Pain Management Coding Alert

Question: I have been training several new coders, and a couple of them are having problems understanding how to use modifiers. In fact, Medicare has returned several of the trainees’ claims as “unprocessable.” When we go back and look at the claims, inappropriate modifier use is almost always the culprit. How can I get these coders to improve at coding with modifiers?

Iowa Subscriber

Answer: Your problem is not an uncommon one. According to JA MAC Part B, the Medicare contractor for Michigan and Indiana, inappropriate modifier usage is one of the most common reasons for claim denial.

For example, 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 will always result in a denial.

In order to mitigate claim denials from inappropriate modifier usage, JA MAC recommends that you:

• Think before resubmitting denied claims. “Adding modifiers … to a denied service continues to be one of the top reasons for requesting a review,” JA MAC reports.
• Remember that two different diagnosis codes alone does not justify modifier 25 use.
• 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.