Primary Care Coding Alert

Hint: Understand when not to append for repeat procedures and tests.

Modifiers can make or break a claim. They help paint a picture for the payer by providing additional details about an encounter. However, when you’re dealing with different procedures, services, and payers, appending the wrong modifier is an easy error to make.

So, if you’ve ever wondered how to appropriately append modifiers to your family medicine claims, here’s a crash course in commonly misused modifiers.

Deal With the Dangers of Misusing Modifiers

A modifier alters the intention because there is a special circumstance of the CPT^® code you are reporting, but you are not actually changing the definition of the code itself, explained Pam Vanderbilt, CPC, CDEO, CPB, CPMA, CPPM, CPC-I, CEMC, CPFC, CEMA, owner of KnowledgeTree, Billing, Inc during her HEALTHCON presentation “Unbundling Modifiers: A Risky Business.”

When you misuse modifiers, a few things can happen, according to Vanderbilt. First, you are put at risk of inappropriate reimbursement. This, in turn, puts you at risk of audits, which puts you at risk of treble damages. These are

damages the court awards to the plaintiff in the amount of three times the actual damages.

Additionally, your providers are put at risk of losing their right to bill insurance, potentially losing their license, or even serving jail time, she added. Coders are put at risk of losing their credentials and may face monetary penalties and jail time.

Master Modifier 25

One of the most misunderstood modifiers is 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). Even when an encounter deserves modifier 25, the documentation may not be complete enough to back it up. Without the documentation, you can’t justify the modifier.

Let’s say a patient presents with a simple ear flush for cerumen removal. The patient has a recurring appointment for this procedure, and on this visit, the patient says their ears are clogged again; but, now they’re also red and there’s a fever.

“The cerumen removal is the procedure. Absent documentation to the contrary, there’s no E/M [evaluation and management] there,” said Jeffrey Lehrman, DPM, FASPS, MAPWCA, CPC, CPMA, principal, Lehrman Consulting LLC, Fort Collins, Colorado, during his HEALTHCON presentation, “What Exactly Is a Significant and Separately Identifiable E/M?”

The fact the patient’s complaining of a new development in the form of a possible infection offers the opportunity for something significant and separate from the procedure. Now, the practitioner can ask questions, interact with the patient about this new problem, diagnose a new problem, manage the condition with an anti-infectious agent, and discuss at-home prevention. However, without a paragraph in the notes describing the evaluation and management of the new problem, there’s no documentation that an E/M service occurred along with the cerumen removal. Without such documentation, it looks like the procedure was the only billable service provided, according to Lehrman. If you were to submit the E/M service with modifier 25 appended, but without that documentation, the payer would undoubtedly deny the claim if it subsequently reviewed the record. Make sure you have that written account of a separate and significant E/M service with the 25 modifier appended.

Learn to Code Laterality with Modifiers

For procedures where it’s relevant to show a payer which side of the body was affected, you might need to append the appropriate LT (Left side …), RT (Right side …) or 50 (Bilateral procedure) modifiers.

There are some instances where the diagnosis code has laterality built in. Let’s consider cerumen removal again. If cerumen is impacted, you must document that with diagnosis codes that specify laterality, such as H61.21 (Impacted cerumen, right ear), H61.22 (… left ear), or H61.23 (… bilateral). Use H61.20 (…unspecified ear) if the documentation does not specify the laterality.

However, you must then choose the CPT^® code that most closely describes the actual procedure your provider performed and that corresponds with the laterality specified in the ICD-10 code. CPT^® includes two codes for removal of impacted cerumen:

• 69209 (Removal impacted cerumen using irrigation/ lavage, unilateral)
• 69210 (Removal impacted cerumen requiring instrumentation, unilateral)

In both cases, CPT^® still instructs you to use modifier 50 for bilateral impacted cerumen removal. However, some payers may want you to report bilateral impacted cerumen removal on two lines with modifier 50 on the second line. Others may prefer two lines with the RT modifier on one line and the LT modifier on the other. So, you will have to check payer guidelines before submitting your claim for this service.

Properly Append Modifier 77

When you are submitting claims for multiple instances of services or procedures, your claims should include an appropriate modifier to indicate that the service or procedure is not a duplicate, said Arlene Dunphy, CPC, provider outreach and education consultants, with the Part B Medicare Administrative Contractor (MAC) National Government Services (NGS) in the recent webinar “How to Avoid Duplicate Claim Denials.”

One of the ways to do this is to append modifier 77 (Repeat procedure by another physician or other qualified health care professional). For example, consider the following primary care scenario:

A patient comes into a multi-specialty practice for an electrocardiogram (ECG). The patient sees a PCP first, who does an ECG as part of the work-up. The PCP determines the patient needs to see a cardiologist in the practice. The cardiologist sees the patient later the same day and repeats the ECG. CPT^® code 93000 (Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report) will apply to all services, but how you report that code will not be the same.

The first encounter, performed by Doctor One will not need a modifier. However, Doctor Two’s first ECG will need modifier 77 to document that the procedure was conducted by a different physician.

Know When to Append Modifier 91 for Repeat Tests

There are instances in primary care when a practitioner has to repeat the same clinical diagnostic lab test twice in the same day. Medical necessity can be shown to the payer by simply reporting the second test with modifier 91(Repeat clinical diagnostic laboratory test).

For example, a young patient with type 1 diabetes feels weak, so the provider administers a glucose test. The result showed the patient was hypoglycemic. The provider gave the patient a glucose gel and administered the test again 15 minutes later. This time, blood sugar levels were normal.

In this encounter, you’ll use 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 2.

Coding alert: Modifier 91 is only necessary when the results of both tests are needed. If the first test used an insufficient amount of blood, or the sample was contaminated, then do not bill as a repeat lab. You may want to consult the payer and the practice manager about policies on user error, but in situations where a second test is necessary because of a mistake made in preparing the first test, you should generally bill for only one test. Per CPT^®, this modifier may also not be used when tests are rerun to confirm initial results.