A Few ‘Tricks’ of the Trade
by Cheryl Nash
Over the years we have looked at many different practices billing and there are some very common errors we see repeated across the nation. I have tried to detail them out for you below.
1. Modifier 25: This is probably the most common error in billing today. Modifier 25 is used to separate an office visit from another service performed on the same day. Great you say, I will make sure to mark that all the time. However, that would be in error. There are some very specific rules to billing a 25 correctly and to keep you from being flagged for an audit.
The definition of modifier 25 is 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. There are multiple resources available to see specific examples for proper use of this modifier, and I have clipped a couple here.
http://www.wpsmedicare.com/j5macpartb/resources/modifiers/modifier-25.shtml; http://www.palmettogba.com/palmetto/webTool.nsf/vTool/mod25.
Another mistake I see is the modifier placed on the wrong CPT code. This modifier is to be placed on an E&M code only, such as 99211-99215. It is never to be placed on a procedural code such as 93970 or 36471. Understanding the use of this modifier will increase reimbursement, and understanding when it is not appropriate will protect the provider from being flagged for, and possibly failing, an audit.
2. Bilateral Services and modifier 50 (or modifiers RT and LT): The biggest question is which to use? Well, there are never easy answers in this business, and this one depends on the payer. Medicare has bilateral indicators for all codes and each defines how that procedure is to be billed. However not all payers follow Medicare’s guidelines, so this is only part of the puzzle. Knowing your payer’s requirements takes time and occasionally sending out a few ‘test claims’ will provide the basis for this knowledge. Do be sure to check that there isn’t already a code for a bilateral service that should be used instead and that the service is allowed more than one time per day.
For instance, Ultrasonic guidance (CPT 76942); Medicare only allows this code to be billed one time per day, regardless of the number of sites accessed. Any commercial payer that follows CMS guidelines will follow suit. Payers that do not follow CMS may pay for the service as a bilateral billed typically with a RT and LT respectively. Don’t be afraid to experiment with a couple claims to see what happens. Follow the processing closely to ensure you are maximizing your coding.
3. Global periods: Most minor and major surgeries carry what is called a Global Period. These can be 10 or 90 days respectively. But what do these entail, and more importantly, what is not included. Novitas Solutions has a good descriptive page on their website that explains the global surgical package here: https://www.novitas-solutions.com/refman/chapter-22.html.
In brief, this includes a pre-operative visit either one day previous to or the day of a surgical service, all necessary items to perform the service such as prep and drape, OR, and surgical trays, the professional service itself, and a period of follow-up care. Some payers also include normal complications of the service, such as hematoma or ‘trapped blood’ after sclerotherapy. Medicare is one of these. Other payers allow this service to be billed within the global however, so it pays to know what your payers allow so you can bill accordingly and maximize your reimbursement. Ultrasounds are not subject to global surgical packages, but office visits are.
The only office visits that may be billed during a global period are required to be completely unrelated (separate part of the anatomy, new condition etc.) to the surgery that generated the global. In this case they may be modified accordingly. Additional surgical services performed within a global period may also be billed and modified accordingly when appropriate. There are a number of global modifiers and I recommend understanding the uses of each, but for Phlebology the most commonly used are 58- staged or related procedure and 79- unrelated procedure within a global period.
4. Diagnosis Pointing and Medical Necessity: For the most part claims are processed by computer programs that are able to detect key elements in a claim and either reject, deny, or allow for payment. One of the things they screen for are the diagnosis and CPT codes to see if they match up against a pre-programmed list defining medical necessity. Even if the primary diagnosis matches, if a secondary or tertiary diagnosis does not, this can cause the entire claim to deny. Each payer has differing levels of sophistication within the software they use, but most have this capability to some degree or another. This is the time to attach, or “point”, a particular diagnosis to a service code.
For example, if you are billing for a follow-up ultrasound (Code 93971) with the diagnosis of 729.81 (because the patient has some significant swelling) and you are also providing some sclero to this patient on the same day, and in that case, the diagnosis is 454.8 would be appropriate. You would then only append, or point this code to this CPT, and remove the other.
Billing would look like this:
93971, primary diagnosis of 729.81
36471, primary diagnosis of 454.8
I regularly see incorrect codes attached to services that they don’t support. This can cause denials that require corrected claims to fix. This adds employee time and essentially lowers the reimbursement for that service. Looking up their payer guidelines and knowing ahead of time which diagnosis are acceptable will greatly reduce errors and ultimately the processing time for your claims.
5. Billing Adjunctive Services: The first step in knowing how to bill for adjunctive services is to understand how CCI (Correct Coding Initiative) edits work. The edits detail which CPT codes are inclusive in other CPT codes. For instance, when a 36478 is billed, CPT codes 76942 and 93971 are considered inclusive – meaning that they are paid for in the allowance for code 36478 and are not to be billed separately. Determining this will help you to understand which of your services may be billed for a particular encounter. CPT 76942 is not considered inclusive in 36471 by most Payers’ standards, and is therefore separately billable. This results in significantly increased revenue for the expertise involved in this service. Again, as I have mentioned before, some payers have differing guidelines, and may or may not follow these rules. If they are clearly published then those guidelines will determine your reimbursement, regardless of the CCI or CPT standards.
I have also had providers ask me how many services codes can they report on a claim? The answer to that is as many as you have provided. There are no limits to how many codes can be on a single claim. Do try to keep one DOS per claim though. This is much easier to follow through processing and work if there are any denials.
Understanding proper coding and the rules that surround this is the key to correct reimbursement and the best protection from being selected for an audit.
Thank you for this information it has been very helpful. I do have one question, lets say I am billing a 36475 LT and doing a 93971 RT (for a follow up check for DVT S/P surgery) what modifier do you use then? You can’t use an E/M code or a 26 because it is global. How do you recommend getting the 93971so it is not bundled with the 36475 as it is totally separate? Thanks