Revenue Cycle Insider

Find out how to limit your audit risk by navigating modifier guidelines.

Modifiers can be powerful coding tools, but they can also create problems when they are added simply to make a claim payable. In cardiology, where diagnostic testing, procedures, and evaluation and management (E/M) services frequently occur on the same date, modifier errors can lead to denials, incorrect payment, or audit exposure.

As you review cardiology claims, focus on what the physician actually performed during the encounter, what portion of the service was provided, and whether the documentation supports reporting separate services. The modifier should explain a legitimate circumstance — you should not use it as a workaround for a National Correct Coding Initiative (NCCI) edit or a payer denial.

Check Same-Day E/M Services Before Reporting Both

Cardiology encounters frequently combine an office visit with a diagnostic test or procedure. Your job is to determine whether the E/M service represents work that stands on its own.

For example, a patient with known coronary artery disease (CAD) presents for a scheduled cardiac test. During the encounter, the cardiologist also evaluates new chest pain, reviews recent symptoms, changes medication, and develops a new treatment plan.

If the documentation supports a separately identifiable E/M service, you may report the appropriate E/M code with 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) appended, when required.

By contrast, if the physician simply reviews the patient’s history and performs the work necessary to conduct the scheduled procedure, a separate E/M service may not be supported.

The AMA advises considering whether the physician performed and documented the E/M work required for the reported level, whether that work could stand alone as a reportable service, and whether it went beyond the typical work associated with the procedure.

Distinguish Modifier 59 From Modifier 25

You should use modifier 59 (Distinct Procedural Service) for certain non-E/M services that would ordinarily not be reported together but are separately reportable because the circumstances support a distinct service.

The Centers for Medicare & Medicaid Services (CMS) states that you should not append modifier 59 to an E/M code. When the issue involves a separately identifiable E/M service performed with another procedure, you should consider modifier 25.

Modifier 59 may be appropriate when documentation supports circumstances such as a different encounter; different procedure or surgery; different anatomical site or organ system; separate incision or excision; separate lesion; or separate injury. You should use another, more specific modifier when one better describes the circumstances.

CMS also recognizes four more specific modifiers associated with NCCI edits:

• Modifier XE (Separate Encounter, A Service That Is Distinct Because It Occurred During a Separate Encounter)
• Modifier XP (Separate Practitioner, A Service That Is Distinct Because It Was Performed by a Different Practitioner)
• Modifier XS (Separate Structure, A Service That Is Distinct Because It Was Performed on a Separate Organ/Structure)
• Modifier XU (Unusual Non-Overlapping Service, The Use of a Service That Is Distinct Because It Does Not Overlap Usual Components of the Main Service)

These are CMS/HCPCS Level II modifiers that CMS developed specifically in connection with the Medicare NCCI program. CMS describes them as more specific subsets of modifier 59 and recommends using the appropriate X modifier instead of 59 when possible. However, they are not inherently “Medicare-only modifiers.” Other payers can adopt them, and some commercial insurers do. You should always check the specific payer’s policy.

Review NCCI Edits Before Adding a Modifier

When a cardiology claim contains two procedure codes that appear to conflict, do not immediately add modifier 59, XS, or XU.

First, check the current NCCI Procedure-to-Procedure (PTP) edits. CMS updates its NCCI policy annually and the edit files periodically, so you should verify the rules applicable to the date of service.

If an edit exists, determine:

• Which code is the Column 1 code and which is the Column 2 code,
• Whether the edit permits an NCCI-associated modifier,
• Whether the clinical circumstances actually support the modifier, and
• Whether another modifier more accurately describes the circumstances.

CMS cautions that you should not use modifiers simply to bypass an NCCI edit. The medical record must support the circumstances represented by the modifier.

Do Not Add 26 or TC Automatically

Not every CPT^® code can be split into professional and technical components.

Before adding modifier 26 (Professional Component) or TC (Technical Component), check the Medicare Physician Fee Schedule (MPFS) database for the code’s professional/technical component indicator and review payer-specific requirements. CMS specifically identifies modifier 26 as representing the professional component and TC as representing the technical component in its MPFS resources.

A cardiology practice that performs both the technical and professional portions of a diagnostic service generally should not append modifier 26 simply because the service involves interpretation. Likewise, a facility should not append TC unless the code and circumstances support separate technical-component reporting.

Heads up: CMS has identified incorrect use of modifiers 26 and TC as a Medicare payment error area, reinforcing the importance of checking the applicable MPFS indicators rather than assuming a service can be split.

Prevent Denials With a Documentation Check

Finally, before submitting a cardiology claim involving modifiers, ask yourself these questions:

• Does the documentation support a separately identifiable E/M service?
• Am I using modifier 25 only on the E/M code?
• If I am using modifier 59 or an X{EPSU} modifier, can I identify the specific circumstance that makes the services distinct?
• Did I verify the current NCCI edits and modifier indicators?
• Does the diagnostic code have separate professional and technical components?
• If I used modifier 26 or TC, did I verify that the code permits component billing?
• Does the documentation support exactly what the modifier says occurred?

Modifiers should clarify the circumstances surrounding a service, not compensate for incomplete documentation or an otherwise unsupported code combination.

The bottom line is simple: Before adding a modifier, identify the coding rule that makes the modifier appropriate. In cardiology, that extra step can mean the difference between a clean claim and a denial.

Suzanne Burmeister, BA, MPhil, Medical Writer and Editor