Urology Coding Alert

Modifier:

Heed Expert Advice to Learn How to Properly Append Modifiers

Published on Thu Dec 09, 2021

Hint: Always check with individual payers about modifier rules.

Chances are, you use modifiers on your urology claims. However, sometimes knowing when and if you can use a modifier on a certain code can be challenging. If you make a mistake, you could be risking a denial.

In the webinar “Avoiding Modifier Rejections” hosted by Part B payer CGS Administrators, presenter Juan Lumpkin shared what information you should know about the most commonly used modifiers and errors you should avoid in your practice.

Apply his advice to use modifiers appropriately in your practice.

Use Modifiers as Supplements

“The use of modifiers is an important part of coding and billing for healthcare services,” Lumpkin said. “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.”

“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 said.

Know That Modifiers Often Prompt Denials

If you think modifiers aren’t important enough to cause denials among your claims, think again. “The category ‘invalid or incorrect procedure code/modifier combination’ is always among the top 10 claims submission errors,” Lumpkin noted.

Differentiate Between Payment, Informational Modifiers

There are different types of modifiers available, he said. 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 a service should be reduced, and the documentation you send with it explains how the payer should manually cut the reimbursement for the service.

Other modifiers are considered informational, showing whether they may meet exceptions that allow you to bypass certain edits. Modifier 59 (Distinct procedural service) is an example of this, he noted.

Always Check With Your Payers on Their Modifier Rules

“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 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 also refer to the MPFS on the CMS website as well, he noted.

Telehealth Modifier Has Caused Numerous Denials

Data from CGS indicates that modifier 95 (Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system) was by far the modifier responsible for the highest number of rejections within the past few months, Lumpkin said.

Other commonly rejected modifiers include 59, GT (Via interactive audio and video telecommunication systems), 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), 26 (Professional component), 51 (Multiple procedures), 50 (Bilateral Procedure), RT (Right side), and LT (Left side).

“CPT^® modifier 95 is for telehealth services,” he said. “I’m sure all of you can agree that there was a lot of confusion early on with telehealth modifiers once the public health emergency (PHE) was announced.”

Although modifier 95 was fairly straightforward prior to the COVID pandemic, it’s become more confusing since the PHE began and the rules were adjusted, he said. “If you’re performing services allowed via telehealth that would normally have been performed face to face but now you’re performing them via telehealth with dates of service on or after March 1, 2020 and for the duration of the PHE, bill with the place of service equal to what it would have been had the service been furnished in person, and with modifier 95, indicating that the service rendered was actually performed via telehealth,” he said.

Most MACs have performed mass adjustments of those claim submissions to account for the confusion that existed early on in the pandemic, he noted.

Double Check Before Using Modifiers RT, LT, and 50

Also, on the list of frequently rejected modifiers are RT, LT, and 50, he said. “RT and LT are location modifiers, used to identify where a procedure was performed. The database on the CMS website will tell you whether a specific code allows for bilateral billing, whether it’s RT/LT or modifier 50. They do the same thing, so look at the definitions of the indicators to tell you specifically whether you can use these.”