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Decoding Common Denial Codes And Missing Modifiers With Medical Billing Services

Missing modifiers or invalid combinations of modifiers can lead to medical billing services claims being denied. This basically means your procedure code doesn’t match the modifier you used. It is important to accurately code treatment. However, it is also crucial that you use modifiers whenever necessary and that you have the right one for your code.

Denials can delay payment and could lead to non-payment. This can have a major impact on the bottom line of your practice. We’ll take a closer look at modifiers and the situations when they should be used. There are also some invalid combinations that you can avoid. This information will help you avoid claim denials.

Understanding Modifiers

What is a modifier? A modifier is a two-character numeric/alphanumeric code. It’s used in conjunction with a CPT number to indicate that there has been an alteration to the performed service, without changing the code definition. You may not receive the expected payment or your claim could be denied. It’s important to keep up to date on the current modifiers and when they are needed.

What are the best circumstances to use modifiers?

Modifiers change the description of a service or procedure that has been offered to a patient. They can be used in many situations, including:

  • One procedure or service was performed by multiple doctors and/or at more locations than one. Some procedures, for example, may require assistance after surgery to address the complexities.
  • A procedure or service has both professional medical billing services and technical components. Radiological procedures, for example – A provider might own the equipment. The physician will then interpret the results.
  • Only a small portion of the service was completed. A bilateral procedure, which means that it is done on both sides, can only be done on one side.
  • The service or procedure has been shortened or extended. A procedure that normally takes only an hour can end up taking two hours because of scar tissue. Another example is when a procedure includes an additional procedure but the second was unnecessary and not needed.
  • Unusual circumstances occurred. One example is when a patient has surgery and suffers an adverse reaction to anesthesia. This led to the termination of the procedure.
  • Multiple times were required to perform the procedure. You could, for example, use separate incisions to remove lesions from different parts of the body.

Invalid Modifier Combinations

  • Invalid modifier combinations can cause claims to be denied in many different ways.
  • Payers may have their own unique modifier combinations. Keep in mind that not all players recognize and use the same modifiers.
  • Multiple modifiers are not properly billed. Some modifiers cannot be combined and may not be charged together.
  • Combinations of CPT/HCPCS and modifiers. Some modifiers cannot be used for all CPT and HCPCS codes.

Modifiers: What You Should Know

Modifier 24

Modifier 24 can be used to indicate that a patient receives evaluation and management (E&M)services on the same day as a non-related surgical procedure. Modifier 24 is used to report a patient who has had surgery but also has a condition that requires evaluation. This modifier is only available for E&M services. You must also provide documentation to explain why the visit occurred during a period after surgery.

Modifier 25

Modifier 25 refers to E&M services that go beyond standard preparation and follow-up. To show the need for additional services, documentation must be attached to this modifier.

Modifier 50

Modifier 50 is a modifier that allows you to report bilateral procedures performed during the same session. They are generally applicable to radiological and surgical procedures as well as certain other diagnostic services. This code should be used to perform a bilateral procedure. To indicate that it was performed bilaterally, add the modifier to the code. This modifier should not be used in conjunction with codes with bilateral descriptions. These modifiers should not be attached to procedures for midline organs such as the bladder, uterus, or esophagus. It should not be used to report on procedures that were performed on the same side as the patient.

RT & LT Modifiers

A modifier RT can be used to identify that a procedure was performed on the right side. The LT modifier is used to indicate that the procedure was performed on the left side of the patient. These modifiers provide additional information for procedures that are performed on pairs of structures such as breasts, eyes, and knees. They don’t affect the payment, but they provide essential information about the location of the service.

How do resolve denials of missing modifiers or inconsistent modifier use?

There are two things you can do if you receive a denial regarding a missing procedure code or a procedure that is inconsistent with your modifier. If you discover that the coding team made a mistake, then you can correct the modifier and submit the claim again. If the claim was not submitted correctly, but it was properly completed, you should contact the claims department. You will need to appeal if the claim is incorrectly denied.

Your practice will be better equipped to avoid claims denials by understanding the common reasons. Medicare complete medical billing services (MSO) is a specialist in increasing revenue and efficiency for medical practices. Contact us at to learn more about how our services can benefit your practice.

No Red Flags: Filing Neat, Complete, And Accurate Insurance Claims With Medical Billing Solutions

You can dramatically increase efficiency in your front office by providing medical billing specialists, transparent communication about office policies, instant insurance verification, daily cash flow monitoring, and customer-focused service.

Once you have completed these steps, you can now move on to the most important task of filing claims in accordance with federal and insurance company guidelines. Private practices are often unable to make a profit due to the fact that insurance companies don’t always calculate full reimbursements until after a claim has been filed. The financial difficulties of private practices are also caused by a few other factors:

  • Medicare:

A doctor will typically be reimbursed less than $30 when treating a Medicare patient, despite the fact that they may require more time and attention than patients who are not covered. Medicare patients have a very low time-to-profit ratio. This is true whether it’s administering specialized tests, taking vitals or answering the increasing number of questions. This marginal reimbursement can cause real harm to a practice’s bottom line depending on how accepting Medicare patients are.

  • Private insurance carriers:

Although the average reimbursement amount for a Medicare patient is almost twice that of a covered patient, the majority of covered patients do not visit the doctor as frequently as their Medicare counterparts. They also see the doctor less often for minor medical billing services issues, which can result in lower reimbursement. But don’t lose heart. You can make meaningful changes to improve your time-profit ratio. This will result in better reimbursements and a steady cash flow.

  • Add testing to the traditional doctor’s exam

Private practices are seeing more lab tests, EKGs, and other basic tests performed in-house, which means that they can make more revenue. These tests are covered by the reimbursement rate, which covers the cost of administering them. This allows the practice to recover some of the revenue lost from patients’ basic exams. Insurance carriers encourage in-house testing, as it is more economical than having the tests administered at acute care facilities.

  • Submit a “clean” claim

To receive full reimbursement from insurance carriers, the doctor must submit a clean claim. This claim should accurately document the exam and include any tests that were performed. Insurance carriers frequently audit physician documentation. The carrier may withhold reimbursements if discrepancies between claims and documentation are found. You should not conduct frivolous testing to increase your revenue. Insurance carriers are alerted to discrepancies when private practices routinely run tests that return negative results. Keep your claims clean, accurate, and complete to avoid any red flags with Medicare MSO Medical Billing services.

There are steps you can take, despite the decrease in reimbursements from carriers for basic doctor visits. You can receive prompt and possibly higher reimbursements if you file a clear claim supported by accurate documentation.

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