Wiki Help with modifiers!

[katiejeanne]

Hello all! We are without a coding manager at our facility these days and are being told to add modifiers to visits that have 2 within a 24-hour period. Apparently we are supposed to do this only on BC/BS visits...We have never done this in the past and are not having any denials, but the business office manager says appending modifiers to the facility charges (whether a lab, xray, or E/M code) is necessary. So what, if any, modifiers do I use? I am the only person that is credentialed and do not want to commit any type of fraud ...I need some back-up from other coders out there! Here are some scenarios:

1) A patient presents at 8 AM for an outpatient lab. They present again that evening for an x-ray, this is registered separately and the business office manager combines these charges and dx codes after coding. We are told to put a modifier -27 or -25 on the second visit charges. I tried to say that this is wrong because this modifier only goes on E/M visits. So what, if any, modifiers should I use?

2) A patient comes in the morning for an outpatient x-ray. He goes home and is called to come back because his x-ray was abnormal. He is registered for an ER visit. These are kept separately but combined when billing.

When would a modifier be used on these visits? And where does it go? What kind of documentation is necessary? I'm sorry this a long question but I have to "figure it out" by Monday...Thanks in advance you guys!!!

Katie, RHIT

Thank you!

 

[MMAYCOCK]

Modifiers

Hello all! We are without a coding manager at our facility these days and are being told to add modifiers to visits that have 2 within a 24-hour period. Apparently we are supposed to do this only on BC/BS visits...We have never done this in the past and are not having any denials, but the business office manager says appending modifiers to the facility charges (whether a lab, xray, or E/M code) is necessary. So what, if any, modifiers do I use? I am the only person that is credentialed and do not want to commit any type of fraud ...I need some back-up from other coders out there! Here are some scenarios:

1) A patient presents at 8 AM for an outpatient lab. They present again that evening for an x-ray, this is registered separately and the business office manager combines these charges and dx codes after coding. We are told to put a modifier -27 or -25 on the second visit charges. I tried to say that this is wrong because this modifier only goes on E/M visits. So what, if any, modifiers should I use?

2) A patient comes in the morning for an outpatient x-ray. He goes home and is called to come back because his x-ray was abnormal. He is registered for an ER visit. These are kept separately but combined when billing.

When would a modifier be used on these visits? And where does it go? What kind of documentation is necessary? I'm sorry this a long question but I have to "figure it out" by Monday...Thanks in advance you guys!!!

Katie, RHIT

Thank you!

Hi, katie:

This is a very broad question and for further guidance, I would suggest you get the BCBS billing guidelines for your state and verify their requirments. E&M visits by the same provider/group on the same date of service are added together and billed as you know.
It's not clear exactly what type of facility you are billing for, so my answers are general guidelines for facility. I'm sure others will have more specific answers.
CPT does list modifiers 25 and 27 as acceptable for Ambulatory surgery center hospital outpatient use.
Here is a link to a supercoder article that is very helpful in explaining modifier 25 vs. 27. http://www.supercoder.com/articles/...-for-ed-facility-versus-professional-service/
Modifiers
CMS says the modifier goes here: Hospitals append modifier –27 to the second and subsequent E/M code when more than one E/M service is provided to indicate that the E/M service is a “separate and distinct E/M encounter” from the service previously provided that same day in the same or different hospital setting.
For repeat labs, the modifier is 91-if the repeat lab is necessary to obtain subsequent (multiple) test results within on the same day. Under these circumstances, the lab test performed an be identified by its usual procedure number and the addition of modifier 91.
I try to do what I can document, so I would request that the billing manager who believes modifiers are needed show you her documentation and help you to build a billing procedurees guideline. Hope this helps a little
Melanie