 26. Before you use that, make sure you refer to the definition of the code,” he said.