Ophthalmology and Optometry Coding Alert

Modifier Madness:

Let the Answers to These 5 FAQs Lead You to Modifier Perfection

Published on Tue Jul 25, 2023

Learn which modifier many MACs would rather you not use.

Modifiers help paint a picture for the payer by providing additional details about an encounter and can make or break a claim. Last month we answered six FAQs to sharpen your skills and minimize modifier mishaps.

Read on for the remainder of our crash course in commonly misused modifiers and how to avoid appending them inappropriately.

Q: Do Minor Procedures Include an Evaluation Component?

A: Typically. One of the most misunderstood modifiers is 25 (Significant, separately identifiable evaluation and management service by the same physician … on the same day of the procedure or other service). Even when an encounter deserves modifier 25, the documentation may not be complete enough to back it up. Without the documentation, you can’t justify the modifier.

Modifier 25 is ranked as one of the most commonly rejected modifiers, according to Juan Lumpkin, provider relations senior analyst at CGS Administrators, LLC in Nashville, Tennessee. “Basically, what this modifier does is pay for evaluation and management (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 explained during the Part B payer’s webinar “Avoiding Modifier Rejections.”

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.

Q: Should I Use Modifier 51 on Multiple Procedures?

A: Many payers, including several Medicare Administrative Contractors (MACs), recommend that you don’t use modifier 51 (Multiple procedures) on multiple procedures, even when appropriate, as it will be added to the appropriate codes by their claims software. This prevents the submission of claims with -51 appended to the wrong procedure code.

Modifier 51 is another code that is rejected fairly frequently, according to Lumpkin. “This is a system-generated modifier used to help payers appropriately price multiple surgical procedures performed on the same date of service,” he said. “If you bill multiple surgical procedures on the same date of service, our system has to determine how to price all of those procedures, so it ranks them by the fee schedule amount, so the service allowed at the highest amount is allowed at 100 percent, but the second through fifth procedures performed on the same date are reduced down to 50 percent. If the services that you bill apply to multiple procedure pricing, our system will add that modifier, so please do not add this modifier because it could cause reimbursement problems for your procedures. The system handles how to rank or price these multiple procedures. If you add it to a procedure, our system may reduce that by an additional 50 percent, so that will cause some problems for you when it comes to reimbursement.”

While this may be true for some payers, it is not a universal process, so your best bet is to check with your individual payers.

“I prefer practices add modifier 51 unless the payer specifically instructs them not to. Payers have been known to apply it to the higher/highest paying code and erroneously take the 50 percent reduction from that service,” says Mary Pat Johnson, CPC, CPMA, COMT, COE, senior consultant with Corcoran Consulting Group.

Q: Can You Offer Any Advice on Appending -RT, -LT, -50?

A: Modifiers LT (Left side …), RT (Right side …), and 50 (Bilateral procedure) are also on the list of frequently rejected modifiers, Lumpkin noted. So before using one of these laterality modifiers, you should check the code descriptor for the procedure performed.

“RT and LT are location modifiers, used to identify where a procedure was performed. The database on the CMS website will tell you whether a specific code allows for bilateral billing, whether it’s RT/LT or modifier 50. They do the same thing, so look at the definitions of the indicators to tell you specifically whether you can use these,” he said.

Q: When Is It Appropriate To Apply Modifier 57?

A: Modifier 57 (Decision for surgery) is used “only when the decision for surgery was made during the pre-op period of a major surgery (services with a 90-day follow-up period),” Lumpkin said. “The preoperative period is the day before and the day of the surgical procedure,” he added.

For instance, during a consultation, an ophthalmologist determines they need to repair a detached retina that day. They perform 67108 (Repair of retinal detachment; with vitrectomy, any method …).

Because the detached retina repair is a major procedure, you should append modifier 57 to the claim for the office visit or consultation. Documentation should specifically note that the exam resulted in the decision for surgery.

Q: What Are the Dangers of Misusing Modifiers?

A: When you misuse modifiers, a few things can happen, according to Pam Vanderbilt, CPC, CDEO, CPB, CPMA, CPPM, CPC-I, CEMC, CPFC, CEMA, owner of KnowledgeTree, Billing, Inc. in Ocala, Florida. First, you are put at risk of inappropriate reimbursement. This, in turn, puts you at risk of audits, which puts you at risk of treble damages. If fraudulent billing is confirmed, treble damages permit the court to triple the amount of the actual or compensatory damages awarded to a prevailing plaintiff.

Additionally, your providers could be at risk of losing their right to bill insurance, potentially losing their license, or even serving jail time, she added. Coders are also put at risk of losing their credentials and may face monetary penalties and jail time.