Pediatric Coding Alert

Plus: Two other payers sound off on their specific claim tips.

When it comes to payer policies, most pediatric coders know that no two coverage decisions are alike. So if you’re sick of poring over the different policies for your patients, let us do the work for you. Pediatric Coding Alert recently researched billing tips from three insurers, and we’ve got the lowdown on how they want you to submit your claims for the fastest, most accurate payments.

1. If No ‘X’ Modifier Applies, Turn to 59

If you’ve been afraid to use the relatively new X{EPSU} modifiers, now is the time to face your fears. That was the word from a 2015 Humana webinar that covered these modifiers, as well as modifier 59 (Distinct procedural service).

“As of January 2015, there are four new distinct modifiers that can be used in lieu of modifier 59,”said Charles W. Moore, provider education consultant with Humana, during the payer’s webinar “Modifier 59 and X{EPSU} Modifiers.” Those modifiers are as follows:

• XE: Separate encounter
• XS: Separate structure
• XP: Separate practitioner
• XU: Unusual non-overlapping service

“One of the X modifiers should be used when it accurately describes a clinical scenario,” Moore noted. “If an X modifier does not exist for a specific situation, then modifier 59 should be used,” he added.

He noted that most claims submitted with the X modifiers or modifier 59 are reviewed during the initial claims adjudication process to ensure that they are being used appropriately. “Remember that the X modifiers are more specific, and therefore an X modifier should be used when appropriate, because it provides more information about the specific situation than modifier 59,” he added.

He offers an example of a case when a patient presents for wart removal on the left foot and a malignant lesion removal on the left thigh. In this case, the provider could use modifier XS or modifier 59 to show that separate structures were addressed during the two different procedures.

Keep in mind that the X modifiers still have some confusion behind them, so you should contact other payers before using them to confirm that each insurer is accepting them.

2. Start Billing Process Before Patient Even Sees Provider

When a patient arrives at your practice, ask for her identification card and always ask whether she has any other insurance, including Medicaid, said Shanna Kenworthy of Wellmark Blue Cross Blue Shield of Iowa, during the 2015 Wellmark webinar “Provider Inquiry Process and Enhancements.”

Double-check the patient’s eligibility and confirm benefits for the date of service, and then make sure that none of the patient’s potential services require pre-authorization. Then, after the visit, look over the claim and ensure that the patient information is accurate and that all of the codes are correct based on the documentation.

You should also ensure that all credentialing is complete for the practitioner or the facility/entity before you submit your claim, Kenworthy said. “We ask that you allow at least 30 days for these claims to be processed, from beginning to finalization of the claim,” she added. “In order for us to ensure that claims are processed appropriately and accurately, that can take a little bit of time.” In addition, always wait until your claim is fully processed before you resubmit another submission of the same claim, she said.

3. Scrutinize Your Modifier 25 Usage

If 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) is your favorite pediatric modifier, it could be time to brush up on your knowledge of how to use it.

An OIG audit found that some 35 percent of audited claims did not meet the requirements for modifier 25, said Shauna Vistad, MBA, CPC, CFE, CFI, manager provider audit and SIU with Blue Cross and Blue Shield of North Dakota during the payer’s Oct. 22 webinar, “Appropriate Use of Modifiers and Other Coding Complexities.”

To ensure that you stay within the 65 percent of practices that are coding this modifier correctly, ask yourself this question, Vistad said: “If all documentation supporting the initial procedure is removed, does enough documentation remain to support a separate E/M service?”

If not, then the E/M your doctor performed is likely inherent to the procedure he performed, and you should not separately report the E/M code and modifier 25.

In addition, if you’re reporting modifier 25 with a preventive visit—which is extremely common for pediatricians—“only the documentation above and beyond the normal preventative visit should be used to determine the E/M level,” Vistad added.