EM Coding Alert

Expert: Second opinion requests often lead to modifier 32 situations.

When a provider performs an evaluation and management (E/M) service that’s been mandated by an outside entity, you’ll want to consider adding modifier 32 (Mandated services) to the claim to bolster your reimbursement chances.

Check out this Q&A on adding modifier 32 to your E/Ms for mandated services.

Q: In which situations would you use modifier 32?

A: Use modifier 32 anytime the provider performs a service that was mandated by someone or by a specific contract, explains Marcella Bucknam, CPC, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, internal audit manager with PeaceHealth in Vancouver, Wash.

For example, a second opinion might be mandated by:

• an insurer (though that’s becoming rare these days)
• a worker’s compensation board
• an auto insurer.

Also: “Courts and law enforcement can also mandate services,” relays Bucknam.

Adding modifier 32 helps the payer identify the reason for the service, and can also help the office identify services that might be grouped together to a specific payer — such as an attorney. Modifier 32 can help you tag these claims, and keep them separate from other services that you might report to a payer, Bucknam advises.

Warning: “This modifier is not appropriate when billing Medicare for federally mandated visits for patients in a skilled nursing facility [SNF] or nursing facility [NF],” says Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare in Lansdale, Pa.

(Medicare can make payment for these federally mandated services based on the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-04, Chapter 12, Section 30.6.13.B.)

Q: Is modifier 32 for E/Ms only?

A: No. It can apply to any service, though E/Ms are absolutely on the spectrum of modifier 32 eligible services.

Q: Who is allowed to “mandate” services?

A: The mandate might be stipulated in a contract, if it’s a third-party payer. Most mandated services, however, are done under the direction of “courts in some legal action. It has to be mandated by someone with authority to command the patient to comply,” according to Bucknam.

If someone has the legal authority to mandate a service, they are “usually going to be someone who can either put you in jail, or fine you, or who has financial control of payment for your care,” Bucknam relays.