Ophthalmology and Optometry Coding Alert

Although every ophthalmology coder uses modifiers on their claims, sometimes the rules surrounding them can get a bit murky. If you find yourself stumped by the nuances of modifier application, help is here.

We went to the experts with your questions, and their answers will help you correctly assign modifiers and submit airtight claims the next time one comes your way.

Q: Do Modifiers Completely Alter Code Descriptions?

A: No. A modifier alters the intention because there is a special circumstance of the CPT^® code you are reporting, but you are not actually changing the definition of the code itself, explained Pam Vanderbilt, CPC, CDEO, CPB, CPMA, CPPM, CPC-I, CEMC, CPFC, CEMA, owner of Knowledge Tree, Billing, Inc during her HEALTHCON presentation “Unbundling Modifiers: A Risky Business.”

In other words, “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,” according to Juan Lumpkin, provider relations senior analyst at CGS Administrators, LLC in Nashville, Tennessee.

“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,” he explained during the Part B payer’s webinar “Avoiding Modifier Rejections.”

Q: Does Frequent Modifier Use Prompt Denials?

A: It can. 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.

Q: Are All Modifiers Created Equal?

A: There are different types of modifiers available, according to Lumpkin. Some are considered 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 payment for 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 considered 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.

Q: Does Every Payer Accept Every Modifier?

A: No. “Just because the 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 CMS [the Centers for Medicare & Medicaid Services] 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 refer to the MPFS on the CMS website as well, Lumpkin noted.

Q: Which Modifiers Commonly Cause Claim Denials?

A: Frequently rejected modifiers include 59, 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care 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).

Data from CGS Administrators 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 back when the COVID-19 pandemic first forced providers to quickly adapt their practices.

“CPT^® modifier 95 is for telehealth services,” Lumpkin said. “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 became more confusing as the PHE spurred adjustment of the rules, he said. Fortunately, most MACs have performed mass adjustments of those claim submissions to account for the confusion that existed early on in the pandemic, he noted.

Q: How Do I Denote an Exception to Bundling Edits?

A: Modifiers that you may use under appropriate clinical circumstances to bypass a National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) edit include anatomic modifiers (e.g., RT, LT), global surgery modifiers (e.g., 25, 57 (Decision for surgery)), and others such as 59 and the X{EPSU} modifiers:

• XE (Separate encounter …)
• XP (Separate practitioner …)
• XS (Separate structure …)
• XU (Unusual non-overlapping service …)

Modifier 59 is also rejected frequently due to errors. “This is the modifier that’s used mostly to let us know that there are two services done on the same date, typically which cannot be billed on the same date of service; however, this service meets the exception,” said Lumpkin. “Use modifier 59 when no other modifier would accurately describe the exception,” he noted. It would also be appropriate to use 59 instead of X{EPSU} if the payer doesn’t accept the X{EPSU} modifiers. You should apply the X{EPSU} modifier that best describes the circumstance that supports the unbundling.

Additionally, “To find out whether or not certain codes can be billed separately, CMS has a great file on its website, the procedure-to-procedure code pairs,” he advised. 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. In the NCCI-PTP edits, CMS assigns each code set an indicator of “0” or ”1.”

0 = Codes may not be unbundled for any reason

1 = Codes may be unbundled and both billed under certain circumstances.

No matter what, your documentation must support the fact that you’re requesting an exception to the edit.

Stay tuned. We’ll answer additional important modifier FAQs next month.