If there is one area of medical coding guaranteed to produce headaches for even the most seasoned coder, it has to be the use of CPT® code modifiers. Get them right, and you capture maximum reimbursement for your provider and avoid the scrutiny of eagle-eyed auditors. Get them wrong, and your claims get held up and, worse, denied, creating problems for your provider and more work for you.
In this, and the following two blogs, we identify 10 of the most commonly misused modifiers to help you become more aware of the issues surrounding them. We’ll help you understand why they are problematic and how you can use them correctly.
First, let’s go back to basics with this refresher on modifier guidelines. According to CPT®, essentially modifiers do the following:
The two go hand in hand, and when your documentation fails to show that a provider has increased, reduced, or otherwise changed a service or procedure described by a specific CPT® code, then payers may question what the provider did and how, or even if, they should pay for the service.
This is especially true of all the modifiers in our top 10, including the first two on our list.
How it’s misused: In some situations, it’s easy to confuse modifier 79 (Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period) with modifiers 76 (Repeat procedure or service by same physician or other qualified health care professional), 78 (Unplanned return to the operating/procedure room by same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period), or 58 (Staged or related procedure or service by the same physician or other qualified healthcare professional during the postoperative period).
But you would use 76, 78, or 58 when the second procedure is related to the first in some way — 76 when a provider administers a second, identical service after the first service did not significantly improve the patient’s condition, 78 when complications arise from the first procedure, and 58 if the first procedure is a precursor to the second. But more of that in our next post.
How you should use it: Pick 79 in a situation where the patient has returned for a second procedure during the first procedure’s global, or postoperative period, and the reason for the second service has no relationship to the reason for the first.
Example: A 19-year-old man falls and breaks the shaft of his tibia. The orthopedist performs an open reduction of the fracture. Two weeks later, the patient trips while going down the stairs with his new cast and breaks his ulna. He returns to the same orthopedist, who performs another open reduction on the new fracture during the global period of the previous procedure.
Since the procedures are completely unrelated, you should report 27758 (Open treatment of tibial shaft fracture (with or without fibular fracture), with plate/screws, with or without cerclage) for the tibia fracture repair. Then, report 25545 (Open treatment of ulnar shaft fracture, includes internal fixation, when performed) for the ulna fracture repair with modifier 79 appended to show that the tibia and ulna repair were unrelated surgeries and that the ulna treatment occurred within the 90-day global period for the tibia repair.
How it’s misused: This modifier can be misused in several different ways. First, you can incorrectly apply it when a procedure is more accurately described with an add-on code. Also, you should not use it with an evaluation and management (E/M) service. And finally, you might incorrectly apply it to the wrong procedure, especially if you are billing claims for Medicare.
How you should use it: Before using modifier 51 (Multiple procedures), consult Appendix D (Summary of CPT® Add-On Codes) and Appendix E (Summary of CPT® Codes Exempt from Modifier 51) in your CPT® manual. If you are dealing with codes on either of these two lists, do not append 51.
And if you are billing for Medicare and payers following Medicare guidelines, make sure you append 51 to procedures that are reimbursed at a lower rate. Medicare reimburses surgeries listed after the first at a 50 percent reduction, so list your most expensive procedure first, and don’t attach 51 to it.
Example: A surgeon performs a 24500 (Closed treatment of humeral shaft fracture; without manipulation) and a 23500 (Closed treatment of clavicular fracture; without manipulation). You would apply the multiple procedures reduction to 23500, which is the lower-paying code (a national Medicare facility fee of $228.24 versus $335.88 for 24500) if your payer requires modifier 51.
Contributing Editor: Chris Boucher
Join us next time when we count down the next four modifiers on our top 10 list of misused modifiers. Can you guess what they might be?
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