Clear Up Your Confusion Over High-Risk Modifiers To Avoid Denials

Why are modifiers 25 and 59 causing so many billing and compliance problems lately? Payers are claiming that providers are frequently misusing these modifiers, which often leads to overbilling – a big no-no.

Modifiers 25 and 59 are typically high-risk, with rampant misuse, and cause a multitude of denials, says coding guru Elin Baklid-Kunz in her Virtual Boot Camp for ProfEdOnDemand, “CMS Modifiers: Coding, Billing, and Compliance Regulations.” But there are certain best practices you can follow to prevent reduced payments and denials when you’re using these modifiers.

Pro Tips: When to Use Modifier 25

Problem: Earlier in 2018, some Blue Cross Blue Shield (BCBS) plans began automatically denying claims that contained modifiers 25 and 59, reported the American Chiropractic Association (ACA). In some cases, BCBS stated in the denials that the modifiers were used inappropriately, while in other cases the denials said that providers’ use of modifiers 25 and 59 was higher than average.

Modifier 59 is for a “distinct procedural service,” while modifier 25 is for a “significant, separately identifiable evaluation and management [E&M] service by the same physician or other qualified healthcare professional on the same day of the procedures or other service,” according to supplemental billing guidance from AmeriHealth Caritas.

Important: Always keep in mind these general guidelines when using modifier 25:

  • You may append modifier 25 to only E&M codes within the ranges of 92002 through 92014 and 99201 through 99499.
  • The provided service must meet the definition of “significant, separately identifiable E&M service.”
  • When appending modifier 25 to an E&M service billed on the same date as a procedure or other service, you must enter documentation for the additional E&M service in a separate section of the medical record. Doing so validates the separate and distinct nature of the E&M service. The E&M service must be able to stand alone as a billable service, with no overlapping of key E&M components, such as medical history, examination, and medical decision-making.

Beware of Modifier 59 Pitfalls

Auditors, payers, and coders alike may consider modifier 59 “the bad boy of coding,” as Mercy Hospital in Portland, ME found out the hard way in 2017 in a $1.5-million settlement, according to a Healthicity report. Mercy’s settlement with the government resolved allegations that it had overbilled Medicare and Medicaid – and the culprit behind the hospital’s legal troubles was misuse of modifier 59.

Beware: More recently, on May 24, 2018, the Centers for Medicare & Medicaid Services (CMS) published two Office of Inspector General (OIG) reports, which revealed rampant overbilling and miscoding among hospitals. The culprit? Again, modifier 59. Specifically, one OIG report found that hospitals often used modifier 59 incorrectly when billing for outpatient right heart catheterizations with heart biopsies.

Back to the basics: AmeriHealth Caritas offers the following general guidelines that you should follow when appending modifier 59:

  • Use modifier 59 to identify procedures or services, other than E&M services, that you would not normally report together but are appropriate under the circumstances.
  • Don’t append modifier 59 to an E&M code. To report a separate and distinct E&M service with a non-E&M service performed on the same date, you should use modifier 25.
  • Make sure the documentation supports that the procedure or service represents a different session or patient encounter, procedure or surgery, anatomic site or organ system, lesion, or procedure not typically performed on the same day by the same individual.
  • Report modifier 59 only if no more descriptive modifier is available and if it is the most accurate modifier that is available to describe the circumstances of the procedure or service. Always consider using other modifiers like XE, XP, XS, or XU.

Looking for CMS Modifiers Billing Guide?

Resource: If you’re struggling with modifier 59 use, check out a special MLN Matters article that CMS published in January 2018. The article contains many specific examples of how and when to use modifier 59—and when not to.

Bottom line: If you want to avoid modifier missteps, make sure you first understand the definitions of modifiers 25 and 59, as well as the basics of how to append them in the correct situations, Baklid-Kunz advises. Stick to best practices and know the compliance risks, common mistakes, and the red flags that payers will look for (so you can avoid them!).

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