b'By David Klein Correct CodingCompliance ANJC Coding &Compliance Consultant with ModifiersMost insurance payers (if not all) track statistical information on25 Modifierdefined as: Significant, Separately Identifiable providers and use these statistics to compare a providers billing LEGAL NUTRITIONCouncil Evaluation and Management Service on the Same Day of the patterns to those of his/her peersthis is called a ProviderProcedure or Other Service. Providers will often add this modi-Profile. One of the easiest ways to track a provider is throughfier to an E/M service (99201-99215) regardless of the situation. the codes they use, and this includes modifiers. When we submitIn other words they will use this modifier any time they bill for an claims we use codes, and payers can then track which ones weE/M service. In chiropractic, (other than certain diagnostic testing use, how often we use them and to what level. Every providerprocedures) this modifier should only be used when CMT and has a profile, and through statistical analysis, payers are able tothe E/M service are done on the same day and the circumstances ANJC Leadership ANJC Leadership determine unusual or aberrant patterns of practice which, in theirsupport its use. By adding the -25 modifier, the provider is letting NUTRITIONthe payer know that the evaluation and management service LEGAL EASE opinion, should be audited.performed is above and beyond the assessment included with In 2015 and again in 2017, I wrote about the importance ofthe CMT service. Overutilization of E/M services with CMT is a proper modifier usage. I decided to repost this article with sometargeted issue by payers. There are four main instances when changes due to the fact I am still seeing a significant increase inCMT and E/M services can be billed on the same day:providers being audited due to improper use and overutilizationNew Patientof modifiers. Modifiers are added or appended to CPT codes30 day re-evaluationto provide additional information regarding service(s) provided. REHAB CouncilExacerbationModifiers allow the provider to explain specific circumstancesPatient presents with a new problem(overriding coding edits) to payers by attaching a two character code to the affected procedure or service. These coding edits59 Modifierdefined as: Distinct Procedural Service. For are normally based on the Medicare National Correct Codinga chiropractor, there are three main instances where the -59 Initiative edits or NCCI edits. The purpose of the NCCI edits ismodifier must be used for proper reimbursement. 1) When to electronically detect codes billed to that would not normallyCMT and manual therapy are performed on the same DOS. 2) LEGAL Q&A CHIROASSIST When CMT and neuromuscular re-education are performed on be used together. These edits to prevent unbundling of services, the same DOS. 3) When CMT and neuromuscular re-education and the consequent potential overpayment to physicians. Executive Directors UPDATE Without a proper understanding of these edits, adding a modifierare performed on the same DOS. In all of these instances, the can have very negative consequences if not properly used. Fortherapy must be performed at a separate anatomical structure example, one of my clients was adding the -59 modifier to allthan where the CMT is performed. For example, Patient A is diagnosed with cervicalgia, cervical subluxation modalities and therapies regardless of whether the NCCI edits applied to the codes he used. This in turn increased his profileand muscle spasms. The provider performs chiropractic and he received an audit request. When we asked why he wasmanipulative treatment (CMT); (CPT98940- spinal, 1-2 Legislative Update chosen for an audit, the payer confirmed that is was primarilyregions) to C2, C3. They then perform myofascial release, INSURANCE Update INSURANCE Update due to his high use of the -59 modifier.(manual therapy CPT 97140) to the cervical paraspinal muscles for 11 minutes. In this instance, most payers would Even though in many of the instances, adding the -59 modifier TECHNIQUE Council view the manual therapy as being performed to the same had no financial impact on the claims (meaning it wasntanatomic structure as the CMT. Therefore, it is NOT appro-necessary to use), it was still the reason he was audited. Basically,priate to bill the manual therapy. when you use modifiers incorrectly you are essentially alerting thePatient B is diagnosed with cervicalgia, cervical subluxation payer that you dont know proper coding rules and run the risk of inadvertently inviting them to have a look around.and adhesive capsulitis of the left shoulder. The provider performs chiropractic manipulative treatment (CMT; CPT MedicareQ&AIn fact, according to the Centers for Medicare and Medicaid98940 - spinal, 1-2 regions) to segmental levels C2, C3. They OUR HEALTH then perform myofascial release (CPT 97140) on the patients Services (CMS), -59 is the most widely used modifier in the CPT coding system. That popularity is partly because the -59left shoulder for 13 minutes. In this instance, the manual modifier can be used in a wide variety of circumstances, suchtherapy IS appropriate and reimbursable because it was as identifying different encounters, different anatomic sites, orperformed to a separate anatomical structure.distinct services. According to CMS, this modifier is associatedIn the above scenarios you can substitute 97112 and 97124 for with considerable abuse and high levels of manual audit activity,the 97140 since the same rules apply to all three codes. Addi-leading to reviews, appeals and even civil fraud and abuse cases.tionally, many payers are requiring diagnosis pointing. Diagnosis Focused Audits: pointers are the letters on the claim form found in box 21 and Currently there are multiple payers in the state of New Jerseyeach letter represents a specific diagnosis. To Point you use that are focused on overutilization of modifiers by chiropractors,box 24E and link the diagnosis to the applicable CPT code(s) specifically modifier -25 and -59.you are billing. For example, you can have three diagnosis on 14 I Spring2019 www.anjc.info'