Some modifier errors are easily avoided by experienced coders or practice management software with an editing function to stop incorrect claims before they are submitted.
But, not all software has all of the edits. Sometimes, we rely on our clinicians to enter charges and add common modifiers. And, sometimes, we coders are overwhelmed by volume.
In primary care or urgent care settings, modifiers can be forgotten. Most remember that an E/M service and a minor procedure (or nebulizer treatment) will require modifier 25 on the E/M service.
But, some forget that the follow up during the global period is included in the payment for the procedure. And, that if that same patient is seen in the ten-day global period for an unrelated problem, modifier 24 is needed.
CPT modifiers example – laceration repair
Patient seen on day 5 for stitch removal after a laceration repair. The urgent care center billed:
The correct coding is 99024, which is the CPT code for post op services. It doesn’t have any work RVUs or associated payment, because it is part of the global payment for the minor procedure.
But, if the same patient comes back with a hacking cough on day five, the group needs to bill:
- 99213-25. (Assuming a level three visit, of course.)
CPT modifiers example – general surgery
Here’s a general surgery example that I reviewed recently, that was sure to bring a denial for an OBS admission and an urgent appendectomy:
Modifier 57 may only be appended to an E/M service. The claim should have been submitted as:
And finally, a surgeon performs an amputation of the toe at the metatarsophalangeal joint and reports CPT code 28820. The disease process progresses and the surgeon returns the patient to the OR during the global period for a transmetatarsal amputation, 28805. The claims were submitted like this, with no modifiers.
- Feb. 10 28820
- Feb. 27 28805
The surgeon should have reported CPT code 28805-58; the global period restarts and payment is expected at 100% of the allowable. This is a more extensive surgery to treat the underlying disease process, a related procedure in the post op period.
- Feb. 10 28820
- Feb. 27 28805-58
Using modifiers correctly is critical to getting claims paid correctly and fast.
Join me May 4 at noon for a webinar, “Using modifiers correctly: every claim line tells a story” and learn how to avoid misplacing and missing modifiers on physician claims. You can sign up here.