Some practice medical billing personnel, even those with experience, exhibit misunderstanding of code modifiers when submitting claims. If you research some payer statistics, you’ll find numerous examples of medical providers re-submitting previously denied claims using the identical modifiers that generated original payer confusion. Payers typically again deny these claims.

Modifier Misuse Results

While most medical billers understand the purpose of modifiers, to further clarify the physician action during patient encounters, sometimes coders repeatedly misuse modifiers, increasing payer confusion. Inaccurate claim submissions increase reimbursement delays or generate claim denials, achieving two negative results.

• Decrease income to the physician, and
• Increase billing costs, as staff time is wasted by re-submitting unreimbursed claims.

Denied Claims Re-Submission Issues

Re-submitting denied claims by using the same modifiers that caused the original payer decision is an exercise in futility. Coders failing to use different modifiers or including additional documentation for clarity have little hope for a positive payer reimbursement decision.

Although difficult to justify, this billing action is an all-too-common procedure. Payers often become equally mystified by claims re-submissions that offer no additional documentation or clarity, leaving payers no alternative but to further delay or deny these claims once again.

If your billing staff submitted the original claim with no modifier, re-submitting with the appropriate modifier helps the payer reverse denial decisions. However, using a potentially ambiguous modifier without clarification often heightens payer confusion, a common reason for the original claim denial.

This lack of accuracy and level of detail can escalate from claim denials, reducing practice income, to costly payer audits, investigations and, sometimes, fines. Frequently submitting claims without modifiers or containing the wrong modifiers generates payer red flags that can cause even more costly actions, increasing the effect of lost income opportunities.

Consider Examples of Modifier Use and Misuse

Modifier 25 is one of the commonly misused modifiers. Targeted to encourage payment for care evaluation and management (E&M) services performed the same day physicians provided an additional procedure for the same patient, coders sometimes append this modifier to the procedure claim in lieu of using the proper E&M code.

Modifier 24 misuse is another example worth noting. Intended for use when a physician provides an E&M service during a post-operative period, but the service is unrelated to the original procedure. Attempts to ‘unbundle’ this service from the original claim when the E&M service obviously relates to the original surgical procedure create payer denials, since they already reimbursed for the procedure. This modifier should only be used for unrelated services, e.g., addiction counseling, not for post-operative evaluations of patient recovery from surgery.

Properly using Modifier 59 allows providers to successfully unbundle claims, when justified. This modifier alerts payers that physicians performed procedures outside normally bundled services. A proper use example is when treating different injuries at sites other than stated in the original claim.

Removing the ‘Modifier Mystery’

The benefits of avoiding claim delays and denials need no further evidence. For reasons that should be equally obvious, removing the ‘cloud of mystery’ created by misuse of modifiers should be a top medical provider priority. These tips should help achieve this goal.

• Review claims before submission. If it confuses the medical provider, the odds are the claim will also confuse payer staff. Provide sufficient documentation that clarifies use of modifiers if you’d like to get paid.
• Be careful when ‘unbundling’ claims. Payers have become more diligent in examining claims for unwarranted unbundling. The increasing incidence of provider attempts to use modifiers to increase payments that are outside payer definitions of unrelated services originally reimbursed has caused payers to closely examine these claims. Successfully unbundling claims requires more clarity to generate payer approval.
• Train billing staff in the proper use of modifiers. The cost of education and training will be more than offset in decreasing claim denials and increasing income.
• Use a top medical billing firm. Leading billing and documentation organizations, like M-Scribe Technologies, use experienced coders who fully understand the proper use of modifiers to increase physician income.
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