If you run a healthcare organization from a small physician’s office to a large hospital, your billing department uses codes to document procedures, medication and techniques used to treat clients. Entering the wrong code can result in improper billing and claims denials. Even if you get it right, the codes themselves often don’t accurately reflect the level of care provided.

Medical codes transform services, procedures and equipment into a universally understood language. However, your billing clerk may need to include more information to ensure that your organization receives the proper compensation. In addition, modifiers help clarify the services provided to insurance companies and billing personnel.

A medical modifier consists of two numbers or letters added to CPT or HCPCS Level II codes. Modifiers provide essential information about the service or procedure without impacting the main code. This blog provides guidance on using modifiers 59, 25 and 91.

When Should You Use Modifiers?

Tack on a modifier to the appropriate CPT code when you need a better description of services provided to clients. It’s important to avoid adding modifiers merely to increase reimbursement. You also cannot use modifiers to bill for procedures bundled with other services.

Working with modifiers requires care and due diligence. The descriptions aren’t always as clear as you might hope. Also, using the wrong modifier can result in suspicion or claim denials on the part of an insurer.

However, modifiers are critical to proper billing for your organization’s products and services. They further clarify a CPT code to document important information. These supplemental descriptions paint a more detailed story regarding services. In this blog, we’re concentrating on three of the most commonly miscoded ones.

CPT modifier 59: Distinct Procedural Service

Medical practitioners use modifier 59 to distinguish distinct procedural services. This commonly misused modifier indicates multiple procedures on different parts of the body during a single visit. Unfortunately, coders often use it to separate services bundled in another code. When used to prevent bundling and increase the total bill, adding modifier 59 becomes part of fraudulent billing practices.

Coders should also avoid using modifier 59 to bypass controls on the insurer’s claims processing system. Therefore, it’s important to use 59 only when there’s no more appropriate code to describe multiple procedures.

Example:

1. A dermatologist performs a Photo Dynamic Therapy session on a patient’s scalp and face.
2. Then, the machine is used to treat other parts of the body.
3. The coder enters 9656796567 – 59 into the claim system.
4. Modifier 59 indicates the second procedure, which required new positioning on a unique body region.

This is a valid use of modifier 59.

Modifier 25: separately Identifiable Evaluation and Management

Modifier 25 is a separately identifiable evaluation. Further, it’s performed by the same doctor or caregiver on the same day. Therefore, medical professionals can use modifier 25 to amend applicable CPT codes when the patient’s condition requires multiple evaluation and management (E/M) services.

Avoid using modifier 25 in the following circumstances:

Avoid using the 25 modifier to bill for postoperative E/M related to a prior surgery.

• Don’t add modifier 25 for an E/M service not followed by a procedure.
• Instruct coders not to append 25 for minimal same-day procedures unless you can show the service was “significant, separately identifiable.”

Example:

1. A patient attends a cardiac appointment complaining of chest pain while exercising. The patient is hypertensive and has high cholesterol. The cardiologist orders a stress test on the same day.
2. The billing clerk enters an E/M visit (99214) and a cardiovascular stress test (93015).
3. Usingmodifier 25 with the E/M code accounts for the significantly separate procedures.

Modifier 91

Use modifier 91 to indicate a test performed multiple times on the same day. If you use the tests for separate specimens for unique results, apply modifier 91 to clarify the billing.

When to avoid using modifier 91:

• Don’t append 91 if re-running lab tests to confirm previous results.
• Avoid modifier 91 if retesting due to problems with the equipment or specimen.
• Don’t use the 91 modifier when another code includes a test series or for procedures that require a one-time result.

Example:

1. A high blood pressure patient takes a plasma renin activity test (84244 Renin) while lying down.
2. The doctor performs the same test in multiple positions to determine whether the position contributes to hyperaldosteronism or other conditions.
3. Repeat renin tests are scheduled for the afternoon, but the patient is standing up this time.
4. The 91 modifier can be added to the second renin (84244) procedure.
5. This results in two sets of lab tests for the same day on the same patient.

Understanding how to use modifiers correctly can help ensure that your claims are processed smoothly and without incident. Refer to the CPT code book for information on other modifiers.

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But, what is modifier 22? It is described in the CPT guidelines as a benchmark that classifies increased procedural service. The CPT code book’s Appendix A explains that a modifier comes to play when the work needed for a particular procedure goes beyond what is typically required.

Using it correctly helps in reimbursing a physician and ensures this group of professionals is compensated for any additional time they are involved in tackling unseen difficulties and other unanticipated complications.

But it is imperative to note, proper reimbursement goes beyond just integrating a modifier to a service code. According to professional coders, there are many other factors and requirements that come into play.

In this regard, this guide seeks to explore how procedural coding works and when to use modifier 22.

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What is a Medical Coding Modifier?

A medical coding modifier is two-character letters or numbers appended to a CPT^® or HCPCS Level II code. Modifiers indicate additional information about the procedure, service, or supply altered by some specific circumstance without a change in its definition or code. They won’t add information or change the outline of service to improve accuracy or specificity.

There are instances when coding and modifier information issued by the CMS differs from the AMA concerning the utilization of modifiers. A clear understanding of Medicare’s guidelines and regulations is vital to assign the suitable modifier(s).

There are numerous instances when a modifier use may be the most appropriate, for example:

• A service or procedure has both professional and technical components.
• More than one location is involved.
• A service or procedure is increased or reduced in comparison to what the code typically requires.
• More than one provider performs the service or procedure.
• The procedure is bilateral.
• The service or procedure is provided to the patient greater than once.

Let us go through some of the most used modifiers in the medical coding & billing industry!

Modifier 59 – Facts to Learn

At times, it is imperative to point out that a procedure or service was distinct or independent from other non-evaluation and management (E/M) service(s) performed on the same day. Modifier 59 indicated usage is for procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances.

It is the most pronounced modifier that affects National Correct Coding Initiative (NCCI) processing

The Medicare NCCI includes edits describe when two Healthcare Common Procedure Coding System (HCPCS) / Current Procedural Terminology (CPT) codes should not be reported together.

A Correct Coding Modifier Indicator (CCMI) of “0” designates the codes should never be reported together by the same provider for the same beneficiary on the same date of service. If these are reported on the same date of service, the column one code is eligible for payment and the column two code is denied.

A CCMI of “1” signifies the codes may be reported together only in defined circumstances, which are identified on the claim using specific NCCI associated modifiers.

CCMI of “9” NCCI editing does not apply.

This modifier may be stated to emphasize that a procedure or service was distinct or independent from other services performed on the same day.

One of the common misuses of this modifier is related to the piece of the definition that allows its use to describe a “different procedure or surgery.”

The code descriptors of the two codes of a code pair edit usually signify different procedures, even though there may be an overlap. The edit indicates that the two procedures should not be collectively reported if performed at the same anatomic site and same patient encounter as those procedures would not be “separate and distinct.”

Modifier is most frequently used are for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures performed at different anatomic sites not ordinarily performed or encountered on the same day and cannot be described by one of the more specific anatomic modifiers.

Appropriate Use Cases of Modifier 59:

• A different encounter.
• Different procedure or surgery.
• Different anatomical site or organ system: If two procedures are performed at separate anatomical sites or at separate patient encounters on the same date of service separate incision or excision
• Separate lesion or separate injury (or area in injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual
• Used for two services described by timed codes provided during the same encounter only when they are performed sequentially.
• A diagnostic procedure which precedes a therapeutic procedure only when the diagnostic procedure is the basis for performing the therapeutic procedure.
• No other appropriate modifier is available. Evaluate other modifiers such as the RT/LT identifying right and left, F1 – F0 to identify fingers, T1-T0 to identify toes, and E1-E4 to identify eyelids
• Evaluate additional modifiers to determine appropriate usage

The CMS established 4 new HCPCS modifiers to provide greater specificity in situations where modifier 59 was previously reported.

• XE – “Separate encounter, a service that is distinct because it occurred during a separate encounter;” use this modifier only to describe separate encounters on the same date of service
• XS – “Separate Structure, a service that is distinct because it was performed on a separate organ/structure”
• XP – “Separate Practitioner, a service that is distinct because it was performed by a different practitioner”
• XU – “Unusual Non-Overlapping Service, the use of a service that is distinct because it does not overlap usual components of the main service”

Inappropriate Use Cases of Modifier 59:

• When appended with an E/M  If submitted on E/M codes 99201-99499, E/M codes are processed as though a modifier were not present (i.e., the code pair will be subject to NCCI editing and has an indicator that does not allow bypass)
• To report a separate and distinct E/M service with a non-E/M service performed on the same date
• When other valid modifiers exist to identify the services, like RT, LT, E1-E4, TA, etc.
• When clinical documentation does not support the separate and distinct status
• When used to indicate multiple administration of injections of the same drug
• When the NCCI tables lists the procedure, code pair with a modifier indicator of “0”

Important Tips for Coder and Biller

• Bill all services performed on one day on the same claim
• Report each service on a different line
• Apply 59 to the subsequent procedures (if applicable)
• More than one line with modifier 59 appended to the same procedure code requires submission of supporting information/documentation on the claim
• Use modifier 59 to identify procedures or services not normally reported together, but is appropriate under certain clinical circumstances
• Claims reporting modifier 59 on multiple lines for the same procedure code without a narrative or documentation to support the additional lines will receive rejection code 969/standard code 16 (Claim/service lacks information or has submission/billing error(s), needed for adjudication)

The key is that a provider’s clinical documentation must support the use of modifier 59 (or any other modifier).

Use Case 1:

Column 1 Code / Column 2 Code – 17000/11100

CPT Code 17000 – Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); first lesion

CPT Code 11100 – Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed.

Single lesion Modifier 59 may be reported with code 11100 if the procedures are performed at different anatomic sites on the same side of the body and a specific anatomic modifier is not applicable. If the procedures are performed on different sides of the body, modifiers RT and LT or another pair of anatomic modifiers should be used, not modifier 59.

Use Case 2:

Column 1 Code / Column 2 Code – 29827/29820

CPT Code 29827 – Arthroscopy, shoulder, surgical; with rotator cuff repair

CPT Code 29820 – Arthroscopy, shoulder, surgical; synovectomy.

Partial CPT code 29820 should not be reported and modifier 59 should not be used if both procedures are performed on the same shoulder during the same operative session because the shoulder joint is a single anatomic structure. If the procedures are performed on different shoulders, modifiers RT and LT should be used, NOT modifier 59.

Reference:

https://www.novitas-solutions.com/webcenter/portal/MedicareJH/pagebyid?contentId=00144545

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Did you know that scheduling and registration errors account for nearly 50% of denied claims? The promising yet also frustrating news is almost 100% of these denials are preventative. In today’s post, we’re going to discuss common reasons why this happens and how you can address the root cause. We’ll also guide you on exactly what information your front desk team needs to be collecting for every visit, regardless of whether it’s a new patient or an existing patient.

The first question you’re probably asking is, why is your front desk team missing these errors? Your initial response may be to reprimand the team for making mistakes. The reality is that we’re all human and make mistakes. However, it’s not as simple as telling your front desk staff to do better and stop making mistakes. Aside from human error, there are several other reasons why front desk denials occur.

Reducing denials is all about being able to identify the trends. How often is someone from your practice reviewing the denial codes and reasons to determine your top denial reasons? If your practice is not doing it currently, the time to start is now or if you’re doing it infrequently, start making it a monthly exercise. The answer to why front-end denials are happening lies in the data. Once you’ve identified the trends, it’s time to figure out the why. Here are three common factors that could answer why your practice is seeing such a high percentage of front-end denials.

Training

Are you confident in your staff’s training? Front desk teams that are improperly trained will, without a doubt, make mistakes. Front desk staff needs to be trained not only on patient interaction and managing the schedule, but they also need an in-depth understanding of insurance and the claims process if they’re expected to collect patient information. Training is also not a one-and-done exercise. If there’s one thing you can count on in healthcare, it’s change, and your practice needs to ensure training on changes is happening. Regular training sessions are imperative to reducing front-end denials. Even if nothing’s changed, reviewing what’s required during scheduling and registration will go a long way.

Lack of Bandwidth

Are the mistakes being caused by the fact that your front desk and scheduling staff are too busy to make sure they’re collecting and verifying patient information? Given your patient volume, is it unrealistic to expect them to collect and verify every patient’s information in addition to their other responsibilities? Keep in mind your front desk staff is also the face of your practice. If patients observe staff running all over the place and so busy they’re unapproachable; your patient satisfaction rate will suffer.

Process

Are you using technology and operational processes that give your front desk staff the best chance to succeed? EMR and practice management software should support the scheduling and registration process. If your team finds it difficult to navigate or time-consuming, it’s time to look at what changes can be made to the current system or evaluate another system that would better support your practice. It’s also good to assess your internal billing operations process from beginning to end to ensure you’ve got the right people in the right position and processes that drive efficiency.

As you’re identifying the cause, here’s a reminder on what patient information must be collected at every patient visit.

• Verify patient demographics
  • Name
  • Birth Date
  • Address
  • Phone Number
  • Any changes since their last visit

• Patient insurance information
  • Any changes in insurance coverage
  • Collect or confirm insurance provider
  • Ask about secondary insurance
  • Collect or confirm the patient’s identification number
  • Collect or confirm the patient’s group id

• Insurance verification
  • Make a copy of the patient’s insurance card
  • Call or visit the payor’s website to confirm the patient’s coverage
  • Confirm patient’s insurance plan details
    • Amount the patient’s deductible
    • Required pre-authorizations
    • Included coverage
    • EDI payor ID
    • Referral requirements
    • Medical necessity LCM and NCD requirements

We understand how frustrating denials can be for practices and the impact they have on your revenue. Hopefully, we’re encouraged you to the first step into addressing your front-end denials by finding the root cause. If you’re still frustrated and are ready to call in an expert, OmniMD is here to help! Click here to schedule a call.

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2020 has been a trying year and health systems have been severely impacted by COVID-19. 

The Center for Connected Medicine completed a survey of over one hundred executives from 112 U.S. health systems to find what the top priorities for Health Information Technology are in 2021. 

Telehealth, Artificial Intelligence, and Revenue Cycle Management are the main topics healthcare organizations will focus on in the New Year.  

Telehealth 

Before 2020, telehealth as an option for care was continually improving but still saw slow adoption rates. When COVID-19 hit, telehealth saw an explosion in growth.  

Reimbursement rates have always been a contributing factor in healthcare systems being slow to embrace telehealth. The pandemic changed all of that, at least temporarily. 

Moving into 2021, COVID-19 has accelerated the use of telehealth resources and many health systems plan to continue utilizing and expand telehealth use. Because it was implemented so quickly that the coming year will focus on improving implementation, and integration and security measures to ensure telehealth is a safe and viable option. 

Many healthcare organizations are concerned telehealth visits will decrease once in-person appointments resume. Additionally, there is concern around reimbursement levels once the pandemic calms down.

It is very likely the telehealth’s growth will continue even after the pandemic is over. Roughly 71% of patients in the United States utilized telemedicine at the beginning of the pandemic, and 50% had already considered virtual appointments. With telehealth already rising in popularity in 2020, the pandemic boosted the industry’s development. This telehealth boom seems likely to break $185.6 billion by 2026.

The success of telehealth will be utmost dependent on adoption by patients. Since most patients are comfortable with telehealth solutions, it is clear that the industry has a strong future and it is the best time to integrate Electronic Health Records (EHR) with telemedicine apps.

Artificial Intelligence

Pre-pandemic, many health systems used Artificial Intelligence (AI) for clinical decision support (CDS), dictation, and transcription and diagnostic medical imaging. 

Moving forward, predictive analytics will continue to grow. By utilizing and improving AI, health conditions like lung cancer may be detected earlier using image-recognition technology. At present, AI is used in limited cases and not at a system-wide level. Artificial Intelligence can profoundly improve the precision, speed, and efficiency of diagnoses.

MIT and Harvard University research team has utilized machine learning to track trends in mental health in correlation to the COVID-19 pandemic. A UCLA project has combined chatbot technology with AI systems to create a Virtual Interventional Radiologist (VIR).

Regulations will play a large part in how AI develops as we move into 2021. There are several areas of concern. The first is the data that is allowed to be placed in AI solutions. Many organizations are fine with current regulations, but there is concern that stricter privacy policies may inhibit further AI capabilities. On the other hand, there is apprehension that data currently kept by vendors and third parties is not secure as well as developing shared public datasets and environment for AI training & testing. Needless to say, it will also be essential to evaluate and establish AI technologies using standards and benchmarks and expand public-private partnerships to accelerate advances in AI.  

Revenue Cycle Management 

Even pre-COVID-19, Revenue Cycle Management (RCM) has needed vast innovation and disruption.  

Many see RCM as overly technical and complex, despite the healthcare technology available. Organizations pointed out fragmented technology and the lack of an all-in-one solution as major issues with RCM. COVID-19 has highlighted a lack of coherency in RCM and shows that major improvement is needed.  

The lack of unity between the government, payers, and providers is another factor stunting RCM growth. Based on what has happened in 2020, many feel the healthcare industry will have to innovate out of necessity. These changes will likely come from improved relationships, regulatory changes from the federal government, and system-wide health care billing improvements.    

The next level of healthcare revenue cycle management (RCM) is seen in hands-free automation of several billing activities, eliminating routine and time-consuming manual work daily, weekly, or monthly. The end goal of technologists in the RCM industry will be to provide flexible setup, easy-to-use navigation, detailed logging of each activity and action, automate medical billing and revenue cycle management processes so minimal-to-no human intervention is needed for 70-80% of the revenue cycle.

Furthermore, the importance of predictive analytics, AI, bots, and automation has already been highlighted for RCM efficiency as well as proactive focus on the front-end processes rather than back-end problems.

Some feel RCM improvements will occur slowly, while others are optimistic improvements will be made in 2021. 

As we move into a new year, healthcare will continue to be impacted by the pandemic. The focus will remain on getting through the pandemic, many are optimistic that several improvements will be made due to the ever-changing healthcare landscape caused by COVID-19. 

Source: https://healthmanagement.org/c/it/news/hit-in-2021-most-important-aspects

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Providing the highest level of care for your patients is your number one goal. However, if you don’t show the same amount of consideration for financial health, you can quickly find yourself out of business. That’s a lesson that has been of particular importance in light of the crushing effects the COVID-19 pandemic has had on private practices. In fact, by August 2020 alone, just five short months into lockdowns, a survey conducted on behalf of ‘The Physicians Foundation’ found that 8% or 16,000 private practices had closed their doors due to the virus’ financial impact.

The good news is that even during rocky financial times, there are ways to protect your practice’s health, visualize trends that tell you how well your practice meets your business goals, and even discover revenue-generating opportunities.

It all begins with business analytics.

Keeping track of the Key Performance Indicators (KPIs) that matter the most for your independent practice allows you to accurately report, benchmark, and analyze outcomes and performance for value-based care. By measuring your success, you’re able to make the strategic decisions necessary to improve performance, grow your practice, and maximize your revenue.

The Most Valuable KPIs for Independent Medical Practices

To combine clinical, operational, and statistical data/trending to get the best picture of your practice’s financial health, a handful of the KPIs you should be tracking right now include:

1. Accounts Receivable

The money owed to your practice by either patients or payers has a time value that can’t be discounted. The longer this money sits uncollected, the longer you’re unable to use it to pay your staff, your rent, and yourself and may lose it partially or entirely as bad debt.

Tracking your accounts receivable allows you to determine which payers maintain the top balances and the average number of outstanding days per payer, as well as the typical insurance and patient aging.

2. Appointments and No-Shows

Patient appointment volume and mix make up the bread and butter of your practice. Therefore, tracking the number of new patients you receive per month and the sources that typically result in referrals can allow you to make future revenue projections and focus on cultivating an increasing number of referrals.

Additionally, it’s vital to realize that just as appointments are what your practice requires to thrive, with no-show rates as high as 30% across the nation and costing your practice an average of $200 each, missed appointments can result in serious financial risk and leave you struggling.

3. Charges

One of the easiest ways to ensure that your practice gets paid every dollar you have coming to is to regularly track your charges to identify ones that haven’t been billed. This allows you to recognize revenue that would have otherwise slipped through the cracks so that it can be recovered and continue to fund your operating needs.

Tracking charges also helps you determine which providers in your office generate the most revenue, which services offer the highest return per visit and more, so that you can focus more on your practice areas with the best ROI.

4. Net Collections

Unlike your charges, your net collections exclude the write-offs. This number gives you a picture of exactly how much you receive out of the total billed, and the higher the better. It can also help you determine the effectiveness of your practice’s current claims follow-up procedures so that they can be adjusted accordingly.

Ideally, your net collections should fall between 96 and 98% to remain financially viable.

5. Claims Follow-up

While your comparison of net collections to charges billed can begin to paint the picture of your claims follow-up, you’ll also want to track denial reports, denial rates and type by the payer and CPT codes and rejection reports.

This information tells you what isn’t being paid so that you can help prevent future denials. The average cost to work on denial is $25.

6. Staff overtime

Overtime pay can be a massive burden on your office. And the extra hours themselves can be hard on your staff and even compromise patient care. By monitoring this metric, you’re able to schedule more efficiently to reduce over time, for healthier finances, happier employees, and improved patient safety.

Drilling down to get the most from your data

It’s also critical to leverage a solution that provides a dashboard with drill-down capability for more useful and more robust reports. Drill-down capability ensures that you’re able to view the data from your practice in a detailed and thorough fashion to achieve a granular view.

Reports should be run daily, weekly, and monthly.

Examples of Daily Metrics to track are:

• Charges
• Payments and adjustments
• Balance
• Appointments and no-shows

Weekly tracking should include:

• Underpayments
• Backlogs on collections
• Backlogs of payment postings

Additional Monthly KPIs to review are:

• Accounts receivable
• Net collections with denials and claims follow-ups
• Production per provider
• Overtime
• Payment aging

Controlling your practice’s financial health with KPI dashboards

The medical landscape was already challenging for many medical practices – a situation that was only worsened by the COVID-19 pandemic. Now more than ever, it’s critical to monitor your practice’s financial health so that you can adjust quickly and continue to thrive.

Key Performance Indicators (KPIs) and KPI dashboards with drill-down capability allow you to assess your revenue cycle’s strengths and weaknesses accurately so that you can save time crunching numbers and prioritize your team’s activity and optimize your income. Remember, better financial performance begins with taking control of your data.

16,000 Physician Practices Have Closed Due to the Effects of COVID-19 – South Dakota Association of Healthcare Organizations

COVID-19’s Crushing Effects on Medical Practices, Some of Which Might Not Survive – JAMA

Missed appointments cost the U.S. healthcare system $150B each year – Health Management Technology

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