Identify Coding Pitfalls to Avoid Common Claim Errors

Posted on 7 Feb, 2019 |comments_icon 0|By Elizabeth Debeasi

Denial management is critical to preserving your bottom line.

Coding errors accounted for 8.7 percent of improper payments made by Medicare in 2018, which cost over $2.75 billion. To avoid costly denials and potential payback demands, it’s essential to review code guidelines before submitting your claims.

If your practice is spending precious hours pursuing appeals, it’s time to get ahead of denials with reliable know-how to fix your claims issues upfront.

In this post, we look at the most commonly cited reasons for claim denials and lay out essential tips to help you reduce your denial rate and preserve your bottom line.

1. Missing modifier: If you bill Medicare for an E/M service reported with a procedure, but forget to append modifier 25, you may see a denial.

  • Look for: Reason code 4
  • Look at: HIM/coding

Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) is one of the most misunderstood modifiers, so if you ever have doubts about whether you’re using it properly, make sure you follow these rules:

  • Only append modifier 25 to evaluation and management (E/M) service codes.
  • Use modifier 25 only when your provider’s documentation supports that he performed a medically necessary and “significant, separately identifiable” E/M service in addition to the procedure. Your physician must include separate history, examination, and medical-decision making for the E/M service in his documentation.
  • The E/M service must occur on the same calendar day as the original procedure, for the same patient.
  • Apply modifier 25 for minor procedures, meaning ones with zero or 10-day global periods. For 90-day procedures, instead use modifier 57 (Decision for surgery) on the E/M service. But keep in mind that Medicare always considers the visit on the day of surgery as part of routine pre- or post-surgical care.

Hint: You do not necessarily need two different diagnosis codes to append modifier 25. While different diagnoses help show the separate nature of the E/M service, they are not required for using modifier 25.

2. Duplicate billing: If your claim looks like a duplicate bill, perhaps due to a forgotten modifier, expect your MAC to deny it.

  • Look for: Reason code 18
  • Look at: Billing system, which may be failing to detect duplicate claims

When you file a claim for multiple instances of a service or procedure, you must include an appropriate modifier to indicate that the service or procedure isn’t a duplicate. The modifier should be added to the second (and subsequent) line items for the repeat service or procedure.

Modifiers that you might need include:

  • Modifier 76 (Repeat procedure by same physician or other qualified health professional): Append modifier 76 when a provider performs a procedure or service and must repeat the exact procedure or service. The procedure may be repeated to render a definitive diagnosis because the patient didn’t respond well to the first procedure, or because the first procedure was unsuccessful.
  • Modifier 77 (Repeat procedure by another physician or other qualified health professional): This modifier is most often necessary when another physician’s expertise is needed to fully care for a patient or in the event of questionable findings. For these circumstances, you append modifier 77 when a provider repeats a procedure or service after the original procedure is done by a different physician or other qualified healthcare professional.
  • Modifier 91 (Repeat clinical diagnostic laboratory test): You may be tempted to use modifier 76 on repeat lab tests when the correct modifier would be 91. Remember to use modifier 91 when a physician requests multiple tests for diagnostic purposes, not when the lab repeats a test due to technical or quality assurance issues, or you will risk your claims being denied.

In some cases, though, even when you use an appropriate modifier, your payer may deny the claim as a duplicate based on medically unlikely edits (MUEs). Be sure to check MUEs before submitting your claims.

3. Two services, same date: In contrast to the above duplicate billing error, you may receive a denial if a payer bundles a service you performed into another service, considering the payment for the second procedure included in the more significant service.

  • Look for: Reason code 236
  • Look at: HIM/coding, Correct Coding Initiative (CCI) edits

Every quarter, CCI puts out a list of code pairs that Medicare — and many private payers– follow when they reimburse physician practices. The CCI edits list pairs of CPT® and HCPCS codes that payers will not pay on when you bill them together. Medicare applies these edits to services you bill for the same provider, for the same beneficiary, on the same date of service.

All edits consist of code pairs that are arranged in two columns (Column 1 and Column 2. Codes that are listed in Column 2 are not payable if performed on the same day on the same patient by the same provider as the code listed in Column 1, unless the edits permit the use of a modifier associated with CCI.

In certain clinical circumstances, you can override CCI edits and receive separate reimbursement for bundled codes. To find out if you can separately bill services your physician performed, first check the “modifier indicator” on the CCI spreadsheet.

  • A “0” indicator means that you cannot unbundle the two codes under any circumstances.
  • An indicator of “1,” however, means that you may use a modifier to override the edit if the clinical circumstances warrant separate reimbursement, such as a separate encounter on the same date, a separate anatomical site, or a separate indication.
  • Modifier indictor “9” means the edit no longer applies. The typical example involves CMS deleting an edit retroactively, meaning it’s as if the edit never existed.

Tip: Do not append a modifier to override a CCI bundle just to get paid or because you do not agree with a bundle. You can use a modifier to override a bundle only if your documentation supports using the modifier.

Contributing Editor: Kristin Webb-Hollering

Learn More

Be sure to join us next week for Part 2 as we explore claim errors related to medical necessity. We plan to home in on E/M pitfalls and provide guidance to help you nail down the correct level of service for your E/M services.

Get fast and effective answers to your Medicare questions with a subscription to Medicare Compliance & Reimbursement. Every issue of this monthly newsletter delivers coding and billing guidance, as well as high-impact tips to conquer the revenue-risking challenges that threaten your claims and compliance success.


Elizabeth Debeasi
Marketing Writer/ Editor

Elizabeth works on an array of projects at TCI, researching and writing about modern reimbursement challenges. Since joining TCI in 2017, she has also covered the nuts and bolts of cybersecurity, compliance with federal laws, and how to tap into the advantages of Telehealth services.

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