Modifiers 24 and 79

A few months ago we had to do some training on our ophthalmologist account regarding when to bill the 24 modifier versus the 79 modifier in the global period to a surgery or in-office procedure. I figure, if our employees are having questions, some of you might be too, and I want you to get the maximum reimbursement for your services. First, the exact descriptions of the modifiers from the CPT book:

24 – Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Post-operative Period:
The physician or other qualified health care professional may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. This circumstance may be reported by adding modifier 24 to the appropriate level of E/M service.

79 – Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period:
The individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. This circumstance may be reported by using modifier 79. (For repeat procedures on the same day, see modifier 76.)

Many of our doctors do both minor and major surgeries, and we all know that patients need to come back in for follow up care on their various incisions, wounds, and ulcers to make sure everything is healing properly. The insurance companies will not pay for these follow up visits, or any visit done in a certain amount of time after the procedure without the proper modifiers as they consider the follow up visit to be an integral part of the original procedure. This time period is called the global period and the length of time varies depending on the procedure performed.  The issue with this no-payment rule comes in when the doctor diagnosis the patient with something additional during the follow up visit, or the patient needs another procedure. At that point, the doctor needs to do a complete visit including review of systems and exam and make a medical decision, and we can all agree that she should be paid for that. Here is how you get her paid. Modifier 24 goes on the office visit and you make sure you have a primary diagnosis that is different than the diagnosis on the original procedure. If the patient needs any in-office procedures, put a 79 on the procedure and make sure the diagnosis is different than the one on the original procedure. If the patient needs another major surgery in that time period, unrelated to the original, use modifier 79 as the first modifier on the surgery.  Just to avoid confusion, whether you use the modifier 24 or the modifier 79, the modifier would go on the visit subsequent to the surgery or in-office procedure.

To answer a popular question, yes, you can use modifier 79 when you are billing for the same surgery on a different body part. For example, if the patient had a cataract surgery on the left eye in January and he is getting cataract surgery on his right eye in February, you can use the same diagnosis of cataracts, the same CPT code for the surgery, and add the 79 modifier. Here is how that would look:

Date                          ICD9 code            CPT Code    Modifiers

01/13/14                 366.17                    66984             LT

02/18/14                366.17                    66984              79    RT

As for using the 24 modifier, there are all kinds of good, justifiable reasons to bill with that modifier and get your office visit paid separately. Here are just a few:

1) Patient is requesting a refill on medication for her chronic condition (hypertension, diabetes, hypothyroidism, migraines, neuralgia)

2) The patient came in with an unrelated chief complaint on his follow up visit

3) Patient came in for the follow up and the doctor identified symptoms of something else during the exam

This is by no means a comprehensive list, so if you are not sure whether or not your particular patient meets the requirements for using a 24 on the office visit, send me a quick email and I’ll let you know how I would bill it. Here is an example of how a charge like that would look.

Date                          ICD9 code                             CPT Code    Modifiers

01/13/14                  366.17                                    66984             LT

02/18/14                 250.60    362.01                  99214             24

I also have another chart for you (I love charts!) detailing the global period for each procedure. It is LONG. I do not suggest you print this one out, but save it on your own computer for reference. Oh, and, the global period for any given code is either going to be 10 days or 90 days, if it has one at all. FYI. As always, I saved the chart to my Links and Tools page for you.

EDIT: Just a quick FYI, global surgery rules do not apply to assistant surgeons. So, anyone who is billing a code for a provider assisting with a surgery, these rules don’t actually apply to you. Just go ahead and use modifiers 80-82 the way you’ve been doing. In fact, if we do send in a claim with modifier 79 (or 78 for that matter), the claim will actually be returned as unprocessable. Thank you, Adam, for helping to clear up the confusion.

The insurance denied your claim, now what?

Today we are going to play Unpleasant Truth Time. All those rules that you painstakingly memorized to get your claims out of the door are just the beginning. Insurance companies have more reasons to deny your claims then I could even begin to list here, and the biggest and most time consuming part of your job will be to unravel those reasons and get your doctor her money. This post will help you to do that. Email me at newgenerationbilling.com for the Cliff Notes version of this post.

There are two kinds of follow up–loose paper follow up and insurance aging follow up. Your loose papers are denials, partial payments, and requests for information from the insurance companies. Even with a healthy account you are going to have your share of these.

When you have denied and partially paid charges, here are your options to get them paid:

1. Resubmission

2. Reprocessing

3. Appealing to the insurance company

4. Appealing to  the insurance commissioner

When you resubmit a claim it is usually to correct an error. When I get a denial from an insurance company, the first thing I do is to make sure that I billed everything correctly, even though I have been doing this for over a decade now. And I make sure to check EVERYTHING. I review the diagnosis, service, date, doctor, facility, insurance, and id#, because these are all things  I have messed up on in the past. Just a quick aside for those of you who are planning on calling us for billing or consulting services, please be assured, those mistakes are very rare. If I was the kind of person to use a smiley face in my professional blog, I would put one here.

When you do make a mistake all you have to do is correct the claim and mark in box 19 that this is a corrected claim and indicate what you fixed. Here is an example. Say you billed a DX of 627.9 (postmenopausal syndrome) to a Mr. Henry Winkler. Now, Mister  Henry Winkler is not going to have postmenopausal syndrome because he is a man. You pull up the superbill and realize that you meant to bill 682.9 (cellulitis). Change your ICD9 code, in box 19 write “Corrected claim, Corrected ICD9 code”, and resubmit your claim.

Most of the denials you receive, however, will not be your fault. This is where you would call the insurance and have them reprocess the claim. Insurance companies process claims wrong all the time. Several times I have even had my claims denied as duplicates to themselves! If the claim was denied due to an error on the part of the insurance, usually all we have to do is call them and get them to send the claim back for reprocessing. Make sure you have the following information available when you call because it will save you a great deal of stress:

1. Your provider’s NPI and Tax ID. They don’t always ask for both of these, but having them in front of you when you do your follow up will save you time with those representatives that do want both numbers.

2. The patient’s ID number, name, and date of birth. They always ask for all three of these things. When you’re on the phone with an insurance company, the rep won’t hurry you, or tell you that you’re wasting her time, or ask you to hang up and call back once you have the information. But if you are scrambling around for it, you are wasting your own time.

3. The date of the charge you are calling in regards to, and total billed amount of the charge. The insurance is going to have a lot of claims on file, so they are going to need the amount of your claim to make sure the two of you are talking about the same thing.

When you request that a claim be reprocessed, please don’t take no for an answer. If the claims representative won’t help you, go up to a supervisor. Hang up and call again. Since you’ve already checked your claim top to bottom, you know that the error was not on your side and you should not have to take any more of your time to resolve this issue.

You will run across things that a phone call cannot resolve. In those cases, we send in written appeals. With my appeals I send a copy of the claim, any documentation I have to support my position, and a letter. In my letter I  explain exactly what my objection is, what documentation I am attaching, and what result I expect to see. Here is a sample Appeal letter for something like a timely filing. I keep templates of my letters on file for the most common denials: timeliness, medical necessity, incorrect duplicate denials. If you want, I can post samples of those as well, just email or comment and I’ll put them up.

Now, no matter how exactly worded your letter, and no matter how thorough your documentation, sometimes your appeals will be denied. Your last resort is to go to the insurance commissioner. You can see your options on the state website http://www.insurance.ca.gov/  and there are step by step instructions on how to file your complaint.

Once all the loose papers on your desk have been taken care of, it is vital that you pull an aging report. The claims that get denied and partially paid are the claims the insurance receives. If you read the appeal letter, you probably realize that many of the outstanding claims you have on your accounts receivable right now are claims that the insurance has “never received.” The insurance will never send you a zero dollar EOB or a request for information, and your time limit to file and to appeal will run out before you realize.

Doctors, office managers, billers, please remember to pull your aging on a monthly basis. Not only will you catch the follow up that you would not otherwise find, you can make sure that your aging is healthy. A healthy aging will have at least 80% of your outstanding balances within 60 days. We have customers with 90% of the charges outstanding within 60 days.

If you pull your aging and you don’t like what you see, that is where New Generation comes in. Call us at (909) 374-5439 or email us at newgenerationbilling.com. You have plenty of options, call us and find out what the are.

Modifer 25 and 59

We are training several new employees right now. Glad to be expanding, progressing as expected, blah, blah, blah. But they are having a great deal of trouble with understanding when to use the modifiers 25 and 59. If we are having issues in here, some of you out there might be as well, and I want to make your life easier. First, for you technical types here are the exact descriptions from the CPT book.

Modifier 25 – Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service:
It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, 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 that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59.

Modifier 59 – Distinct Procedural Service:
Under certain circumstances, it may be necessary 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 or services, other than E/M services, that are not normally reported together but are appropriate under the circumstances. Documentation must 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. However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available and the use of modifier 59 best explains the circumstances should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25.

Now for some practical application. The modifier 25 goes on the office visit.  Here are the situtations in which you need a modifier: 1) If a patient gets a procedure on the same day as an office visit, 2) medication injected same day as an office visit, 3) pap smear done same day as an office visit, 4) physical done same day as an office visit. Don’t worry, we’re about to go through and lay out how we are supposed to use them.

If you need to bill an office visit and a procedure, you would use a modifier 25 on the office visit line. A procedure counts as any CPT code between 10000 and 69999. Plus, you need a different diagnosis on the procedure than you have on the office visit. Here is an example:

A patient comes in with ear pain and the doctor diagnoses her with an ear infection and does an ear lavage. If you want to get both the 99213 and the 69210 paid on the same visit here is how you would enter that charge:

Ear pain/otalgia (ICD9 388.70) (ICD10 H92.09)           99213  –  25

Ear infection (ICD9 382.9) (ICD10 H66.90)                   69210

When you put it in with a different dx on the office visit and  a 25 modifier the insurance will pay each line item separately.

Paps and physicals work in a similar way. The medical dx go on the office visit and the V-codes go on the preventive service. I could write a whole post on paps (and probably will) but we are going to keep it simple here.

465.9 (ICD10 J06.9)    462 (ICD10 J02.9)                      99213  –  25

V70.0                                                                               99395

When you need to bill an office visit and an injection on the same day, you have two options. The cpt 96372 is for an intramuscular injection of a J-code. You can bill the office visit and the substance all day and they will all get paid separately with no modifiers. The injection administration is what the insurances like to include in the office visit. However, you will get paid about $20.00 for each administration billed correctly and that can add up. Say a patient comes in with knee pain and the doctor diagnoses him with osteoarthritis and wants to give him an injection of Toradol. You put the symptom on the office visit with a 25 modifier and the substance and the admin have the condition. Then, you put a 59 modifier on the 96372. So, it would be three line items and it would look like this:

Knee pain       719.46 (ICD10 M25.569)                        99213  –  25

Osteoarthritis  715.96 (ICD10 M17.9)                            J1885

Osteoarthritis  715.96 (ICD10 M17.9)                            96372  –  59

I have attached an Updated modifier chart that will tell you when a service needs a modifier. We printed this out and gave it to all the new people and it seemed to clear up most of the confusion.

As always, call or email if you have any specific questions about something that didn’t make it through here on the blog.

Medicare and Immunizations

Medicare routinely pays for two immunizations and will pay for two others under specific circumstances. Specifically, they will pay for influenza and pneumococcal as preventive, and Medicare will pay for the tetanus and hepatitis B vaccines in certain cases with medical necessity. Read on.

The new Medicare flu codes have been around for a while,  but we recently ran into a few offices in 2012 who told us they have been having a hard time getting paid for their flu shots from Medicare. Long story short, they were using the wrong substance AND administration codes. And since Medicare will pay  just under $30 for the administration of the injection and $7-$15 for the substance itself, missing out on those can turn into a loss of hundreds of dollars per year. So, lets fix that, shall we?

All of our posts are going to follow the same format; we are going to first explain the important bits, and then we give you the charts and links that we personally use and distribute to our customers. So remember to bookmark us or add us to your favorites, because here you can keep all of your invaluable tools in one place.

The CPT codes for Medicare to bill the flu shot break down by the brand the doctor purchases. If you’re at the office, take a look in the fridge, but if you are at a billing service, you need to please call your office manager and get that information. The reimbursement varies significantly depending on the code, and we can get our providers audited if we just make that decision ourselves. Medicare uses codes Q2034–Q2038, and here is the specific breakdown.

Brand         CPT

Agriflu      Q2034
Afluria      Q2035
FluLaval   Q2036
Fluvirin     Q2037
Fluzone    Q2039

Remember to bill the G0008 administration code along with the vaccine. The Q-code is only for the substance. It is the G-code that we bill for the actual service–the process of injecting the immunization into a patient’s–ahem–hip. If the patient is ONLY seen for the flu shot, then you would simply bill those two codes. If the patient had an exam on the same visit you can bill an E&M code as well and Medicare will pay them all separately without any modifiers necessary. Just remember to put your V04.81 (ICD10 Z23) diagnosis primary on the Q-code and the G-code and your medical diagnosis on the E&M. Please remember, these codes are just for Medicare. For the rest of your private insurances, you still use the 90658 for the substance and the 90471 or 90472 for the admin.

The pneumo, Hep B, and the tetanus are a little bit easier.

For the pneumococcal, you bill with the diagnosis of V03.82 (ICD10 Z23) and the CPT code 90732. Use G0009 for the administration. Easy.

Medicare will pay for the tetanus immunization, however, they will not pay it as a preventive service. Patients who come in with wounds (ICD9 codes 860.xx0-894.xx and ICD10 codes S00-T14) are eligible for reimbursement on the tetanus vaccine. Remember to use the wound diagnosis primary and the V03.7 (ICD10 Z23), tetanus toxoid alone, as secondary. The tetanus can be billed with 90471 as the administration.

For hep B, Medicare will only pay for the immunization series for patients they consider as “high risk.” A high risk patient is one with renal disease, or hemophilia, or a client of institutions for the mentally handicapped.

A word of caution: Medicare has VERY strict rules regarding the frequency of these immunizations. The flu and the pneumo vaccines can be administered once per year. If 365 days have not passed since the last immunization you WILL NOT be paid. No amount of appealing will change this. Please, make it clear with your front desk, your MA’s, and most importantly, with your doctors, that we need to check the date of the last immunization for our established patients BEFORE administering the vaccine.

Here are your tools:

• For starters, we reference this handy-dandy chart for all of our customers that breaks down the Medicare flu shot codes. Print it out, stick it on your wall. That’s what I did.
• This is a link directly to the CMS Medicare site with all the information you could ever want regarding their immunization policies.

If this doesn’t answer all of your questions, call us at (909) 374-5439 and ask for Heather. Or you can email us at newgenerationbilling@gmail.com.