Wiki Can a modifier be added at the request of the insurer even if CMS/AMA guidelines don't require one?

[mcochran]

We have some CPTs that have been denied by an insurance company for "missing modifier". CPT 99291 was paid then the payment was recouped as "within global period". After our appeal, we received a letter that stated "the claim submitted did not have a modifier appended to the E/M service". After review by our coding department it was decided that the claim was billed correctly. Does an insurance company have the "right" to request a modifier and would the law be broken if a modifier was "added" to the claim per the insurer's request?

Also, we have CPTs that are denied as "mutually exclusive or incidental procedure" when it not listed as "mutually exclusive" per CMS NCCI. When we appeal these claims with the CMS NCCI info, we are told that we are "missing a modifier" that would unbundle the claim. We are told that the insurer has their own internal auditing system that requires a modifier. Again, after review by our coding department it was decided that the claim was billed correctly. Does an insurance company have the "right" due to their own internal auditing system to request a modifier and would the law be broken if a modifier was "added" to the claim per the insurer's request?

Thank you for your help with this matter!

 

[csperoni]

While many commercial insurance companies choose to follow CMS guidelines, they are permitted to create their own internal policies that replace or add to CMS guidelines. Most carriers will post them on their website. It is not illegal for carriers to have these policies, but it certainly does create a hassle for medical offices. You certainly are permitted to add modifiers if required by the carrier, provided the records would support that modifier.
Real life example, United Healthcare bundles a visit & sonogram billed the same day. Provided the note supports a visit and the test, you may bill E/M -25 and SONO -59, even though it's not a CCI edit. Obviously, if the note only said "Pt here for sonogram, which revealed thickened uterine lining of 22mm.", you should never have billed E/M in the first place.
Most electronic billing systems will allow you to create rules for specific carriers to help you moving forward before sending the claim out. When we were on our own billing system, I probably had set up 20-25 rules for various carriers for common issues we would get denials on.

 

[mcochran]

While many commercial insurance companies choose to follow CMS guidelines, they are permitted to create their own internal policies that replace or add to CMS guidelines. Most carriers will post them on their website. It is not illegal for carriers to have these policies, but it certainly does create a hassle for medical offices. You certainly are permitted to add modifiers if required by the carrier, provided the records would support that modifier.
Real life example, United Healthcare bundles a visit & sonogram billed the same day. Provided the note supports a visit and the test, you may bill E/M -25 and SONO -59, even though it's not a CCI edit. Obviously, if the note only said "Pt here for sonogram, which revealed thickened uterine lining of 22mm.", you should never have billed E/M in the first place.
Most electronic billing systems will allow you to create rules for specific carriers to help you moving forward before sending the claim out. When we were on our own billing system, I probably had set up 20-25 rules for various carriers for common issues we would get denials on.

Thank you so much for that insight. We always want to do the right and legal thing but don't want to write off claims that could be paid. Thanks again!