Pathology/Lab Coding Alert

Question: I’ve recently begun coding for our lab because we’re short staffed, and I’ve noticed that I have a lot of trouble with modifiers. I have received my share of denials for claims I coded, and payers return a majority of them because they are “unprocessable.” I review each unprocessable claim with our coding supervisor, and inappropriate modifier use is almost always the reason for the denial. How can I get better at coding with modifiers?

Codify Subscriber

Answer: You’re in good company with this problem — 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.

First, you can turn to resources and articles that help you learn how to use appropriate lab modifiers, such as “Modifier TC/26 Not For Every Code,” and “Maneuver Modifier 90 Pitfalls to Bill Referred Lab Tests” in Pathology Lab Coding Alert.

Second, to mitigate claim denials from inappropriate modifier usage, JA MAC recommends that you do the following:

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.

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.

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.