Experts warn: prepare to comply with CPT modifiers
Experts warn: prepare to comply with CPT modifiers
With hospitals facing a HCFA mandate to add two-digit modifiers to the Common Procedure Terminology (CPT) codes on their claims, compliance officers had better ensure that coding staffs are acclimated to using them, experts warn.
This isn’t just a CPT coding issue. It could also could have false claims implications. For example, modifier 73 refers to a procedure discontinued before anesthesia is applied, says Baltimore-based coding consultant Andrea Clark. Medicare will pay 50% of the charge. But HCFA will pay 100% if a modifier 74 is used, indicating the procedure was terminated after anesthesia was induced. Billing a 74 when you should have billed a 73 means, at the least, you’ve overcharged Medicare. And regardless of whether you use 73 or 74, Medicare will get suspicious of providers who constantly bill for discontinued procedures, Clark says. "If you have a lot of 73s and 74s, there will be a medical review," she says.
Some modifiers may be particularly prone to misuse, says Linda Howrey, a coding consultant in Worcester, Mass. For example, there’s modifier 59, which allows hospitals to bill separately for an individual component of a comprehensive procedural code. This could allow an unscrupulous or careless provider to unbundle a procedure involving multiple sessions and services, says Howrey.
Physicians have been using modifiers for years, but this is the first time that hospitals have been forced to use them.
The 37 outpatient modifiers were supposed to take effect July 1, 1998, but just prior to that date HCFA said it would not be using the modifier edits for now.
Nonetheless, HCFA has made clear that even if they mostly don’t affect reimbursement for now, hospitals are still required to use them. "If you’re not using them, you’re non-compliant," Clark says. HCFA has yet to say when it will begin applying the modifier edits, though Clark says it could begin as early as this summer.
Yet hospitals have been slacking off on their training of coders since HCFA announced it wouldn’t apply the modifiers yet, says Clark. In addition, hospitals are coping with daunting technical problems. While medical records departments have the technical capability to use modifiers, getting them on to the UB-92 claim form or the chargemaster has been a problem, according to Clark.
The modifiers affect both CPT and HCFA Common Procedure Coding System (HCPCS) codes. Ironically, these two-digit modifiers (two modifiers can be added to a five-digit CPT code) are supposed to help hospitals, notes Sue Prophet, director of coding and classification for the American Health Information Management Association. Ideally, the modifiers should lower the chance of a payment denial. HCFA intended them to add supplementary information to a CPT code so that payers and hospitals would not have to spend weeks arguing over missing or contradictory claims data, such as, "Is this a different lesion on a different extremity?" notes Prophet. She agrees hospitals need to begin using modifiers immediately, to give their coding staff time to familiarize themselves with the new codes. The modifiers aren’t extremely complex, but they are specific enough to require some practice, and will be a change for hospital coders who are not accustomed to using modifiers.
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