Updated: Sep 1, 2021
1. If I use a modifier, I will get paid for this service
The purpose of the modifiers is to communicate to the payer that services that are typically bundled or not paid separately should be paid separately under specific circumstances. It is important to use modifiers only if the clinical circumstances justify it. A modifier should not be appended to a HCPCS/CPT code solely to bypass an NCCI PTP edit if the clinical circumstances do not justify its use. Make sure you have clearly documented the service to support the modifier you are choosing to use. Appending a modifier to a code indicates records are available for review that support the modifiers use.
2. I always use my EHR validation tool. If the coding passes validation, then the claim is accurate and coded correctly
Validation tools only check for NCCI Procedure-to-Procedure edits and LCD rules for CPT/ICD-10 coding errors. They are not designed to validate coding or modifier usage accuracy. So just because the code choice passes validation, it does not mean it is accurately billed. All billing and coding must originate from the documentation and be those that best describe services and condition.
3. My patients all have serious health issues and are considered high risk. Using the highest level E/M code is appropriate (99204-99205, 99214-99215)
Routine billing of the highest level of E/M codes are a red flag for audit. A payer may expect documentation to be submitted or may request records for post-payment review. These codes often require prior approval under some contracts and may even be excluded from the fee schedule. The best advice for billing these codes is FOLLOW THE RULES AND DOCUMENT. The documentation guidelines for E/M services changed this year (2021). It is recommended that health care providers and their billing staff receive regular training on these guidelines to ensure compliance.
4. I can charge for an office visit and a procedure at the same time if I use the modifier -25
Modifier -25 can be used to describe a “significant, separately identifiable E/M service same physician or other qualified health care professional provides on the same day as the procedure or other service.” Documentation is the key as many times the payer will request documentation either before payment or after payment. Bill with caution. Over-use of this modifier may be seen as an attempt to bypass PTP (procedure-to-procedure) edits. Avoid potential audit by ensuring the documentation is clear.
5. If I do multiple procedures, I need to use modifier -59 so I can get paid for all of them
Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. It is described as “the modifier of last resort” and is always appended last when other modifiers are used on the same code. As with modifier -25 documentation may be requested and is typically required prior to payment. However, payers may process claims with this modifier and pay the provider. Remember that this modifier is one of the top audit triggers so avoid using this modifier unless the documentation clearly supports.
Different procedure of surgery
Different site or organ system
Separate incision/excision, separate lesion
Separate injury (or area of injury in extensive injuries)
Not ordinarily encountered or performed on the same day by the same individual
6. I don’t have to look up the codes in a code book. The billing slip is a coding cheat sheet. I can just use that
Billing slips and encounter forms are a common communication tool in medical practices. They are often misused as a coding tool, but that is not their purpose. An audit of billing slips shows that these documents may not be regularly reviewed for accuracy and many times contain outdated or truncated verbiage that could cause confusion and erroneous coding. Coding should always start with the documentation and a comparison of the documentation with current CPT and ICD-10 code sets.
7. I only have to follow Medicare billing and coding guidelines when I am billing Medicare
Many payers follow Medicare guidelines. Payers may have their own rules, based in Medicare guidelines and will follow current regulation. Regardless of who the payer is, understanding the documentation guidelines and billing and coding rules set forth in each contract should be clearly understood and followed by all persons in the billing process. Always read and understand each payer contract to ensure compliance and protection from an audit.
8. As long as I have not intentionally billed incorrectly, I won’t be held liable for any wrong-doing
Unfortunately, this is untrue. The verbiage in the regulations is clear. Anyone who knowingly submits or causes to be submitted an incorrect claim can be held liable under the False Claims Act. The FCA states that “the terms "knowing" and "knowingly" mean that a person, with respect to information (1) has actual knowledge of the information; (2) acts in deliberate ignorance of the truth or falsity of the information; or (3) acts in reckless disregard of the truth or falsity of the information, and no proof of specific intent to defraud is required.” Penalties for submitting false claims include monetary and other penalties up to and including incarceration.
Practices should fully understand how to bill for the services they render starting with proper documentation. When all coding is done from the documentation, the practice can be confident that their claims will stand any scrutiny.