Incorrect Coding and Lack of Medical Documentation Leads to Inaccurate Payment

Physicians and other health care professionals are required to follow correct coding guidelines, such as those published by the American Medical Association (AMA) and the Centers for Medicare & Medicaid Services’ National Correct Coding Initiative (NCCI), to receive timely and accurate reimbursement.

A review of the bill payment appeal inquiries submitted to HCS revealed the following trends:

• Incorrect use of a modifier when a modifier is not allowed for the codes combination reported for a specific date of service.
• Failure to use a modifier where a modifier is required to identify multiple surgical procedures.
• Failure to use a modifier where a modifier is required to identify a distinct service or procedure.
• Failure to provide documentation to support the code that was reported on the bill.

When billing for medical services, you must use the CPT® codes that best describe the services performed, as referenced in AMA coding guidelines. Some CPT code combinations cannot be billed together because reimbursement for services is considered inclusive of the more comprehensive code; use of a modifier is not allowed.

Modifiers such as modifier -51 have specific guidelines. Modifier -51 must be used when reporting multiple procedures performed by the same health care provider during the same operative session. An exception is procedure codes that are listed in the CPT guidelines as -51 exempt. For these procedure codes, inaccurate reimbursement may occur without the -51 modifier.

Modifier -59 is defined as a “distinct procedural service.” Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M (evaluation and management) services that are not normally reported together, but are appropriate under the circumstances. In instances where the modifier is appropriate but not reported, the procedure will not be considered for additional reimbursement.

Remember, all billed services must be supported by medical documentation. For example, to be eligible for reimbursement of a distinct procedure billed with modifier -59, the medical records must clearly identify the distinct procedure or different anatomical site.