One of the common reasons your medical claims may be denied is for missing modifiers or invalid modifier combinations, which basically means that your procedure code isn’t consistent with the modifier you’ve used. Accurate coding of treatment is essential, but it’s also important to ensure you include modifiers when necessary and ensure you’ve used the correct one for the code you’re using.

When denials occur, they not only have the potential to delay payment, they could result in non-payment, which has a significant impact on your practice’s bottom line. Here’s a closer look at modifiers, the circumstances when they need to be used, a few invalid combinations to avoid, and additional information to help you avoid this common reason for claims denials.

Understanding Modifiers

What is a modifier? It’s a two-character numeric or alpha numeric code that’s used along with a CPT code to indicate there’s been some alteration to a performed service without changing the code or definition. Without the correct modifiers, you may not receive the full payment expected for a claim or the claim could be denied, so it’s essential to be up-to-date on current modifiers and when you need to use them.

In What Circumstances Can You Use Modifiers?

Modifiers alter the description of a procedure or service that’s been provided to a patient, and they can be used in a variety of circumstances, including:

• A procedure or service was done by more than one physician and/or at more than a single location. For example, some procedures may require an assistance surgeon to deal with complexities that arise.
• There’s both a technical and professional component to a procedure or service. For example, radiological procedures – One provider may own the equipment and then a physician will be the one that interprets the findings of the procedure.
• Only a portion of the service was performed. For example, a bilateral procedure (which means it’s done on both sides) is only done on a single side.
• The procedure or service has been reduced or increased. For example, a procedure that usually takes just an hour ends up taking two hours due to scar tissue. Another example is a procedure that usually includes an additional procedure, yet the second one wasn’t necessary and was not performed.
• Unusual events occurred. For example, a patient underwent surgery only to have an adverse reaction to the anesthesia, resulting in the termination of the procedure. 
• The procedure or service was done multiple times. For example, excising lesions off various areas of a single body part via separate incisions.

Invalid Modifier Combinations 

Claims can be denied in a variety of different ways for invalid modifier combinations, such as:

• Modifier combinations that are unique to payers. Remember, not every payer uses and recognizes similar modifiers.
• Inappropriate billing of multiple modifiers. Certain modifiers may not be billed together and not all modifiers can be used on the same claim form or line item. 
• CPT/HCPCS to modifier combinations. Not all modifiers can be used for all HCPCS and CPT codes.

Modifiers You Need to Know 

Modifier 24

Modifier 24 is used with evaluation and management (E&M) services that are provided to a patient on the same day of a surgical procedure that’s unrelated to the procedure. This means that if the patient has surgery but has a condition that needs evaluation that’s separate from anything related to this procedure, the E/M service is reported along with modifier 24. Remember, this modifier can only be used with E&M services. Documentation must also be provided to describe why the visit during a postoperative period occurred and was unrelated to surgery.

Modifier 25 

Modifier 25 is another E&M modifier in which E&M services are provided that exceed normal preparation for a procedure and standard follow-up. Documentation must be included with this modifier to reflect the necessity of the additional services.

Modifier 50 

Modifier 50 is a modifier used to report procedures done during the same session that are bilateral. Generally, they apply to radiological procedures, surgical procedures, and certain other diagnostic services. This code should be used when doing a procedure on bilateral body parts, appending the modifier to the code to note it was done bilaterally. However, this modifier should not be used with codes that already have bilateral descriptions. They also shouldn’t be appended to procedures for the midline organs, such as the uterus, bladder, or esophagus. It also shouldn’t be used to report procedures performed on different areas of the same side of the patient’s body.

Modifiers RT and LT

Modifier RT is used to specifically identify a procedure was done on the right side of the patient’s body. The LT modifier is used to identify that the procedure was done on the patient’s left side. These modifiers offer supplementation information for procedures done on pair structures, such as the breasts, eyes, knees, arms, or lungs. While they don’t affect payment, they do offer some essential information that identifies the location of the service provided.

Resolving Denials for Missing Modifiers or Inconsistent Modifier Use 

When you first receive a denial for a missing required modifier or a procedure code that’s inconsistent with the modifier you use, there are a couple things you can do. First, if you find that the coding team did make a mistake, you can update the modifier and resubmit the claim. However, if it was submitted appropriately and the claim was incorrectly denied, then you need to get in touch with the claims department. If the claim is denied incorrectly, you’ll likely need to submit an appeal and ensure you have supporting documents on hand.

By better understanding common reasons for claims denials, your practice is better equipped to prevent them. M-Scribe Medical Billing specializes in boosting revenue and efficiency for your medical practice. To learn more about how we can help your practice prevent denials, improve efficiency, and boost your bottom line, contact us today at M-Scribe.com for more information. 

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