Orthopedic Coding Alert

Question: We've been having some problems with payment for our nonphysician practitioners (NPPs); it seems like some private payers aren't covering patient encounters with NPPs. What's going on?

California Subscriber

Answer: If that particular payer is UnitedHealthcare, you may have noticed that you've been having issues with successful claims for the past six months.

All claims for evaluation and management (E/M) services dated on or after Sept. 1, 2017, require modifier SA (Nurse practitioner rendering service in collaboration with a physician) when these services are provided by nurse practitioners (NPs), physician assistants (PAs), and clinical nurse specialists (CNSs), according to UnitedHealthcare's June 2017 Network Bulletin.

But don't forget one of the golden rules of billing: Each payer has different requirements. Make sure you check with each individual insurer as to what they require and when, especially as the use of a particular modifier may impact reimbursement.

"The CPT^® and CMS modifiers are generally well-known to the billing professionals of small and/or large practices," says Catherine du Toit, CPC, CPMA, CGIC, of Clean Claims Coding Consultants. "If each insurance carrier is planning to add its own set of modifiers to indicate that NPs, PAs, and other clinical staff members performed E/M services in collaboration with the physician, things could get confusing."

To wit: The UHC policy isn't universal; in fact, other payers specifically advise practices to avoid modifier SA.

For example: Take a look at the Tufts Health Plan policy for clarity. "Effective for dates of services on or after January 1, 2017, the SA modifier should not be present when billing for services that are 'incident to' professional services," the policy emphasizes. However, keep in mind that the "incident to" concept does not apply in facility settings like the emergency department (ED).

Payment issues:  Although UHC doesn't indicate in its policy whether using modifier SA will impact payment, some payers actually do cut reimbursement when modifier SA is appended. Additionally, the policy does not clearly indicate if it should be added on claims that are reported under the NPs, PAs, or CNSs.

Cigna's policy, for example, states that modifier SA will pay "85 percent of fee schedule or usual and customary/maximum reimbursable rate."

The bottom line: It's vital to check with your individual payers to find out their modifier SA payment policies, whether the modifier is required on any particular claim types (procedures versus E/M services), and whether your use of the modifier will impact your reimbursement.