Avoid Modifier Missteps To Reduce Denials
Published on Tue Jan 01, 2002
Modifiers remain a mystery to many coders who think they know how and when to append them, yet frequently find their claims denied. The problem is so pervasive that improper use of modifiers has been cited as one of the top-10 billing errors by federal, state and private payers and is considered a major fraud, abuse and noncompliance issue.
Following are some of the modifiers used most often by family physicians, common mistakes in appending them, and suggestions for proper usage. All the modifiers can be identified with two digits, e.g., -24, as used below, or by adding a 099 prefix, e.g., 09924.
Modifier -21
Modifier -21 (prolonged evaluation and management services) indicates that services provided to a patient lasted longer than the usual time for the highest level of E/M service in a category. Medicare does not recognize the code, but Mary Falbo, MBA, CPC, president of Millennium Healthcare Consulting Inc., in Lansdale, Pa., says some payers will provide additional reimbursement for modifier -21 with written documentation.
For example, an established patient visits his family physician because of multiple concurrent diseases: osteoarthritis, gout, emphysema, advanced diabetes and a stasis ulcer. After the examination, the physician counsels the patient and his family, resulting in a visit that lasts 65 minutes, 25 minutes longer than the norm for the highest-level E/M (99215) in the category. The coder appends modifier -21 to 99215. Because many payers view modifier -21 as information only (i.e., as a code they recognize but for which they generally do not provide additional reimbursement), Falbo recommends filing on paper instead of electronically and writing a letter explaining the case's complexity and requesting additional reimbursement of a specific amount (usually 25 to 30 percent more).
Some coders are also confused about when to use modifier -21 in lieu of the prolonged services codes, 99354-99357. To use the prolonged services codes, the office must document that the doctor spent at least 30 minutes of extra time, but that time does not need to be continuous.
"Use modifier -21 when prolonged services are continuous and last less than 30 minutes," Falbo says. "In addition, modifier -21 is used when the face-to-face time or floor/unit service provided is prolonged or otherwise greater than usually required for the highest level of E/M service within a given category."
Modifier -21 may be reported with 99205 (office or other outpatient visit for the evaluation and management of a new patient) or 99215 (office or other outpatient visit for the evaluation and management of an established patient), but it would not be reported with any of the other levels of service reported by the physician, e.g., 99204 (office or other outpatient visit for the evaluation and management of [...]
