4 Modifier Mistakes That Will Cost You CMS Medicare Claims

Modifier mistakes leads to Claims denials. They slow your revenue cycle, take up valuable staff time, and put a dent in your bottom line. We get it—coding and billing is complicated enough without having to worry about Medicare modifiers. But incorrect use of CMS modifiers is one of the top reasons for claims denials. Not only that, but using CMS modifiers inappropriately can lead to claims audits and running afoul of federal fraud and abuse laws. Are you willing to take that compliance risk?

The good news is that once you learn best practices for CMS modifiers and common mistakes to avoid, you can dramatically reduce both your audit risk and your denial rate. Keep reading for the top four most common modifier mistakes, plus how to fix them.

 

  1. Not paying attention to payer rules.

All payers are different, and we’re not just talking about reimbursement rates. Medicare and commercial payers have different sets of rules for how to use modifiers, and you’d better know them. For example, use modifier 50 to indicate a bilateral service—procedures that are performed during the same operative session or same day on both sides of the body—when billing Medicare. However, other payers may require that you bill bilateral procedures using modifiers LT and RT instead.

  1. Using modifier 59 too often.

This is one of the most commonly used—and abused—CMS modifiers. As a result, it is continually under a high degree of auditor scrutiny. Use modifier 59 (distinct procedural service) to indicate a separate and distinct service from another non-E/M service with which it is typically bundled. Some providers use modifier 59 to routinely bypass NCCI edits, which results in overpayment and is also fraudulent. Before using modifier 59, be sure that all of the criteria are met and that no other, more specific modifier would more appropriately describe the situation.

  1. Confusing modifiers 26 and TC.

Modifier 26 indicates the professional component (physician’s interpretation or report) of a diagnostic, lab, or pathology service, while modifier TC represents the technical component. You’d use these modifiers only when billing the professional and technical components of a service separately. For example, a patient’s primary care provider takes a fundus photo to screen a patient for diabetic retinopathy. The PCP then forwards the photos to an ophthalmologist for interpretation. In this case the PCP would bill the service using modifier TC, and the ophthalmologist would bill the service using modifier 26.

  1. Applying modifier 51 to the wrong service.

First things first: you should never append modifier 51 (multiple surgeries/procedures performed on the same day, during the same surgical session) to an E/M service. If you do have a situation that warrants use of modifier 51, you must think carefully about which of the multiple procedures you’d append it to. Why? Medicare will reduce your reimbursement by 50 percent for all of the services listed after the primary service on the claim form. This means that to maximize your reimbursement, you should list the highest-paid procedure first, with the lower-paying service(s) after. Append modifier 51 to the lower-paying service.

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