Appropriate Use of Modifiers and Other Coding Complexities

Transcription

1 Appropriate Use of Modifiers and Other Coding Complexities Shauna Vistad, MBA, CPC, CFE, CFI Manager Provider Audit and SIU Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross Blue Shield Association Noridian Mutual Insurance Company

2 Modifiers Current Procedural Terminology (CPT ) states that a Modifier is used to indicate that a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code. Modifiers help tell the story. 2

3 Reasons and Purpose Reasons for Use Professional and technical components More than one health care professional involved in care Service increased or reduced Bilateral procedure performed Unusual events occurred Purpose of the Modifier Provide additional information Clarify the service or procedure Enhance specificity Indicates a change to the procedure performed 3

4 Inappropriate Use of Modifiers Modifiers become a problem when They are used to by-pass system edits Are added to increase revenue not supported by the work completed by the provider Misrepresent the work completed 4

5 Modifier 25 Significant, Separately Identifiable Evaluation and Management Service by the same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service CPT The patient s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure performed. 5

6 Red Flags with Mod-25 Documentation must be very clear that services were required above and beyond The separate documentation must support the level of E/M billed OIG audit found 35% of audited claims did not meet requirements An E/M is inherent to all procedures, if all documentation supporting the initial procedure is removed does enough documentation remain to support a separate E/M? 6

7 Examples of Potential Misuse Billing with a preventative visit must be Significant and only the documentation above and beyond the normal preventative visit should be used to determine the E/M level Note BCBSND payment policy regarding this Billing with Chemotherapy Administration CPT Assistant states, The chemotherapy administration codes include confirmation or recalculation of doses based upon the condition of the patient on the day of chemotherapy administration. 7

8 More Examples of Misuse Initial evaluation for minor surgical procedures This is already included in the global package For major surgical procedures Follow up visits during the global period related to the procedure (Modifier 24) 8

9 Modifier 59 Distinct Procedural Service Used to indicate that a procedure or service was distinct from other non-e/m services performed on the same day Documentation must support: Different session, different procedure or surgery, separate incision/excision, different site or organ system, separate lesion, or separate injury 9

10 Modifiers 26 and TC Procedure should be billed either without either modifier or two claims billed one with each modifier. Do not bill One claim with modifier 26 and one without a modifier One claim with modifier TC and one without a modifier 10

11 Modifier 50 Bilateral Procedure Health Care News (HCN) 343 June 2012 Bilateral surgical procedures performed by a physician or allied provider must be billed on a single line with modifier 50. The procedures should not be billed: On separate lines With more than 1 unit 11

12 Other Coding Complexities Cloned Medical Record Documentation Policy HCN July 2015 Documentation identified as cloned, copied and pasted, pulled forward, or inserted via template without identifiable and appropriate updates specific to the current visit will not be considered for the purposes of determining services provided for that visit. 12

13 Only 1 Unit Debridement of nail(s) by any method(s); 1 to or more Destruction premalignant lesions, first lesion Add on code of should be used for 2 14 and is appropriate to bill with more than 1 unit Destruction premalignant lesions, 15 or more lesions Not billed with or

14 Only 1 unit Destruction of benign lesions other than skin tags or cutaneous vascular proliferative lesions; up to 14 lesions or more lesions 14

15 Only 1 unit 20670/20680 Removal of implant; superficial/deep Per CPT Assistant - describes a unit of service that is reported only once provided the original injury is located on one site, regardless of the number of screws, plates, rods or incisions. 15

16 Repairs ( ) Sum the lengths of repairs for each group of anatomic sites based on classification of Simple, Intermediate, and Complex When more than one classification is used, the more complicated is the primary procedure and the secondary is billed with Modifier 59 Documentation must support the level of classification 16

17 Time The following are standard rules unless a specific section of the CPT manual provides information to the contrary: Time is the face-to-face time with the patient A unit of time is attained when the mid-point is passed When billing a time-based service with an E/M, time associated with the concurrent service should not be included in the time reporting the time-based service 17

18 Time Challenges Psychotherapy billed with E/M Time spent on Psychotherapy must be distinguishable in the documentation Physical Medicine codes Providers should not bill for services if less than a total of eight minutes is spent with the patient. One Unit 8-22 minutes Two Units minutes Three Units

19 Questions? Thank you for your time and attention! Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross Blue Shield Association Noridian Mutual Insurance Company