Understand and Avoid Costly Mistakes for Modifiers 51, 52, 53, 58, 59, 25, 78 and 22
It’s important to understand modifier usage to avoid costly mistakes. Modifiers can also have significant impact on claims and payment. When used correctly, modifiers can positively affect reimbursement and offer a clear picture of the service performed.
Use Modifiers Correctly and Avoid the Potential for Abuse: Modifier 52 and Modifier 53
Modifiers identify circumstances or procedures that vary from the original code description. They alert the payer that something unusual has occurred. And, because modifiers address exceptions and not the rule, the potential for misuse or abuse of them is often significant.
Two Facts Increase Payment Success
“Coders who recognize two foundational truths about modifiers increase their reimbursement success,” Carol Pohlig, BSN, RN, CPC, who works in the department of medicine at the Hospital of the University of Pennsylvania, says.
“First, coders must recognize that not all insurers treat modifiers the same way. Medicare, for instance, recognizes most of the modifiers that appear in the CPT manual. Other insurers recognize none of them. Still others recognize some, but not all. Coders should work closely with payer representatives to understand how that particular insurer approaches modifiers,” she explains.
Second, coders must submit the claims in the most effective manner. Many coders don’t realize that claims containing certain modifiers should drop to paper (e.g., modifier 52, or modifier 53). They are typically automatically denied, with a request for more information explaining the circumstances requiring the modifier. Rather than wait for the denial and request for supporting documentation, practices are better off submitting the claim on paper with the progress notes or procedure report already attached.
If modified claims are denied after submission of the documentation, coders should request peer review. They need to make sure the claim is...
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