October 2, 2014

Auditing Modifiers


It is not enough to merely audit the codes billed by the provider of healthcare services. You also must review the modifiers appended to the services to validate that they were used in an appropriate manner. The modifiers must be validated to verify that their use is corroborated within the medical documentation and medical necessity of the medical record.

Coders, billers, and auditors alike know or are familiar with the key modifiers that represent an increased risk for audit, and all have varying opinions on the use of the modifiers. Quite commonly we note that some billers may lack a clear understanding of the impact of the modifiers from a scrutinization level, but they do understand the impact of their use in an effort to get claims paid and to reduce practice accounts receivables, at times resulting in their appending the modifier in a more haphazard manner.

On the other end of the spectrum, coders quite commonly suggest that providers avoid the use of “triggering” modifiers in order to reduce scrutiny by an auditor, which may result in decreased reimbursement for circumstances that were justified. Lastly, we have the view of the auditor on the use of the modifier. Typically the auditor’s view on the use of modifiers is simply based on what the documentation actually supports – which at times may lead to an oversimplification of descriptions of services when the documentation does not completely convey the circumstances that support the modifier’s use. All of these opinions lead us to the notion that if the documentation supports the use of the modifier, then we should append and bill the modifier regardless of the possibility of doing so flagging an audit (besides, any carrier audit would find the billing was correct, in this case). And of course, the modifier must not be appended in an erroneous fashion.

The documentation within the medical record to support the use of each modifier should be obvious – neither inferred nor implied, but rather blatant and obvious. It is within the documentation that we will find whether each modifier is supported or it should be removed as a billing component on the claim for the service.

The modifiers that most often come to mind for causing the most claim scrutiny are 22, 24, 25, and 59. This does not mean that other modifiers may not be triggering elements, but we do note that to CERT and OIG, these modifiers are “hot” concerns. Learning and addressing the documentation that would best justify each of these modifiers will help create a more compliant billing structure.

Remember, the key to modifier usage is understanding that the modifier is identifying to the carrier a CPT-defined service or procedure that was somehow altered and no longer meets the description associated with the billing code. So by reviewing the documentaion, the record will be evaluated to identify what makes the service different from the CPT descriptor on the relevant date of service.

Modifier –22, Increased procedural service: This modifier indicates a service that, according to the CPT descriptor, represents additional work to the provider on the case being billed. Therefore, use of the modifier often leads to the record being scrutinized for documentation of the “extra” work or service involved with each particular case. Common examples of this include excess BMI of the patient or copious scar tissue that leads to extra work (all of which may absolutely be valid reasons to support the use of the modifier). However, does the documentation support this claim? It is not enough for the surgeon to indicate that the patient had a BMI of 62 or that the patient had copious scar tissue; the surgeon should also include within the documentation the impact that this caused on the work involved in the surgical encounter. This is what truly supports the medical necessity associated with the use of the modifier. For this reason, it is recommended that the physician consider dictating the specific extra work involved, and this is best accomplished by providing a separate paragraph within the OP report to address the issue. However, auditors also should note that they should not deny the use of the modifier simply because it was not documented in this way. Upon review of the record, the elements that represent extra work should be easy to identify not only by their specific nature, but also by the impact they had on the surgical encounter.

Modifier -24, Unrelated E&M service by the same physician or other qualified healthcare professional during a postoperative period: This particular modifier has reached such a level of scrutiny that many carriers will not reimburse claims using it until the record is submitted and reviewed for validation of use during the global encounter. When reviewing the documentation for claims billed with this modifier, the documentation should specifically identify the condition unrelated to the global services. In many instances, the best qualifier of the use of the -24 modifier is related to the medical necessity associated with a change in the diagnosis code. If the problem is significant and separately identifiable enough to require use of a new or different diagnosis code, then the initial consideration would be that the use of the modifier would be supported. However, this would not include diagnoses that are merely external factors associated with the post-operative care. Remember that CMS policy indicates that services related to the diagnosis and associated with the need for surgery are all-inclusive in the global package, with the exception of those that require a return trip to the OR (OR does not mean an in-office procedure room). Furthermore, it would be advised that the provider include within the documentation of such an encounter very distinct information that is separable from any post-operative evaluation. This does not mean that two separate documentations are required, but rather that there is a specific separation of documentation within the history, exam, and medical decision-making relating to the separate issues in the encounter.

Modifier -25, Significant, separately identifiable E&M service by the same physician or other qualified healthcare professional on the same day of the procedure or other service: The NCCI Policy Manual offers little wiggle room for providers when evaluating patients and providing acute-care services to patients during the same encounter. This modifier has always been intended to be used for a significant E&M service, but in the most recent editions of its manual, NCCI has restricted its use further by indicating that in the evaluation of patients for a procedure, regardless of their status with the practice (i.e., regardless of whether they are new or established patients), the medical evaluation needs to review the history and the severity of the patient clearly (according to the patient), examine the area of the complaint along with associated organ systems, and ensure that the use of the provider’s complex medical assessment skills is non-eligible to bill the E&M encounter with the procedure. NCCI contends that this is indicative of pre-operative services, even for those services that include only an associated 0-10 global days. This alone presents grounds for a full article to discuss the implications of this policy and its effect on not only physician practices, but also on the resulting patient care and associated inconvenience to the patient; however, this section is intended to discuss the documentation that should be expected to support the use of the -25 modifier. The documentation should demonstrate one of two forms of an encounter in order to support the use of the modifier. The first would be an encounter in which the patient is treated for multiple problems, only one of which resulted in the need for a procedure. The documentation would be expected to demonstrate that an appropriate history, exam, and assessment was performed on the separately identifiable circumstances. Although CMS/NCCI Policy specifically states that the use of the -25 modifier does not require that there be two diagnoses noted, the intent is associated with an antiquated policy that no longer exists. The second type of encounter for which documentation would appropriately support the use of the -25 modifier would be one in which not only an evaluation of the affected organ system for an “eval and treat” scenario was performed, but also where an additional other organ system had to be specifically addressed to evaluate its impact on the affected organ system. Within the NCCI Policy Manual, a specific example is used of a patient that reports for head trauma and requires laceration repair. The “trauma” of the head that requires the acute full attention and medical observation and evaluation of the provider is not enough to substantiate the need for the use of the modifier -25 in order to bill the E&M and the laceration care, but what could be the defining factor is if the provider also performed a complete neurological examination of the patient as well. Good medical care, one would assume, would require a neurological examination of a patient who presents for “head trauma.” However, unless documentation includes a reasonable separation in the medical necessity of the need of the additional evaluation, the encounter may not necessitate the need for the modifier.


Modifier -59, Distinct Procedure: This is a modifier that receives such a high level of scrutiny that CMS has announced “spinoff” modifiers associated with the -59 that will become effective in 2015. Again, referring to NCCI Policy Manual edits, they are specific enough to indicate that modifier -59 is the modifier of last resort, meaning that claims should be reviewed to see if any other possible modifier exists to support the claimed service prior to relying on its use. While the manual fails to provide us with a specific example to support the use of this modifier, it is very specific in indicating that “documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual.” Due to these very specific guidelines, it is strongly recommend that once again the provider include a statement within the OP report that helps identify this relationship and the support of the medical necessity to support the use of the -59 modifier. The documentation would be expected to identify specifically the absolution between the two procedures, which means that within the OP report we should be able to distinctly identify the different body parts associated or the separate sites of service/injury. The last thing a provider would want to happen when reviewing a medical record is for one to have to interpret the findings. Not only does CMS indicate that a provider’s documentation should always paint a portrait of the patient, but the provider’s documentation should have very clear detail to accurately convey the complexity and the appropriate medical necessity to not only support the actual service, but also the use of modifiers such as the -59. As the new modifiers are rolled out in 2015, it will become more evident through the proper appending of the subset modifiers to ensure that the documentation adequately supports the use of this modifier.

As previously stated, there are other modifiers in which overutilization could lead to a focus- driven review by a carrier audit; however, these modifiers are representative of a “most watched list” and should be carefully scrutinized prior to claim submission. There are useful resources available that include decision tress, examples, and rationale as to when the modifier usage is warranted.

The resources often can be found on the different MAC carrier websites. It is a recommendation that prior to the submission of any claims that include the use of these modifiers, the documentation should be carefully reviewed in order to ensure that upon request for documentation review, whether pre-bill or retro-review by audit circumstance, the record be found to be inclusive of the needed elements to support the service. 

About the Author

Shannon DeConda is the founder and president of the National Alliance of Medical Auditing Specialists (NAMAS) as well as the President of Coding & Billing Services and a Partner at DoctorsManagement, LLC. Ms. DeConda has more than 16 years of experience as a multi-specialty auditor and coder. She has helped coders, medical chart auditors, and medical practices optimize business processes and maximize reimbursement by identifying lost revenue. Since founding NAMAS in 2007, Ms. DeConda has developed the NAMAS CPMA® Certification Training, written the NAMAS CPMA® Study Guide, and launched a wide variety of educational products and web-based educational tools to help coders, auditors, and medical providers improve their efficiencies.

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