Do you know which modifiers may affect your payments?
Even if you’re brand-new to optometry coding and billing, you likely are familiar with at least a few modifiers. But even seasoned coders know that keeping modifiers straight can be a challenge, especially when you have to choose between a few that seem quite similar.
Read on for some expert advice on minimizing modifier mayhem, and maximizing your deserved reimbursement.
There are several modifiers commonly used in optometry and ophthalmology practices, says Ryan Price, CPC, AHIMA-Certified Instructor who presented a Modifiers seminar at the recent CodingCon conference:
In addition, there is a series of “X modifiers” (XE, XS, XP, and XU) which were introduced to replace modifier 59. More on those below.
Know the Payment Vs. Pricing Difference
To understand how a modifier attached to a CPT® code affects your claims, you need to know the “payment vs. pricing” distinction, Price says. The two things to consider are:
Payment modifiers: If you neglect to append these modifiers when they’re justified, Price says, it may affect whether or not the insurer reimburses for the service. Payment modifiers include:
Pricing modifiers: If you neglect to add one of these modifiers when it’s called for, Price says, it may affect the value of the code – i.e., how much you will be reimbursed for it. Pricing modifiers include:
Lean on X(EPSU) Instead of 59 When Appropriate
The Centers for Medicare and Medicaid Services (CMS) has described modifier 59 as “the most widely used HCPCS modifier,” which certainly holds true for most practices, which use it routinely to split codes that have been bundled together by the Correct Coding Initiative (CCI). But CMS notes that many providers misuse it for that purpose. The 59 modifier often overrides the edit in the exact circumstances for which CMS created it in the first place,” CMS has said.
To address the problem, CMS created “more precise coding options” with the X(EPSU) modifiers, introduced in January 2015:
“CMS will not stop recognizing the 59 modifier but notes that CPT® instructions state that the 59 modifier should not be used when a more descriptive modifier is available,” says a CMS transmittal released in 2014. “CMS will continue to recognize the 59 modifier in many instances but may selectively require a more specific X(EPSU) modifier for billing certain codes at high risk for incorrect billing.”
And as for 59 and X(EPSU) themselves, “only use these modifiers if there aren’t more specific modifiers available,” Price advises.
Keep Your Modifiers in Order
When multiple modifiers apply to a procedure, which should you list first?
If you are reporting a code that is bundled into another procedure by the National Correct Coding Initiative (NCCI), you should first list any modifiers that justify reporting the two procedures together – modifiers like 59 that show that the procedure was necessary and distinct from the other service, say experts.
Next: List any modifiers that affect payment, such as 50 or 51.
Then: List any “informational” modifiers – such as RT or LT – that will not affect the reimbursement for the CPT® code but provide more specific information such as what side the optometrist performed the procedure on.
Listing informational modifiers before payment modifiers may lead to denials, experts say.