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Radiology Coding Alert

Use the Most Common Radiology Modifiers with Ease

Published on Fri Feb 01, 2002

Few days pass when radiology coders who often code dozens of reports in an eight-hour workday aren't faced with the prospect of adding modifiers to the services their physicians provide. In some cases, the choice of modifiers is clear and the circumstances requiring them undeniable. At other times, the coding may be less than clear-cut.
 
"Modifiers have been implemented with a very clear purpose," says Carol Pohlig, BSN, RN, CPC, who works in the department of medicine at the Hospital of the University of Pennsylvania. "They identify circumstances or procedures that vary from the original code description. It alerts the payer that something unusual has taken place. Because modifiers address exceptions and not the rule, the potential misuse or abuse is significant."
 
To ensure no misuse or abuse takes place, Radiology Coders must understand the distinctions between modifiers, when they should be applied, and how best to submit modified codes for the highest ethical payment.

Two Facts Increase Payment Success

Professional coders who recognize two foundational truths about modifiers increase their reimbursement success, adds Michelle Juette, CPC, RCC, business services manager for Yakima Valley Radiology in Yakima, Wash. "Often, the policies affecting modifiers are carrier- and state-specific. Coders must recognize that not all insurers treat modifiers the same way. Medicare, for instance, recognizes most of the modifiers that appear in the CPT Manual . Other insurers have different approaches." Coding experts recommend that radiology practices work closely with payer representatives to understand how that particular insurer approaches modifiers.
 
Second, Pohlig adds, coders must submit the claims in the most effective manner. "A lot of coders don't realize that claims containing certain modifiers should drop to paper (e.g., -22, Unusual procedural service; -52, Reduced services; -53, Discontinued procedure). Typically, they are automatically denied, with a request for more information explaining the circumstances requiring the modifier. Rather than wait for the denial and the request for supporting documentation, practices are better off submitting the claim on paper with the progress notes or procedure report already attached."
 
If modified claims are denied after submission of the documentation, Pohlig advises, radiology coders should request peer review. "Make sure the claim is reviewed by a radiologist who is familiar with the study or procedure. They are the only ones who will completely understand the circumstances and the service, thereby increasing the likelihood of it getting paid."

Distinguishing Between Modifiers -51 and -59

Among the modifiers most often used by radiologists are -51 (Multiple procedures) and -59 (Distinct procedural service), which are also easy to confuse. Modifier -51 is used when multiple services are performed and communicates that the codes submitted are not being added to the claim in error. For instance, -51 should be appended when multiple CT or radiographic services are provided to the same patient on the same date of service, especially if the same CPT code is used more than once on the claim. When used in compliance with Correct Coding Initiative (CCI) rules, the -51 modifier should prevent the rejection of the second and/or subsequent procedures as duplicates or included services. Under other clinical circumstances modifier -59 would be used. Often called the "modifier of last resort," modifier -59 is usually appended to the component code when the CCI attaches an indicator of "1" to a specific code pair, which means a modifier may be appended to bypass the edit.
 
Modifier -51 might be used, for instance, when a patient has three single-view chest x-rays on the same date of service and the coder wants to ensure that the last two codes are not rejected as duplicate submissions. Modifier -59 might be used when a four-view knee film is obtained and a fracture is diagnosed. After reduction and casting, a two-view knee series is performed. The two-view series is bundled into the four-view series by the CCI edit. However, the radiology practice would use -59 with the second study to ensure payment.

Understanding Bilateral Modifiers

Although the definition of a bilateral modifier is easy to understand it describes a service performed on both the left and right sides of the body use of the appropriate indicators may be confusing.
 
Some insurers accept CPT's modifier -50 (Bilateral procedure). This may be used, for instance, if catheterization was performed on both the left and right internal iliac artery (e.g., 36247, Selective catheter placement, arterial system; initial third order or more selective abdominal, pelvic, or lower extremity artery branch, within a vascular family). When reporting these catheterizations to payers that require modifier -50, coders would report 36247 twice, with the -50 modifier appended to the second use of the code (36247, 36247-50). However, some payers require that the code be reported once with the -50 modifier attached (36247-50).
 
Other payers prefer that coders use the -RT/-LT distinction to indicate right and left sides of the body. When this occurs, the procedure code will appear twice on the claim form, once with the -RT designation and once with the -LT designation (36247-RT, 36247-LT).

Reporting Reduced and Discontinued Procedures

Another modifier commonly used in radiology practices is -53, says Juette. "This is an important modifier. In the past, radiologists may not have had a way to recoup any of their costs when they were unable to finish a procedure. Modifier -53 provides that opportunity." She adds that modifier -53 is appended to the CPT code when the radiologist was forced to stop midservice. "Perhaps the patient wasn't tolerating the procedure well or it became clear that the procedure posed some sort of threat to the patient's well-being."
 
Pohlig adds that radiology practices should not reduce their charges when they submit a code modified with -53. "They should submit their full charge on paper with a description of how far they progressed with the procedure. Usually, the insurer will pay a percentage based on what part of the service was completed."
 
The use of modifier -53 may also require an additional diagnosis code. One of the following codes is typically added in addition to those diagnoses describing the reason for the procedure:

V64.1 Surgical or other procedure not carried out because of contraindication
V64.2 Surgical or other procedure not carried out because of patient's decision
V64.3 Procedure not carried out for other reasons.

Modifier -52 is handled similarly, Juette adds. "A radiology coder would use this modifier when the radiologist did not complete the entire service described in a code definition or when a limited service is provided as directed by the patient's clinical needs. For example, 73050 describes the bilateral examination of the acromioclavicular joints with or without weighted distraction. If a unilateral study of the acromioclavicular joint was performed, the practice should use the -52 modifier to describe the limited nature of the examination."
 
As with modifier -53, practices would not discount their fee, but would supply complete documentation to indicate what portion of the complete service was conducted. "This is important to do," Juette says. "For instance, a practice may take only one view during an x-ray instead of the two views. Taking only one view represents more than half of the service provided when two views are taken, because of the staff time involved in setting up the room, equipment and related care. Insurers will factor that in when they determine the final payment."
 
Note: Some coding experts disagree with recommendations not to reduce charges when submitting claims appended by modifier -52 or -53. They advise coders to charge only for what was done. If only a partial study is performed, the practice should not charge for the complete service.

Modifier -22 Rarely Produces Increased Payment

Modifier -22, on the other hand, is appended to codes when the procedure took significantly greater time or effort than typical. "Codes appended with modifier -22 require special documentation," says Pohlig. "For instance, if a procedure took 40 minutes when it typically only requires 20 minutes, the radiologist would describe the circumstances that necessitated the longer time and greater effort." She recommends that radiology practices increase the charges submitted to the insurer to reflect adequately the additional effort involved when using modifier -22. "Don't count on the payer to automatically increase payment. They won't understand the value of the additional service."
 
Even so, whether the insurer will pay the higher rate is uncertain, Juette says. "Modifier -22 is jokingly called 'the feel-good modifier,'" she says. "It feels good to try to get a higher level of reimbursement for your radiologist, but that seldom happens. Whether modifier -22 reaps greater payment varies greatly from payer to payer."

Don't Interchange Modifiers -76 and -77

Most coding experts note that modifiers -76 and -77 are easy to understand. The -76 modifier is assigned when the same procedure is repeated by the same physician. For instance, maybe three abdominal x-rays (KUBs) are taken on the same patient throughout the day and read by the same radiologist. Modifier -77 is very similar to modifier -76, but is assigned when a repeat procedure is conducted by another physician perhaps follow-up x-rays are interpreted when a second radiologist is on duty. In both cases, the modifier is appended to the second and subsequent occurrences of the code on the claim form.
 
The need for repeated procedures may arise, for instance, if a newborn has suffered from respiratory stress syndrome (769). It may be medically necessary to perform four or five portable single-view chest x-rays on the same day to assess how well the infant's lungs are functioning. The first x-ray would be reported using 71010 (Radiologic examination, chest; single view, frontal). Subsequent
x-rays read by the same radiologist would be assigned 71010-76. If another radiologist within the same group practice or a different professional organization read any of these x-rays, they would be coded 71010-77.
 
In all situations calling for modifiers, prudent coders should always verify what the payer wants. Often, so-called "standard" modifier use results in denied claims because payers have set up their own rules about these modifiers.

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