Neurology & Pain Management Coding Alert

Although CPT modifiers are intended to allow neurologists to clarify and support their charges for services provided, the reality is sometimes just the opposite. Professional coders report increased difficulties with Medicare and third-party payers when some modifiers are used. To minimize these problems, neurology coders need to ensure they are assigning modifiers correctly and must know how to respond effectively when they believe a legitimate claim has been denied.

Correctly Assigning Modifiers -25 and -59

Two modifiers that are particularly problematic are -25 (significant, separately identifiable evaluation and management services by the same physician on the same day of the procedure or other service and -59 (distinct procedural service), and many local Medicare carriers have issued bulletins to clarify the correct usage of each.

Over time, the specific applications of certain modifiers can subtly change, points out Barry Haitoff, president of Medical Management Corporation of America, a billing and management firm in Brewster, N.Y., that supports neurology practices throughout the state. Its important to keep the latest interpretations in mind as youre assigning modifiers.

According to Cindy Dumond, a coding and billing specialist with Medical Billing Services in Jacksonville, Fla., which supports approximately 75 neurologists in the state, modifier -25 is assigned correctly when a neurologist sees a patient who presents with specific symptoms and a separate procedure subsequently is performed. One example illustrating how modifier -25 is used may be when a minor procedure is decided upon at the time of the visit, she says. For instance, a new patient may come into the office with back pain (724.2, lumbago; low back pain, low back syndrome, lumbalgia). After examination, the neurologist elects to do a procedure, like trigger point injections.

In this instance, the trigger point injection would be coded 20550 (injection, tendon sheath, ligament, trigger point or ganglion cyst). The appropriate level of new patient office visit code (99201-99205) also would be reported, but would carry the -25 modifier. If the visit included a 30-minute examination, for example, it would be assigned 99203-25.

This is a change from how the -25 modifier has been interpreted in the past, however, Haitoff reports. For a while, our local Medicare carrier recommended that -25 should be used only if two separate diagnoses applied, just to be on the safe side. They suggested, for instance, that you shouldnt use this modifier unless the patient came in with back pain and for some reason you discovered a need to inject his or her knee as well.

Using modifier -59 is more straightforward, both Dumond and Haitoff agree. If you report more than one service in one day, you would add modifier -59 to the second and subsequent services, Haitoff explains. For instance, if a patient was given trigger point injections in his or her shoulder and knee, you would report 20550 for the shoulder injection and 20550-59 for the knee. These are different sites and distinctive services.

Document Payers Modifier Requirements

Nonetheless, correct use of modifiers doesnt guarantee payment, as many coders discover. In some cases, insurers may have established policies that disallow or reduce payment on certain modifiers, or perhaps their computer software is an older version and simply doesnt recognize current modifier usage. In any event, coders should contact major payers to determine which modifiers they accept, which they deny, and which alternative coding techniques they require.

If the neurologist is a participating member of an HMO, however, the coder should review closely the payers literature. If the HMO is not abiding by its own policies, the neurology practice has grounds to challenge all denials and reductions.

In situations where the insurers policy legitimately requires the use of modifiers in ways contrary to CPT recommendations, getting the payers requirements in writing is imperativepreferably from a supervisor or manager, not simply the customer service or claims representative. In addition, coders should get the name and the title of the insurance company representative who provides the information. This process provides the neurology coder with documentation to support the use of modifiers or alternatives in the future.