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Billing with unnecessary modifiers

  1. Default Billing with unnecessary modifiers
    Medical Coding Books
    Can a provider be penalized for billing CPT code with an unnecessary modifier. Example would be a claim with 99397-25 only, no e/m on the claim, no e/m documented in the chart. I believe this is just incorrect coding and will most likely receive a denial. My concern is that if one is aware this is being done, there could be a penalty.

  2. #2
    I don't know if you will get penalized, that seems unlikely. What could very well happen is the carriers will reject these so it will slow up your reimbursement, which in the A/R world is not good.

    Laura, CPC, CEMC

  3. Default
    Hi Laura,

    Thanks for the reply. Do you know if it is only considered fraud when a claim is sent with incorrect coding which results in incorrect payment? Or, is it considered a violation only if payment is involved?


  4. #4
    I don't know about a penalty however, it can/will raise a red flag that his or her coding is not being done properly. Insurance carriers do flag certain coding patterns and that could lead to something more invasive.

    Overuse of certain modifiers such as 25 and 59 can be flagged by an insurance carrier and could trigger an audit.
    Jill Tom, COC, CPC, CPMA, CPC-I
    East Valley Kachina Coders
    East Valley Mesa, AZ AAPC Local Chapter
    President 2011
    President-Elect 2010
    New Member Development Officer 2009

  5. Default Louise Cardillo, R.N. B.S, CPC, LNCC
    Dear Coding members,

    If you are billing with inappropriate modifiers to avoid lower payment and the claims are paying you could be at least a witness or an accomplice to fraud. The definition of fraud is not whether you are paid or not, but the intent. If you determine a pattern of billing to gain financially then you or the provider intended to gain. Thus, that is fraud. I would suggest that if no documentation is present that you research the correct codes for the provider to utilize and educate them. do it with the fraud as part of the education. If they don't care, then find a new job. According to our office and the local law enforcement and federal agents the misuse of modifier 25 are the easiest cases to prosecute.

    Good luck,
    Louise Cardillo, R.N. B.S. CPC, LNCC
    Clinical Analyst/Fraud Investigator
    MVP Healthcare
    Rochester, NY

  6. #6
    Charleston, South Carolina
    Very nice reply Louise!
    Machelle Morningstar, CPC, COC, CEMC, COSC
    AHIMA Approved ICD-10-CM/PCS Trainer

  7. #7
    More than anything, I think billing in this incorrect manner will red flag your provider and could lead to an investigation of a plethra of other things. I am address the improper billing of modifier -25 in our practice now and I am doing it by means of education the physicians with the proper use of this code. I am using the CMS definition in my education material attached below.

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