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How do Modifiers Enhance Medical Coding?

What are Modifiers?

Modifiers are very powerful coding tools for reimbursement. With the addition of these two digits, procedure codes are further defined for a variety of reasons. All modifiers are informational by nature but the ones most commonly utilized are what we define as payment modifiers. This means that the payment of the procedure(s) is directly impacted by the modifiers applied.

Modifier 25

Modifier 25 - Significant and Separately Identifiable Evaluation and Management (E/M) Services.

The most billed category of procedure codes is Evaluation and Management (E/M), so it stands to reason that modifier 25, which can only be appended to E/M codes, is a very commonly utilized payment modifier. The purpose of modifier 25 is to ensure providers are reimbursed for an E/M service in addition to another procedure they perform on the same date. Without the addition of modifier 25, typically only the procedure will be reimbursed. This is called bundling since all procedure codes inherently include some level of E/M. When appending modifier 25, providers are unbundling services. Inappropriate unbundling is a major issue in healthcare coding and billing which has created a lot of payer scrutiny in regards to modifier 25 usages.

How to Properly Document Modifiers

Documentation must support the use of any and all codes, including modifiers. Too often modifiers are applied based on billing edits without checking documentation to ensure it is appropriate to append any modifier(s). While use of modifier 25 isn’t as clear cut as modifiers such as RT (right) or LT (left), indicating a specific side of the body, there are basic guidelines which must be adhered to. Here are a few rules of thumb to help properly apply those guidelines:

Basic guidelines

  • Significant and separately identifiable E/M
  • Above and beyond normal pre- and post- operative work of the procedure being performed
  • Medically necessary

Rules of thumb

  • If the procedure was ordered at prior visit and only the procedure is being performed at the current visit
  • If all the documentation related to performing the procedure was removed from the clinical note, would there still be enough to support an E/M

While a different diagnosis is not required to bill for both an E/M and a procedure on the same date of service by the same provider for Medicare, some commercial carriers have different requirements. It is the responsibility of the provider to follow the appropriate rules for the appropriate carriers and services. Be sure and follow the published guidelines for all services in order to remain compliant and correct.

How can modifiers impact your revenue cycle?

How can The Rybar Group help your hospital?

Whether you are interested in a quick probe review or a highly detailed audit including one-on-one provider education with an auditor, we are here to meet your needs as they arise. For more information on how The Rybar Group can assist you, please contact us.

Julie Hardy, MSA, RHIA, CCS, CCS-P

Director, Revenue Cycle