Most people have had to deal with medical insurance companies at least once in their lifetime. For better or for worse, those organizations are the keystone to the health system. If you have ever had a medical claim denied, you understand the frustration of waiting in a phone queue only to get someone who has no authority to make changes or assist in any manner other than simply reading the script they have been provided. This can drive anyone crazy, so your best chance to avoid these headaches is by avoiding the problems in the first place.
Did you know that some of the issues derive from a hidden portion of the insurance system that often stays in the shadows? Medical coding is much more complicated than most people realize. Proper, accurate, and capable medical coding software and professionals can make the difference between a frustrated client and a satisfied patient.
One of the most frequent errors can result from the submission of invalid modifier combinations. Here are the three most common invalid modifier combinations that cause medical claims to be denied payment:
Modifiers 24 and 25:
Modifier 24 refers to the evaluation and management services provided to the patient on the day of a surgical procedure unrelated to the procedure itself. Modifier 25 identifies the evaluation and management services as unique services provided on the same day by the same medical professional. These two modifiers are only valid when used in conjunction with the proper E/M codes such as 99201-05 or 99231-23.
When this particular modifier is included in the medical claim, it can render certain other modifiers invalid (such as 26, LT, RT, and TC). Modifier 50 is only added to a medical procedure when that particular procedure is completed bilaterally, or on both sides. Modifiers LT and RT refer to a procedure completed on only the left or right sides. Modifer 26 refers to the professional component of a service or the interpretation of such services. Modifier TC references the technical component of such service or the interpretation thereof.
If the Modifier 76 is included in the medical claim, then it is considered invalid if used with Modifier 59. The Modifier 59 refers to procedures or services completed on the same day that are because of special circumstances and are not normally performed together. Modifier 76 refers specifically to the same procedure performed multiple times by the same medical professional after the initial service.
In conclusion, simple logic can explain why most of these modifiers cannot co-exist on the same claim. They are mutually exclusive to one another. For example, you cannot perform a surgery on the right side of the body only at the same time you are performing the same surgery bilaterally. It simply does not work.
Many of these invalid modifier combinations can be avoided with properly trained medical coding personnel as well as specifically designed software. If you are interested in streamlining your back-office operations and reducing errors in your coding submissions, we invite you to contact us, so that we can discuss a customized solution for your business.