Orthopedic Coding Alert

Question: When we see a claims denial in our practice, some of our staff is quick to resubmit the claim with a modifier to “solve” the problem. That doesn’t work so well. Do you have some guidance about this that I can share with the staff?

Codify Subscriber

Answer: According to at least one Medicare Administrative Contractor (JA MAC Part B), using a modifier in the wrong way is one of the most common reasons for claim denial to begin with. And quickly re-submitting with a different modifier doesn’t solve the problem. In fact, “adding modifiers … to a denied service continues to be one of the top reasons for requesting a review,” according to JA MAC Part B.

Do this: Have all your facts straight before calling the payer for a review. “We have experienced providers calling and asking to add a modifier. Then, when that modifier did not get the claim paid, they want to try another one. This is inappropriate,” JA MAC reports.

JA MAC also offers these documentation tips to make your claims containing modifiers as clean as possible:

• Write “additional documentation available upon request” in the narrative field of the claim, if you’re submitting extra info to support your modifier use. »
• Get your documentation in as soon as possible. When payers request documentation due to modifier usage, not returning the info in a timely manner is “the number one reason for denial,” JA MAC reports.

Educate staff about correct modifier use. For instance, a huge number of denials stem from adding modifier 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) to a procedure code rather than an E/M code.