Otolaryngology Coding Alert

Avoid misusing modifiers or risk inappropriate reimbursement, audits, and more.

Although every coder uses modifiers, sometimes the rules surrounding them can get a bit murky. For those of you seeking to clear up some of the confusion surrounding the nuances of modifier application, help is here.

Otolaryngology Coding Alert went to the experts with your questions, and their answers will help you correctly assign modifiers and submit airtight claims.

Q: What Is the Function of a Modifier?

A: “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: 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.

Payment modifier 22 (Increased procedural services), on the other hand, indicates to the payer that payment should be increased because the service provided was “significantly more involved than that represented by the CPT^® code, usually at least 25 percent more than described by the CPT^® code. Putting information in Box 19 of the claim helps the payer determine how much less (in the case of modifiers such as -52) or more (for modifiers like -22) is being represented in the claim,” says Barbara J. Cobuzzi MBA, CPC, COC, CPC-P, CPC-I, CENTC, CPCO, CMCS, of CRN Healthcare Solutions of Tinton Falls, New Jersey.

Payers consider other modifiers to be informational, showing the services may meet exception criteria that allow you to bypass bundling edits and enable both charges to be paid. Modifier 59 (Distinct procedural service) and the X{EPSU} modifiers are examples of this. Similarly, informational modifiers, such as -58 (Staged or related procedure or service by the same physician …), -78 (Unplanned return to the operating/procedure room by the same physician … for a related procedure during the postoperative period), and -79 (Unrelated procedure or service by the same physician … during the postoperative period), are used “to inform the payer why the service is not included in the global period and separately payable,” she adds.

Q: Do Minor Procedures Include an Evaluation Component?

A: “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 [the Centers for Medicare & Medicaid Services] CMS assigns to minor

procedures includes an evaluation component to it already. So, under normal circumstances, an additional [evaluation and management] E/M service is not allowed,” explained Lumpkin. So exercise caution before reaching for modifier 25 (Significant, separately identifiable evaluation and management service by the same physician … on the same day of the procedure or other service).

Modifier 25 is ranked as one of the most commonly rejected modifiers. “Basically, what this modifier does is pay for E/M services any time a minor procedure is done on the same date,” he noted. However, you should only append modifier 25 to the E/M code when the otolaryngologist performs a distinct, separately identifiable E/M service along with the procedure and provides detailed documentation in support of its significant and distinct nature.

Note: 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.

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 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.

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