Find out when you’re most likely to use modifier 25 for PV procedures
The OIG is taking aim at your modifier 59 and 25 claims. Here’s how to stay out of the bull’s-eye.
Warning: The Office of Inspector General found a 40 percent error rate for modifier 59 and a 35 percent error rate for modifier 25. Therefore, the OIG is encouraging Part B carriers and Recovery Audit Contractors to monitor claims with these modifiers, which means you can expect to see an increase in both prepayment and postpayment audits for both modifiers.
Protect Your Practice and Toe the Modifier 59 Line
Keep yourself out of trouble by watching your claims for these red flags related to modifier 59 (Distinct procedural service).
1. Confirm that the procedures you claim are distinct and weren’t performed at the same session, the same anatomic site, and/or through the same incision.
Example: NCCI bundles 37215 (Transcatheter placement of intravascular stent[s], cervical carotid artery, percutaneous; with distal embolic protection) into 36216 (Selective catheter placement, arterial system; initial second-order thoracic or brachiocephalic branch, within a vascular family). You should only unbundle the two by reporting 37215 and 36216-59 if the second-order catheter placement is on the opposite side of the neck …quot; not in the carotid on the side where the stent was placed, says Jackie Miller, RHIA, CPC, senior consultant for Coding Strategies Inc. in Powder Springs, Ga.
2. Be sure your documentation supports both services.
3. Append modifier 59 to the second code, rather than the primary service code or both codes. In the example above, you should apply modifier 59 to 36216 to separate the NCCI edit. Code 36216 is the secondary code.
4. Be certain you’re reporting the correct code. This may sound obvious, but 7 percent of the incorrect modifier 59 claims the OIG audited used the wrong code.
Resource: CMS posted an article on modifier 59 on its Web site. Check it out under “Downloads” at www.cms.hhs.gov/NationalCorrectCodInitEd/01overview.asp.
Fix Modifier 25 Problems Before They Occur
The OIG pointed out three main problems with claims involving modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). Here’s how to avoid them.
1. Be certain your claim includes E/M services that are significant and separately identifiable. The E/M should be above and beyond the usual preoperative and postoperative care associated with the procedure.
2. Focus on compiling complete documentation of both the procedure and the separate E/M.
3. Don’t append modifier 25 if an E/M is the only service your physician provides the patient that day.
When you’re applying modifier 25, you should remember the maxim “If you don’t have a HEM, you can’t bill an E/M,” [...]