Otolaryngology Coding Alert

Learn which modifiers are most likely to stand in the way of claim success.

Modifiers can make or break a claim. Understanding how to use these two-character codes correctly and what’s at stake if you don’t is crucial for coders, as they help to paint a comprehensive picture for the payer by providing additional details about an encounter.

Last month we answered four of your FAQ about modifiers. Read on for the remainder of our crash course to sharpen your skills and minimize modifier mishaps.

Q: Does Frequent Modifier Use Prompt Denials?

A: “It can, if the modifier usage is incorrect,” says Barbara J. Cobuzzi, MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, CMCS, of CRN Healthcare Solutions of Tinton Falls, New Jersey.

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,” according to Juan Lumpkin, provider relations senior analyst at CGS Administrators, LLC, a Part A/B Medicare Administrative Contractor (MAC) in Nashville, Tennessee.

Q: Which Modifiers Commonly Cause Claim Denials?

A: Frequently rejected modifiers include 59 (Distinct procedural service), 25 (Significant, separately identifiable evaluation and management service by the same physician … on the same day of the procedure or other service), 26 (Professional component), and 51 (Multiple procedures).

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.

Although modifier 95 was fairly straightforward prior to the COVID-19 pandemic, it became more confusing as the PHE spurred adjustment of the rules. Fortunately, most MACs have performed mass adjustments of those claim submissions to account for the confusion that existed early on in the pandemic, Lumpkin noted during the Part A/B MAC’s webinar “Avoiding Modifier Rejections.”

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

A: Modifiers 50 (Bilateral procedure), RT (Right side), and LT (Left side) are also on the list of frequently rejected modifiers, Lumpkin explained. 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 [Centers for Medicare & Medicaid Services] 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,” Lumpkin 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). The preoperative period is the day before and the day of the surgical procedure,” Lumpkin noted.

For instance, during a consultation, the otolaryngologist determines they need to repair a deviated septum that day, and they perform 30520 (Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft).

Because septoplasty is a major procedure, you should append modifier 57 to the claim for the evaluation and management (E/M) service billed for the consultation. Documentation should specifically note that the exam resulted in the decision for surgery.

Q: How Do I Denote Bundling Edit Exceptions?

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), and others such as -59 and the X{EPSU} modifiers:

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

At the top of the list of frequently rejected modifiers is -59. “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,” according to Lumpkin. “Use modifier 59 when no other modifier would accurately describe the exception,” he explained. It would also be appropriate to use 59 instead of an X{EPSU} modifier if the payer doesn’t accept X{EPSU} modifiers. Otherwise, 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,” Lumpkin advised (www.cms.gov/medicare/coding-billing/national-correct-coding-initiative-ncci-edits/medicare-ncci-procedure-procedure-ptp-edits). CMS posts changes to each of its NCCI PTP published edit files quarterly. If you download this sheet, you’ll see the different code pairs and determine whether two codes can be billed together on the same date of service with the appropriate modifier appended. No matter what, your documentation must support the fact that you’re requesting an exception to the edit.

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.