Pediatric Coding Alert

Tighten your documentation before you append, experts say Insurers will cast a spotlight on the use of modifiers 59 and 25 this year, and they are just waiting for your pediatric practice to make mistakes. If you want to stay off the radar screen, documentation for your modifier 59 and 25 claims will be key.

The U.S. Department of Health and Human Services’ Office of Inspector General (OIG) recently found a 35 percent error rate for modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) and a 40 percent error rate for modifier 59 (Distinct procedural service) in a sample of claims. Experts warn that private payers are sure to follow the OIG’s lead in scrutinizing claims that bear these modifiers, which could affect your pediatric practice.

“The good news is that most pediatric practices aren’t subject to OIG audits in the same way that specialists with high Medicare patient rates are,” says Heather Corcoran, coding manager at CGH Billing Services in Louisville, Ky. “The bad news is that private payers frequently follow the OIG’s lead and start auditing the same claims that the OIG audits.”

To protect payment for your modifier use, follow our experts’ tips.

Confirm Documentation Before Using 59 To ensure that you’ve been appending modifier 59 properly, pull a sample of your modifier 59 submissions and verify that the claims properly represent distinct procedural services.

One way: Make sure the physician is working in a separate body area before you use modifier 59, says Margie Scalley Vaught, CPC, CPC-H, PCE, CCS-P, MCS-P, a coding consultant in Ellensburg, Wash.

Or if the physician performs more than one procedure on the same site, you should be able to prove the medical necessity of both procedures. You should also make sure you use separate ICD9 Codes for the diagnoses behind the separate procedures whenever possible, Vaught says. Put 59 on the Secondary Code
 
You should always append modifier 59 to the secondary code. The National Correct Coding Initiative publishes a “list of mutually exclusive codes that contains edits consisting of two codes (procedures) that cannot reasonably be performed together based on the code definitions or anatomic considerations,” says Laurie Green, CPC, coding and compliance analyst at Group Health Cooperative in Seattle. Each edit consists of a column 1 code (which is the primary procedure) and column 2 code (the comprehensive, or bundled, code).

How bundles work: Suppose your payer, such as Medicaid or Blue Cross, follows NCCI edits. If [...]