Pediatric Coding Alert

Learn from these 3 scenarios and make denials a thing of the past.

Whether you append a pricing modifier or an informational modifier to a procedure performed by your pediatrician, modifier choice will affect your revenue. In fact, “the non-use, misuse, and overuse of any kind of modifier can have financial implications,” said Jennifer Swindle, VP Quality and Service Excellence at Salud Revenue Partners in Lafayette, Indiana, during her presentation “Modifiers’ Impact on the Revenue Cycle” at HEALTHCON 2021.

Swindle’s presentation focused on several modifiers, but four in particular have big implications in pediatric coding and for your bottom line. Here they are, along with some examples from the pediatric setting to help your coding.

Repeat After Me (1) — When and How to Report Repeat Procedures

“When we use modifiers, we are trying to tell the whole story, so when we report a code with a 76 [Repeat procedure or service by same physician or other qualified health care professional] or 77 [Repeat procedure by another physician or other qualified health care professional], we’re saying [to a payer] ‘we know we already billed this once, we did it more than once, we want to be paid for both,’” says Swindle.

However, if you do use either modifier, you must show that the repeat procedure “is medically necessary,” Swindle cautions.

Example: A patient reports to your pediatrician’s office with an acute asthma exacerbation. After your pediatrician administers an albuterol treatment, the patient’s symptoms remain the same, making a second treatment medically necessary. Thirty minutes later, the patient returns to the office and your pediatrician administers a second albuterol treatment.

This would be a situation where you would report 94640 (Pressurized or nonpressurized inhalation treatment for acute airway obstruction for therapeutic purposes … with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing (IPPB) device) “with no modifier on the first entry, and modifier 76 [for the same provider, same date] or 77 [for a different provider, same date] on the next,” suggests Swindle.

Coding alert 1: Some payers may want you to report two units of 94640 on the same line, but the modifier will still need to be appended to the code. Otherwise, the payer will likely only pay for one procedure and bundle the other.

Coding alert 2: Modifiers 76 and 77 are only needed when the procedure is performed on the same day for the same patient.

Repeat After Me (2) — When and How to Report Repeat Tests

“If the repeat service happens to be a lab service, you will capture that using modifier 91 [Repeat clinical diagnostic laboratory test]. That says it is medically necessary to do the lab more than one time in one day,” says Swindle.

Example: A young patient with type 1 diabetes arrives at your office saying that he is feeling weak and unsteady. Your pediatrician administers a glucose test that shows the patient is hypoglycemic. Your pediatrician then decides to give the patient a glucose gel; 15 minutes later, the provider administers a second glucose test that shows the patient’s blood sugar levels have returned to normal.

You would code this encounter using the appropriate lab test code, such as 82947 (Glucose; quantitative, blood (except reagent strip)), on two lines, appending modifier 91 to the lab test code on line two.

Coding alert 3: You would only use modifier 91 on the second test, and “only when the results of both labs are needed. If the initial sample is contaminated, or if there is not enough blood or an adequate sample, then it should not be billed as a repeat lab,” Swindle cautions.

Be Distinct — When and How to Report Separate Procedures

“I’ve heard for years that modifier 59 [Distinct procedural service] is the modifier of last resort. It does not change reimbursement; however, it may allow reimbursement. But be careful when you use it, as payers do monitor it. It’s going to be heavily scrutinized,” Swindle warns.

So, how do you use modifier 59 correctly?

First, it is important that you only use it to distinguish between two different procedures or services, not between a procedure or service and an evaluation and management (E/M) service. Additionally, the two distinct procedures or services should not normally be reported together but are appropriately performed on the same individual on the same day. And those services or procedures must be an edit pair per National Correct Coding Initiative (NCCI) edits with a modifier indicator of 1, which means you can unbundle them using an appropriate, NCCI-associated modifier on the column 2 code.