Appropriate Use of Modifiers 25 and 59 in Chiropractic Medical Billing

Appropriate Use of Modifiers 25 and 59 in Chiropractic Medical Billing

According to recent reports, chiropractic practices received denials from Blue Cross and Blue Shield (BCBS) for claims billed with modifiers. Medical billing outsourcing companies that provide chiropractic billing services found that most of the claims denied were those that required the 25 and 59 modifiers. The Explanation of Benefits (EOBs) indicated that the modifiers were used inappropriately or utilization of the modifier was higher than average. In December 2017, the Illinois Chiropractic Society (ICS) reported that in the cases they reviewed, the procedure code and modifiers were billed correctly based on the claims information, but that the denials are the result of a new code-editing feature that BCBS announced to all provider types.

The ICS strongly urged chiropractors to:

  • Appeal the specific denial by demonstrating a valid use of the modifier
  • Appeal the denial by pointing to the specific documentation that clearly demonstrates medical necessity

This experience has put the spotlight on the use of modifiers for chiropractic coding and billing. Chiropractic modifiers are reported along with CPT codes to tell the insurance company that there is something unique about the services being billed. Correct use of modifiers can increase reimbursement. On the other hand, if codes that require a modifier are billed without one, the carrier will reject the claim with an explanation on the EOB of bundling with another service. The key to using modifiers to ensure maximum reimbursement is to understand each payer’s specific recommendations on the matter.

Appropriate Use of Modifiers 25 and 59 in Chiropractic Medical Billing

The American Medical Association describes chiropractic manipulative treatment (CMT) (98940-98943) as a form of manual treatment to influence joint and neurophysiological function. The five spinal regions referred to for CMT are: cervical region (includes atlanto-occipital joint); thoracic region (includes costovertebral and costotransverse joints); lumbar region; sacral region; and pelvic (sacro-iliac joint) region.The five extraspinal regions are: head (including temporomandibular joint, excluding altanto-occipital) region; lower extremities; upper extremities; rib cage (excluding costotransverse and costovertebral joints) and abdomen.

The CMT CPT codes are:

98940: spinal, 1-2 regions
98941: spinal, 3-4 regions
98942: spinal, 5 regions
98943: extraspinal, 1 or more regions

Let’s take a look at the use of modifiers 25 and 59 when reporting chiropractic services.

Modifier 25

The general guidelines on reporting modifier 25 with CMT codes are as follows:

  • CMT codes include a pre-manipulation patient evaluation.
  • Additional evaluation and management (E/M) services may be reported separately using modifier 25, if the patient’s condition requires a separate E/M service, above and beyond the usual pre-service and post-service. So if manipulation and E/M codes are billed for the same visit, it is necessary to attach modifier 25 modifier to the E/M code.
  • Providers should check commercial and federal payer guidelines when using modifier 25
  • As the E/M service may be caused or prompted by the same symptoms or condition for which the CMT service was provided, different diagnoses are not required for the reporting of the CMT and E/M service on the same date.

The bottom line: modifier 25 should be used only when DCs perform an assessment above and beyond the adjustment.

Modifier 59

The National Correct Coding Initiative (NCCI) edit program developed by the Centers for Medicare and Medicaid Services (CMS) is used by carriers and third party administrators in an effort to prevent improper payment when certain codes are submitted together. Modifier 59 and some other modifiers are exceptions to the NCCI PTP (procedure-to-procedure) edits.

Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures and services, other than E/M services, that are not normally reported together but are appropriate under the circumstances.

CMS instructs that documentation should support a different session, different procedure or surgery, different site or organ system, separate incision or 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. Modifier 59 allows the claim to pass Medicare bundling edits, which would lead to additional reimbursement for the physician.

Chiropractic manipulative treatment codes — 98940, 98941, and 98942 — comprise three procedures, that is, pre-assessment (history), manipulation, and post-assessment, bundled together. These procedures are cannot be routinely unbundled. If a distinct procedure is performed that is not inherent in the manipulation, a modifier should be appended to communicate to the carrier that an exception exists.

In January 2015, CMS released new subsets of the 59 modifier, that is, modifiers XE, XS, XP, and XU that may be used in lieu of modifier 59. When providing services such as neuromuscular re-education (97112), massage therapy (97124), manual therapy or trigger-point therapy (97140), and billing Medicare, doctors of chiropractic (DCs) should use the 59 modifier only as a “last resort”. Instead, using the XE, XS, XP, or XU subset modifiers would be more appropriate.

Modifier XE: Separate encounter—the service is distinct because it occurred during a separate encounter.
Modifier XS: Separate structure—the service is distinct because it was performed on a separate organ or structure.
Modifier XP: Separate practitioner—the service is distinct because it was performed by a different practitioner.
Modifier XU: Unusual non-overlapping service—the service is distinct because it does not overlap usual components of the main service.

In a 2017 article, CMS provides the following example of modifier 59 usage for CPT codes 97140/97530:

97140 – Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes

97530 – Therapeutic activities, direct (one-on-one) patient contact (use of dynamic activities to improve functional performance), each 15 minutes

CMS states that modifier 59 may be reported if the two procedures are performed in distinctly different 15minute time blocks. For e.g., one service may be performed during the initial 15minutes of therapy and the other service performed during the second 15 minutes of therapy. The therapy time blocks may also be split. For e.g., manual therapy might be performed for 10 minutes, followed by 15 minutes of therapeutic activities, followed by another 5 minutes of manual therapy.

CPT code 97530 should not be reported and modifier 59 should not be used if the two procedures are performed during the same time block.

The bottom line:

  • Modifier 59 and other NCCI-associated modifiers should be only be used when appropriate and not to bypass a NCCI edit.
  • Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier that is used.
  • Before using NCCI-associated modifiers, DCs should check with their local Medicare carrier for guidance.

Outsourcing chiropractic medical billing and coding is a practical option to ensure that chiropractic services billed to Medicare and other payers are medically necessary, correctly coded and adequately documented. Coders and billing specialists in experienced medical billing outsourcing companies work alongside DCs to understand that specific ways chiropractic services are reimbursed, promoting accurate claim submission, reduced risk of scrutiny and denials, and optimal reimbursement.

CMS’ New Medicare Cards (MBI) – Get Ready for It!

CMS’ New Medicare Cards (MBI) – Get Ready for It!

Based on the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015’s requirement, the Centers for Medicare & Medicaid Services (CMS) recently announced that they would provide new member ID cards for its beneficiaries. Healthcare providers as well as medical billing companies they employ should prepare their systems to accept the new format.

The agency will replace Health Insurance Claim Numbers (HICN) or Social Security Numbers (SSNs) with Medicare Beneficiary Identifiers (MBI) by April 2019. The replacement will be done on the new Medicare cards for Medicare transactions like billing, eligibility status, and claim status. The major reason behind the removal of SSN from Medicare cards is to fight medical identity theft for people with Medicare. Also known as Social Security Number Removal Initiative (SSNRI), the mission aims at protecting Private health care and financial information, Federal health care benefit and service payments.

While HICNs are the beneficiary’s 9-digit Social Security Number with a one or two-byte alphanumeric Beneficiary Identification Code, MBIs will be 11 bytes, alphanumeric, with key positions at 2, 5, 8, and 9 always alphabetic.

The transition period for the SSNRI will begin April 2018 and end December 31, 2019. CMS will begin mailing beneficiaries their new cards in April 2018. Healthcare providers who submit or receive transactions containing the HICN must modify their processes and systems to be ready to submit or change the MBI by April 1, 2018. With some exceptions, HICNs will no longer be used after January 2020.

Medicare Cards (MBI)In order to educate the healthcare industry on the Social Security Number Removal Initiative (SSNRI), CMS has provided certain instructions on Provider Open Door Forums. For physician practices to get ready for the change, CMS recommends to –

  • Attend CMS’ quarterly calls that provide updates and ongoing information about the Social Security Number Removal Initiative.
  • Verify patient’s address and confirm with the patient that it matches the address Medicare has on file.
  • Make sure that the claims processing system of their medical billing and coding companies can accept the 11-digit alphanumeric MBI.
  • Teach patients about the new Medicare cards.

Providers should remember that beginning October 2018 through the end of the transition period, when a valid and active HICN is submitted on Medicare fee-for-service claims, both the HICN and MBI will be returned on remittance advice.

CMS has also confirmed that the MBI won’t change Medicare benefits. People with Medicare may start using their new Medicare cards and MBIs as soon as they get them.

What Mandatory Bundling Payment Programs mean for Hospitals

What Mandatory Bundling Payment Programs mean for Hospitals

As the fee-for-service environment becomes outdated, medical billing companies are well aware that the future of revenue cycle management in healthcare could be influenced by alternative payment models such as bundled payments. Under the bundled payment model, healthcare providers and facilities will be paid a single payment for all the services performed to treat a patient undergoing a specific episode of care. An “episode of care” is the care delivery process for a certain condition or care provided within a defined period of time. The aim of this model is to enhance improve care quality and coordination, while also decreasing costs for patients.

In December 2016, the Centers for Medicare and Medicaid Services (CMS) released the final rule detailing bundled payment models for cardiac services with the goal to reduce costs for patients with heart attack or who undergo bypass surgery. In March 2017, CMS announced it will delay from July 1 to October 1, two bundled payment programs for heart attack treatment and bypass surgery billed through Medicare. The delay will give CMS more time to review the programs and also give providers more time to prepare for the payment changes under the models.

The proposed mandatory payment models-the Acute Myocardial Infarction (AMI) Model and the Coronary Artery Bypass Graft (CABG) Model-are retrospective, 90-day bundles in which hospitals will need to reduce their episodic costs below a target quality-adjusted cost threshold lower than the historical average. The payment models are aimed at rewarding hospitals for high quality coordinated care that will avoid complications, prevent hospital readmissions and speed recovery. They are set to take effect in 98 metropolitan areas.

Bundling Payment ProgramsEach year, CMS will fix the target prices for different episodes of care based on a combination of regional historical data and hospital-specific data on total costs for Medicare fee-for-service patients admitted for heart attack and bypass surgery – from hospitalization through 90-days post-discharge. The bundled payment model for cardiac services would works as follows:

  • The hospital admitting the patient for heart attack or bypass graft surgery would be responsible for the cost and quality of the care provided to Medicare fee-for-service beneficiaries during their inpatient stay and 90 days post-discharge.
  • Target prices will be adjusted based on the complexity of treating a heart attack or performing bypass surgery
  • Hospitals would be paid a fixed target price per episode and those that deliver higher-quality care will get a higher target price.
  • At the end of the model year, the actual spending for the episode of care will be compared to the targeted price which is an indication of the quality of care outcomes of the hospital.
  • Hospitals and physicians that meet or exceed quality standards while providing the necessary care for less than the quality-adjusted target price, will share in all or a portion of the savings
  • Hospitals that do not meet the above-mentioned standards would be required to repay Medicare the difference, and will thereby lose revenue.

To succeed in the bundled payments model, all the healthcare organizations involved in the episode of care should work together to provide quality care and reduce costs. They should educate themselves and their teams on the new payment models. As diagnosis-related groups (DRGs) drive the conditions to bundle, accurate DRG assignment and DRG coding will be crucial. Electronic medical records must have accurate data on patient diagnoses and co-morbidities; service dates, types, and cost, and patient and provider identifiers. Reliable medical coding services are necessary to avoid ICD-10 coding errors. As the Alabama Association for Health Information Management (AAHIM) points out, medical coding companies can also work as data analysts and help providers evaluate patient care processes and information flow.

How Artificial Intelligence can Improve the Medical Billing Process

How Artificial Intelligence can Improve the Medical Billing Process

New government regulations and payment methodologies, constantly changing medical codes and other reform measures have made the medical billing process prone to errors. Recent reports say that an estimated 30 to 40 percent of medical bills containing errors. Physician practices and the medical billing companies that serve them need to be alert to medical billing and coding errors, which can lead to losses amounting to thousands of dollars for both providers and patients. The good news is that artificial intelligence (AI) can play an important role in improving healthcare revenue cycle management.

  • CNBC recently reported on how AI is set to transform medicine – from coding to cancer – by improving medical diagnosis. According to the report, Massachusetts General Hospital is examining the potential of computers to diagnose breast cancer early in mammograms and whether AI can help physicians use the huge volumes of patient data to make more personalized therapeutic decisions. In fact, experts are now training computers to comb digital slides, and learn how to differentiate cells that are cancerous from healthy ones.
  • The article also describes a novel system known as Deep Patient that allows researchers to scour de-identified health data across the hospital system and combining information different ways to better predict diseases from schizophrenia to cancer to severe diabetes.
  • According to a new Health Data Management report, the use of next-generation automation tools can improve resource utilization and support quality improvement to meet Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) goals.
  • Innovative automation tools can also help accurately code and classify all diagnoses, symptoms and procedures. Natural language processing offers tools to extract accurate ICD-10 codes by mapping the physician’s consultation notes against a multi-level medical dictionary. This can minimize recovery audit risks and associated costs.
  • Experienced medical billing and coding service providers already use advanced technology to help medical practitioners manage patient appointment scheduling and claims processing. Automating scheduling and sending appointment reminders to patients reduces the chances of missed appointments, driving efficiency and improving revenue cycle management. AI-enabled automated systems can help organizations track and improve performance on key healthcare metrics.
  • With the increasing number of patients and the dynamic healthcare scenario, healthcare providers need more accurate and efficient back-end systems. For instance, bundled payments are an innovative alternative payment model that represents a great opportunity for the use of information technology. Providers will need to fully optimize information systems to manage bundled payment requirements, provide value-based care, and receive appropriate reimbursement.

Medical billing outsourcing can help providers exploit the power of automation and concentrate on providing patients the treatments they deserve. A technologically advanced medical billing and coding company would use the latest billing software in a way that it easily bridges the gap between the provider and the biller. With changing codes, payer rules, and new technologies, the support of an experienced service provider can prove invaluable to drive transformation, revenue and improved care.

Appropriate Use of Modifiers 25 and 59 in Chiropractic Medical Billing

Learn the Facts about Modifier 57

Learn Facts about Modifier 57Coding experts in established medical coding companies are well-versed in the use of various modifiers to comply with industry guidelines. Simple two-character designators that indicate how the code for the procedure or service should be applied for the claim, modifiers add accuracy and precision for recording the patient encounter. Some modifiers increase or decrease reimbursement while others are only informational. If used incorrectly, they can lead to denials, payer scrutiny and audits, refunds, and penalties. It is found that physicians are confused about certain modifiers, especially those that involve reimbursement. One example is modifier 57.

Modifier 57 describes the Decision for Surgery: indicates that an Evaluation and Management (E/M) service resulted in the initial decision to perform surgery either the day before a major surgery (90 day global) or the day of a major surgery.

This has led to the belief that this is just a modifier that signals a decision for surgery. A recent AAPC report focused on clearing the confusion and clarifies that modifier 57 should be used when the physician determines the need for any major procedure, regardless of whether it surgical or non-surgical.

Private payers go by the guidelines of the Centers for Medicare & Medicaid Services (CMS) with regard to the definition of minor and major procedures. A major procedure is defined as a procedure with 90 global days. Medicare contractors are required to pay for an evaluation and management (E/M) service on the day of or on the day before a procedure with a 90-day global surgical period if CPT modifier 57 is used to indicate that the service resulted in the decision to perform the procedure. An E/M service that takes place prior to the decision for surgery or the E/M service at which the decision for surgery is made is not bundled to the surgery payment.

Points to note:

  • An initial evaluation prior to a major surgical procedure is always payable.
  • Modifier 57 should be appended to any E/M service on the day of or the day before a major surgical procedure when the E/M service results in the decision to perform surgery. This informs the payer that the physician determined the surgery was appropriate and medically necessary.
  • Modifier 57 should be appended only to the E/M procedure code.

Modifier 57 can be appended to an initial hospital visit on the day of an emergency surgery. For instance, suppose a surgeon sees a patient, appropriately documents the encounter, and recommends a laparoscopic appendectomy (CPT 44970, 90-day global period) be performed later that day. In this case:

  • The E/M visit resulted in the initial decision to have surgery and is therefore separately payable
  • It is appropriate to use CPT modifier 57 in this case.

Another example is non-surgical fracture care which has a 90-day global period. Closed treatment of a clavicle fracture, (both CPT 23505-with manipulation, and CPT 23500-without manipulation), is not a “surgical” procedure, but is a major procedure that has a 90-day global period. In this case, when properly documented, separate payment of an E/M service with modifier 57 is appropriate.

Modifier 57 should not be:

  • Appended to a surgical procedure code
  • Appended to an E/M procedure code performed the same day as a minor surgery. If the decision to perform a minor procedure is made immediately before the service, it is regarded as a routine preoperative service and is not billable in addition to the procedure
  • Reported on the day of surgery for a preplanned or prescheduled surgery
  • Reported on the day of surgery if this procedure is one that will be performed in multiple sessions or stages
  • Reported on the E/M for the decision for surgery if the surgery is scheduled later than the day after the E/M service

To avoid confusion related to code and modifier use, most physicians opt to rely on expert medical coding services. With CMS increasing scrutiny about modifier use, such support is crucial to help physicians avoid misunderstandings and file medical billing claims correctly.

Ensure Reimbursement for Significantly Complex Procedures with Proper Use of Modifier 22

Ensure Reimbursement for Significantly Complex Procedures with Proper Use of Modifier 22

General surgery medical billing and coding is quite complex. When a surgeon performs an operation, it may entail more than what was planned, in which case modifier 22 increased procedural services may be applicable. Knowing how to code correctly for the surgical procedure is crucial to optimize reimbursement. Experienced coders in medical billing and coding companies accomplish this by scrutinizing the physician’s documentation.

When Modifier 22 is Relevant

The National Correct Coding Initiative states: “If a procedure utilizing one approach fails and is converted to a procedure utilizing a different approach, only the completed procedure may be reported.

From this it is clear that the surgeon should accurately document the unusual circumstances of the procedure within the operative report. This should include a proper description of how the service provided differs from the usual service or the one that was planned. The physician should explain and identify additional diagnoses, pre­‐existing conditions, or unexpected findings or complications that led to the extra time and effort.

Every procedure code involves a probable range of complexity, length, risk, and difficulty. Modifier 22 has to be added to the procedure code if the service provided goes beyond these normal ranges and can be described as more complicated, complex, technically difficult, or needing significantly more time than usual. For instance, excessive blood loss relative to the procedure is a circumstance in which Modifier 22 can be appended. In this case, the surgeon’s documentation should explain the steps taken to control the blood loss.

Other situations that may support Modifier 22 include:

  • Extreme obesity that complicates surgery significantly
  • Presence of excessively large surgical specimen
  • Co-morbidities that cause complications during the surgery
  • Trauma extensive enough to complicate the particular procedure and not billed as additional procedure codes
  • Other pathologies, tumors, or malformations (genetic, traumatic, surgical) that interfere directly with the procedure but are not billed separately
  • Services rendered that are significantly more complex than described for the CPT® code in question

Submitting Correct Claims for Unusual Surgical Procedures – Other Points to Note

It is crucial that the physician’s documentation submitted along with the claim specifies the extra time taken for the procedure – for instance, that the surgery took four hours instead of the usual two hours.

Every year, the Centers for Medicare & Medicaid Services (CMS) provides a “Work Time” Excel file that contains important information about median time values for all procedures listed in the CPT® codebook, and also the types of E/M services that may be encountered in the pre- and post-operative periods of a procedure. Column E on the time sheet – “Median Intra Service Time” – is especially important in general surgery medical billing and coding for reimbursement of modifier 22. The values in this column represent the time usually spent for surgical procedures. A typical surgical procedure may take more or less time than that given in the list, but the median time can be used to determine the approximate value of procedures billed with modifier 22.

Professional Medical Billing Services for Proper Reimbursement

The complexities associated with the use of modifier 22 underlines the importance of expert medical billing support. Failure to use modifiers properly can badly affect reimbursement. Certified medical coders in professional medical billing and coding companies are familiar with the use of all CPT modifiers and can help surgeons maximize their reimbursement.

Payers may reject or refuse additional reimbursement for modifier 22. A reliable medical billing company will also follow up on rejected claims and appeal the decision in cases where the procedure note is thorough and clearly reveals that additional compensation is justified for the unusual service provided.