Strike back at insurance-company denials by becoming an expert on coding modifiers

We can all thank advanced technology for our insurance claims being denied due to missing modifiers. Sophisticated scanners and processing equipment can now detect the missing two-digit number or alpha suffixes, and instantly deny or delay claim forms on the spot. Using modifiers used to be considered an occasional exception, with little consequences to their omission. However, they are now a must-do-or-deny situation. The National Correct Coding Initiative, and its “CCI edits,” has identified several bundled and/or denial situations that allow insurance carriers the right to reject procedures that are not properly coded with complete current procedural terminology (CPT) and modifier extensions.

Here is a guide to the most frequently used modifiers (by a chiropractic office), with their definitions and rules.

Evaluation and Management
Generally speaking, only two evaluation and management (E/M) modifiers are commonly used:

–21: prolonged evaluation and management service. Use this modifier when the face-to-face or floor/unit service(s) provided is prolonged or otherwise greater than that usually required for the highest level of E/M service within a given category. The separate five-digit modifier code 09921 may also be used. A report may also be appropriate.

This modifier is used when increased time is needed for a particular level of E/M service, without having the necessary clinical requirements for a higher level of E/M or a separate prolonged service add-on code.

–25: Use this for significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service, or use the five-digit code 09925.

This modifier is always used with the E/M code when, and if, a CMT (chiropractic manipulative therapy) code is being billed the same day to indicate the difference between the usual pre- and post-evaluations and a specific and separate examination or re-examination. The modifier –25 is used after the 992 new-patient and/or established-patient E/M code.

The –21 and –25 modifiers can only be used with an evaluation and management service. Neither can be used with manipulation or physical medicine codes.

“Greater Than” or “Reduced”
–22: Unusual procedural services. Use this modifier when the service or services provided are greater than that usually required for the listed procedure. The five-digit code 09922 may be used.

–52: Reduced services. Under certain circumstances, a service or procedure may be partially reduced or eliminated at the physician’s discretion. Or use the five-digit code 09952.

The –22 and –52 modifiers can be used with services such as x-ray or physical medicine to indicate that the service (and/or time) is above or below the qualifying level of service. For example, a –22 might be used when a timed service is over the basic 15 minutes but does not qualify for a full 2-unit pricing increase. Or, a –52 might be used when not all views are taken on a “complete” x-ray series, yet no other CPT code fits the explanation of service.

Professional/Technical Component
–26: Professional component. Certain procedures are a combination of a physician component and a technical component; use when the professional component only is being billed. Or use the five-digit code 09926.

–TC: This is an unofficial modifier—not found in the CPT or HCPCS (Healthcare Common Procedure Coding System) manual—accepted in most states by most insurance carriers to indicate the technical component. Note that several years ago, the modifier –27 was used for the technical component. However, –27 is now a “hospital E/M encounter.” Do not use –27 to indicate technical component.

Medicare Modifiers
Probably nowhere are modifiers more important than in Medicare billing. With confusion over national mandates set forth by the Centers for Medicare and Medicaid Services (CMS), and regional carriers adding and deleting their own modifiers, Medicare modifier madness is in full swing. Following is a list of the CMS modifiers. Check with your local carrier for specific modifiers.

Manipulation Modifiers
–AT (active therapy): This indicates that the covered service is a part of an ongoing, active treatment regimen with a treatment plan. On Oct. 1, 2004, CMS required –AT to be attached to all CMT codes when the service was rendered for correction care.

–GA: This modifier is used in conjunction with a CMT code only when an advance beneficiary notice (ABN) has been signed by the patient. An ABN is a written notice given by a provider to a Medicare beneficiary before a service is furnished; this indicates that Medicare likely will not pay for the service, indicates why Medicare denial is expected, and asks the beneficiary to sign an agreement to pay personally for the service. The –GA modifier is not to be used on every visit, or on any services other than manipulation.

Physical Medicine Only Modifiers
–GP: Apply this modifier to all physical medicine codes. Even though Medicare does not cover physical medicine services (except in the trial areas), many Medicare claims are forwarded to supplemental carriers for consideration of services. To receive the proper denial, a –GP–GY (see Non-Covered Service Provider in the next section) would be used on all physical medicine services rendered to a Medicare beneficiary when Medicare is primary.

Non-Covered Service Modifier
–GY: The –GY modifier simply indicates that the service is not a covered procedure. With the exception of the areas of the CMS demonstration project to expand Medicare coverage of chiropractic services, this would mean all services other than a CMT code.

For example: an E/M service may be billed –25–GY (when an exam and CMT are both billed on the same day), an x-ray would be billed with the –GY only, and a therapy code would be billed with a –GP–GY.

Health Shortage Physician Area (HSPA)
–AQ: This modifier applies to physicians providing services in a rural and urban HSPA.

All underserved areas are now modified with –AQ. The modifiers QB and QU are no longer used.

Finally, one HCPCS modifier is used when renting DME services:

–RR: This modifier is used to indicate that the device (such as a TENS unit) is being rented, not purchased.

There are many more modifiers, both CPT (level 1) and HCPCS (level 2). This article discusses the most commonly used in conjunction with chiropractic billing.  Remember, codes and modifiers may change or be deleted. It is advised that your office purchases appropriate coding manuals yearly. CP

Ces Soyring, CA, is cofounder of the National Academy of Chiropractic Assistants (www.naca-online.com) and a chiropractic consultant. Contact her at naca_csoyring@yahoo.com.