Part B Insider (Multispecialty) Coding Alert

Published on Sat Apr 15, 2006 PDF

6 tips for keeping track of which modifiers your non-Medicare payors want

If every payor wanted to see exactly the same modifiers, life would be simple. Unfortunately, every non-Medicare payor has its own finicky modifier requirements.

“You occasionally learn that certain payers have quirks about one modifier or another,” says Dianne Wilkinson, director of quality assurance with MedSouth Healthcare in Dyersburg, TN. Keeping up with them can be a major chore. Here are some tips:

1. Start out on the right foot. Assume from the get-go that everything you send out will be coded correctly, including modifiers--and then find out what each payor’s exceptions to the normal “correct coding” rules are, advises Quinten Buechner, a consultant with Pro-Active Consulting located in Cumberland, WI.

When you start working with a payor, contact it upfront and get their policy in writing if possible, Buechner adds. Many payors will have their modifier preferences in their policy manuals, notes Chris DuBois, coding and compliance coordinator with Western Mass Physician Associates in Holyoke, MA.

2.  Have a dedicated staff person. “We have somebody who does nothing but research the Web sites” for payment rules, says Rachel Mitchell, a coder with Applied Medical Systems in Durham, NC. If your practice has a quality assurance (QA) staffer, make modifier expertise part of his or her job description.

3.  Use software. Charter Professional Services in Salem, MA uses a program called ClaimsManager from Ingenix that allows it to create different payment rules based on payor guidelines. For example, if MassHealth doesn’t recognize the 25 modifier, then the software will throw up a red flag any time MassHealth and the 25 modifier appear on a claim together, says Diane McEntire, director of provider billing.

Using software means that your practice isn’t dependent on any employee to keep track of payor guidelines. That way, you don’t lose the knowledge if a staffer ups and leaves.

4.  Keep track of your denials. Analyze your denials, if any, to see if you have any particular problems, Buechner advises. Create a spreadsheet of denials by payor and by problem. Challenge any denials where modifiers aren’t being processed properly. Be prepared to go all the way to the payor’s medical director and challenge any deviations from the CPT coding rules that don’t reflect the payor’s policies.

5. Write to the payor. For example, if the payor rejects the SB modifier for midwife services, write a letter explaining about the midwife service and why it was needed, urges DuBois. Get the payor’s response in writing if possible, so you’ll know how to bill for those services in future. In one case, when DuBois wrote to a payor, a rep wrote back and said not to use a modifier at all in future.

6.  Be aware of non-modifier issues. Make sure you know how your payors’ coding rules differ from CMS’s. Sometimes payors will accept all modifiers, but won’t accept Medicare coding concepts, such as allowing an evaluation & management visit on the same day as a minor surgical procedure, says Collette Shrader, compliance and education manager with Wenatchee Valley Medical Center.