Radiology Coding Alert

Few days pass when radiology coders who often code dozens of reports in an eight-hour workday aren't faced with the prospect of adding modifiers to the services their physicians provide. In some cases, the choice of modifiers is clear and the circumstances requiring them undeniable. At other times, the coding may be less than clear-cut.
 
"Modifiers have been implemented with a very clear purpose," says Carol Pohlig, BSN, RN, CPC, who works in the department of medicine at the Hospital of the University of Pennsylvania. "They identify circumstances or procedures that vary from the original code description. It alerts the payer that something unusual has taken place. Because modifiers address exceptions and not the rule, the potential misuse or abuse is significant."
 
To ensure no misuse or abuse takes place, Radiology Coders must understand the distinctions between modifiers, when they should be applied, and how best to submit modified codes for the highest ethical payment.
Two Facts Increase Payment Success
Professional coders who recognize two foundational truths about modifiers increase their reimbursement success, adds Michelle Juette, CPC, RCC, business services manager for Yakima Valley Radiology in Yakima, Wash. "Often, the policies affecting modifiers are carrier- and state-specific. Coders must recognize that not all insurers treat modifiers the same way. Medicare, for instance, recognizes most of the modifiers that appear in the CPT Manual . Other insurers have different approaches." Coding experts recommend that radiology practices work closely with payer representatives to understand how that particular insurer approaches modifiers.
 
Second, Pohlig adds, coders must submit the claims in the most effective manner. "A lot of coders don't realize that claims containing certain modifiers should drop to paper (e.g., -22, Unusual procedural service; -52, Reduced services; -53, Discontinued procedure). Typically, they are automatically denied, with a request for more information explaining the circumstances requiring the modifier. Rather than wait for the denial and the request for supporting documentation, practices are better off submitting the claim on paper with the progress notes or procedure report already attached."
 
If modified claims are denied after submission of the documentation, Pohlig advises, radiology coders should request peer review. "Make sure the claim is reviewed by a radiologist who is familiar with the study or procedure. They are the only ones who will completely understand the circumstances and the service, thereby increasing the likelihood of it getting paid."
Distinguishing Between Modifiers -51 and -59
Among the modifiers most often used by radiologists are -51 (Multiple procedures) and -59 (Distinct procedural service), which are also easy to confuse. Modifier -51 is used when multiple services are performed and [...]