Six Tips To Getting Paid For CPT Modifiers
Incorrect or incomplete coding information can prove to be expensive to medical practices. This is most often the case when additional procedures are performed with the main treatment. The codes for the additional procedures may not be entered, resulting in partial reimbursement for services. Read below for more information on the six steps to getting paid for CPT modifiers, in the article written by our own Toni Elhoms for Medical Economics magazine!nnCPT modifiers help payers understand all of the distinct services and procedures physicians perform. As the scope of practice for today’s internists continues to expand, these modifiers are also increasingly required to ensure accurate payment, says Toni Elhoms, CCS, CRC, CPC, director of coding and compliance at Welter Healthcare Partners , a healthcare consulting company in Arvada, Colo.nn
nnFor example, say an internist performs an annual wellness exam and addresses a skin lesion during the same visit. If the physician doesn’t append modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the evaluation and management (E/M) service for the lesion, most payers will disregard the E/M service and only pay for the annual wellness exam, says Elhoms.nnAppending a modifier when it isn’t warranted can also be costly. For example, an internist owns their own radiology equipment. If they append modifier -26 (professional component only) to each radiology service, they actually miss out on revenue, depending on the service, says Elhoms. For example, when appending modifier -26 to the CPT code for chest x-ray, single view (71045), physicians could lose approximately $13 for every test performed.nnElhoms cites the case of an internal medicine practice with its own radiology equipment that saw an immediate 60 percent increase in reimbursement simply by removing this modifier from the radiology CPT codes it reported.nnOn the other hand, when a physician incorrectly appends a modifier and subsequently receives payment, they could be subject to a post-payment audit. “I’ve seen so many recoupments regarding inappropriate use of modifier -25 that have put private practice physicians out of business,” says Elhoms. “There’s a false sense of security when it’s paid. Recoupment requests can come out of nowhere.”nnElhoms knows of one family medicine practice that couldn’t recover from a $250,000 recoupment after a payer audited the practice’s use of modifier -25 on E/M office visit codes when providers rendered osteopathic manipulation treatment (OMT) during the same encounter.nnThe payer alleged that the documentation didn’t support a significant and separately identifiable service, and the payer felt the OMT was part of the typical work associated with the E/M code and shouldn’t have been paid separately, she says.nnIs there anything physicians can do to collect the payment they deserve while also avoiding compliance risk? Here are six tips experts recommend:nn1. Know your payer policies.nJust because one payer accepts a modifier doesn’t mean all will, says Michael Miscoe, JD, founding partner of Miscoe Health Law LLC in Central City, Pa. For example, one payer might accept modifier -25 in all instances consistent with the CPT definition of “significant, separately identifiable” while another might not permit it at all for certain services (e.g. when a physician reports an E/M code in addition to a code for a pain management injection).nnTake the time to identify the modifiers each payer does—and doesn’t—recognize. “Check each payer’s medical policies for service-specific as well as general policies regarding separate reporting,” says Miscoe.nn2. Hire a certified coder.n
“Ideally, you would have at least one person in-house who can assist with modifiers and be proactive about monitoring denials and providing education,” says Elhoms. Another option: Keep a trusted compliance consultant on stand-by as questions arise, she adds.nn3. Focus on clinical documentation.nFor example, when physicians report modifier -25, their documentation must support the history, exam, and medical decision-making for two separate services, says Elhoms.nnThink of each service as a separate encounter even though they’re rendered during the same visit, she adds. For modifier -59 (distinct procedural service), documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual.nn4. Take a closer look at your billing system.nDoes your vendor incorporate National Correct Coding Initiative (NCCI) edits and update these edits quarterly? If so, are you certain that each payer has adopted those edits in its reimbursement policies? Do templates or billing automation encourage modifiers when they aren’t warranted or omit modifiers that are required?nn5. Append each modifier to the correct code.nFor example, modifier -59 should accompany a procedure or service code but not an office visit E/M code. Always refer to the NCCI procedure-to-procedure edits or specific payer bundling rules when determining what procedure or service code should include this modifier.nnExample: When reporting an excisional biopsy and lesion destruction, append modifier -59 to the code for the lesion destruction. When removing an intrauterine device and inserting a Nexplanon during an office visit, append modifier -59 to the code for the IU removal. Modifier -25, on the other hand, is always appended to an E/M office visit code when supported by the circumstances of the encounter, says Elhoms.nn6. Know what to do if you run into payment problems.nConsider the following advice:nnBalance bill the patient. While most payer contracts don’t permit this, a physician who is not under contract with a commercial payer may have the option to do so if all other state statutory advance notice requirements are met. Physicians are not permitted to balance bill patients with Medicare, and some states are enacting statutes to limit exposure of patients to either non-covered service costs or disallowed amounts for services that are covered, says Miscoe.nFight the denial. If the payer hasn’t published a policy on modifier usage, physicians may be able to successfully appeal the denial by citing standard industry guidance (e.g., CPT definitions of various modifiers, the NCCI Policy Manual for Medicare Services, or even medical policies of other major commercial payers), says Miscoe.nNegotiate your payer contracts. Ask payers to accept modifiers in all or certain circumstances, says Elhoms.nnTaking proactive steps to ensure compliant use of modifiers pays dividends in the long run, says Elhoms.nnOriginal article published on Medical Economics.
This is a 46-year-old black female. She had prolapsed uterus causing her pressure, but she also had 2 previous bladder repair procedures that we removed the mesh, removed the suture, gave her proper time of healing, give her Estring cream for re-estrogenizing the vagina, and then we decided to go ahead and repair this. So, the patient was prepped and draped in the usual manner. Observing all aseptic technique, she was given a general anesthetic and prepped and draped. We put in a uterine manipulator and a Foley catheter and then we turned our attention to the above. We put in 4 port sites. These port sites were docked to an X1 robot, 1 port was for the camera, 1 port was for the PK bipolar cautery and laparoscopic scissors of the port, and then we had an assist port. The patient was docked to the patient’s side-docking in a steep Trendelenburg position. Then, we turned our attention to the console.nnAfter the patient was docked appropriately, we want on inspecting and saw a large right ovarian cyst that we thought would need to be removed. We looked at the left side. The left side was totally normal. So, we started on the left side at the round ligament. This was cauterized with the PK and then laparoscopically we cauterized and then developed an anterior and posterior aspect of the broad ligament. Then, we looked at the infundibulum and in the ovarian ligament. This was cauterized until secure, and then, laparoscopically we used scissors for cautery as well as to excise the tissue. We skeletonized and want down to the bladder flap anteriorly and went posteriorly and then we skeletonized and saw the uterine vessels they were cauterized until secure.nnThen, we turned our attention to the right side, which was a large ovarian cyst. We took the right ovary by going through the infundibulopelvic pelvic 1igament, IP. This was cauterized and cut until secure and then we went up to the broad ligament inc1uding removing the fallopian tubes and then the round ligament. We excised anteriorly again to deve1op bladder flap posterior1y just to get down to the uterine vessels that were cauterized. Then, once they were cauterized and secure next our attention to pushing the bladder well off the cervix. By using the uterine manipulator, the caudal ligaments were secure and then we circumferentially removed the cervix and then we pulled it out the cervix.nnThe uterus and the right tube and ovary through the vagina, irrigated, and then we used the V-Loc running locked stitch to secure the cuff, running it forward and backwards for good hemostasis. AlloWrap was used to put on the cuff to prevent any adhesive disease, and then we put in a pain pump, On-Q pain pump for pain. This was put in without complications. Then, as my assistant was closing the port site and undocking the robot, I turned my attention to below.nnAt this point, the patient was still in the dorsal lithotomy position, 1.5 cm from the urethral meatus, we did do a vertical incision and removed that 1 stitch that was from a previous surgery and then undermined until we got to the operative fossa. This was done bilaterally and at the level just below the pubic ramus, but also below the obturator fossa and then we used the Co1oplast TOT, and we anchored it on one side to the left side first and then we made sure the sling was lying flat and at the center of the posterior urethrovesical angle and then the second right side was placed and without complications.nnWe secured it and tied it up with tension. Then, we cut the suture and then we reapproximated the incision with 0 and 3-0 Vicryl in a running locked stitch. We took out the catheter. There was no need for cystoscopy since we did not do a TVT or TOT. The urine was clear. There was no air into the Foley catheter. We discontinued the procedure. The patient was transferred to the PACU in satisfactory condition.
Healthcare costs have been an increasingly popular conversation among doctors, patients, insurance companies and even the government. Colorado Governor, Jared Polis is getting involved and proposing the potential of reducing healthcare costs in Colorado. Read the article below from KOAA News5 of his new plan.nnDENVER – Gov. Jared Polis and Lt. Gov. Dianne Primavera announced their plan to reduce healthcare costs for Coloradans Thursday morning in Denver.nnGov. Polis laid out his “Roadmap for saving Coloradans money on healthcare” in an announcement outside Denver Health.nnThe plan featured six main points, which Polis billed as short-term solutions to reducing health care costs.n
nnRecently the Office of Inspector General’s (OIG) website has posted cases of recent penalties that practices and providers have been charged due to incorrect billing of Incident-To. Are you at risk? The numbers are stomach turning and something that every practice should be aware of. We aren’t just talking about the huge hit in penalties, which are in the hundreds of thousands of dollars, but factor in the 15% hit you will take to your reimbursement for claims. With numbers like that it could mean a small practice having to close it’s doors.nnIncorrect submission of these claims is not something any practice aims to do. However, not submitting these claims is leaving money on the table. Read below for the enforcement actions as stipulated by the OIG and contact us today for more information.nn
Welter Healthcare Partners acknowledges the contributions of physicians to the overall health and well being of our communities. We would like to wish all physicians and specialists a very Happy Doctor’s Day, 2019. nnWe value your service and dedication.nn
You’ve just been assigned a major project. Naturally your mind is racing with a million different thoughts on where to start and what you’ll need to get the job done on time. As a result, you start creating a to-do-list that is massively bulky.nnThe problem with these out-of-control to-do-lists is that they’re overwhelming and prevent you from being productive. That’s because you’re multitasking and directing your energy to unimportant tasks and activities.nnInstead, keep your to-to-lists lean and mean by only focusing on your 3 to 5 most urgent, important, and challenging tasks for the day, aka your Most Important Task (MIT). Focus on one task at a time before moving on to less critical tasks. When you do, you’ll feel more productive and less anxious.nnLou Babauta of ZenHabits suggests that at least one of your MITs should be related to your goals and you should work on them in the AM Whether if it’s at home or in the office, tackle your MIT first thing in morning.nnAccording to Lou, “If you put them off to later, you will get busy and run out of time to do them. Get them out of the way, and the rest of the day is gravy!”nn2. Measure your results, not your time.nWhen it comes to productivity we often focus on how long something takes to complete; as opposed to what we actually accomplished in a day. For example, you just spent four hours writing a 1,000-word blog post. You may be be a bit bummed since that took a nice chunk out of your day.nnBut, what if you focused on the smaller parts of the blog post? For example, you broke into five 200-word sections, formatted it properly, added headings, ran a spellcheck and added images. Suddenly you realize you actually completed a lot in that timeframe.nnIn fact, research from the Behance team found “that placing importance on hours and physical presence over action and results leads to a culture of inefficiency (and anxiety).”nn”The pressure of being required to sit at your desk until a certain time creates a factory-like culture that ignores a few basic laws of idea generation and human nature: (1) When the brain is tired, it doesn’t work well, (2) Idea generation happens on its own terms, (3) When you feel forced to execute beyond your capacity, you begin to hate what you are doing.”nnOne way to assist you with measuring results instead of time is by generating done lists. This is simply an ongoing log of everything you completed in a day. By keeping this list you’ll feel more motivated and focused since you can actually see what you accomplished.nnAdditionally, according to Buffer co-founder Leo Widrich, done lists allow “you to review your day, gives you a chance to celebrate your accomplishments, and helps you plan more effectively.”nn3. Have an attitude adjustment.n
The team over at Mind Tools state that we’re more effective at work when we have a “positive attitude.”nn”People with a good attitude take the initiative whenever they can. They willingly help a colleague in need, they pick up the slack when someone is off sick, and they make sure that their work is done to the highest standards.”nnAnd, you’ll never hear them say that their work is “Good enough.” That’s because they go above and beyond.nnFurthermore, a good attitude at work will help you set standards for your work, ensure that you’re taking responsibility for yourself, and make decisions easier since they’re based on your intuition. “This admirable trait is hard to find in many organizations. But demonstrating ethical decision-making and integrity could open many doors for you in the future.”nn4. Communicate, communicate, communicate.nRegardless if you’re freelancer, entrepreneur, or employee, there will be times when you will have to work with others. As such, you should strengthen your communication and collaboration skills. When you do, you’ll eliminate unnecessary rework and wasted time from straightening out any misunderstandings and miscommunications.nnYou can start by enhancing your active listening skills and staying on one topic when communicating. For example, when composing an email, keep it short and to point. Don’t throw too much information in the message since it will only confuse the recipient.nn5. Create and stick to a routine.n”We are creatures of habit, and so are our brains. When we establish routines, we can carry out tasks faster since we don’t have to ‘think’ about the task – or prepare for it – as much, and can work on autopilot,” says Hallie Crawford, a certified career coach, speaker, and author.nn6. Automate more tasks.n
Want to the secret of getting more done? Reduce the amount of decisions you have to make throughout the day. That’s why Mark Zuckerberg wore that same outfit for years. Most days he still does. It prevented fatigue. I will say though, I tried this and it was hard on my relationship with my wife. Make sure you find your balance.nn”The counterintuitive secret to getting things done is to make them more automatic, so they require less energy,” wrote Tony Schwartz, president and CEO of The Energy Project, in the Harvard Business Review.nn”It turns out we each have one reservoir of will and discipline, and it gets progressively depleted by any act of conscious self-regulation. In other words, if you spend energy trying to resist a fragrant chocolate chip cookie, you’ll have less energy left over to solve a difficult problem. Will and discipline decline inexorably as the day wears on.”nnIn other words, build routines and habits so that you’re not deciding. You’re just doing. Hence why Zuck wore the same clothes everyday. By eliminating those silly or frivolous, he could focus all of his energy on more important work decisions.nn7. Stop multitasking.nWe all believe that we’re multitaskers. In fact, humans just aren’t capable of doing multiple things at once.nn”People can’t multitask very well, and when people say they can, they’re deluding themselves,” said neuroscientist Earl Miller. “The brain is very good at deluding itself.”nnInstead, we’re simply shifting our attention from one task to another very quickly.nn”Switching from task to task, you think you’re actually paying attention to everything around you at the same time. But you’re actually not,” Miller said.nn”You’re not paying attention to one or two things simultaneously, but switching between them very rapidly.”nnIn fact, researchers have found that they can actually see the brain struggling when multitasking.nnSo the next time you have the urge to multitask, stop. Take a breather and then go back to focus on the one thing that needs to get done right now. Once that’s done, then you can move on to something else.nn8. Take advantage of your procrastination.nThis may sound counterproductive. But, there’s actually a method to the madness here.nnAccording to Parkinson’s Law, which was named after after historian Cyril Northcote Parkinson, “If you wait until the last minute, it only takes a minute to do.”nnThink about it. You’ve had a deadline at work looming over your head for a month, but you just cranked it during the final week.nnThis doesn’t give you permission to wait until the 11th hour. It does, according to Thai Nguyen of the TheUtopianLife.com, provide “great leverage for efficiency: imposing shorter deadlines for a task, or scheduling an earlier meeting.”nn9. Relieve stress.n
Since stress can cause physical, emotional, and behavioral problems – which can impact your health, energy, well-being, and mental alertness – it’s no surprise that stress hinders your work performance.nnThe good news is that you may be able to relieve that workplace stress.nnAccording to the American Psychological Association, “the most effective stress-relief strategies are exercising or playing sports, praying or attending a religious service, reading, listening to music, spending time with friends or family, getting a massage, going outside for a walk, meditating or doing yoga, and spending time with a creative hobby.”nnThe least effective strategies, however “are gambling, shopping, smoking, drinking, eating, playing video games, surfing the Internet, and watching TV or movies for more than two hours.”nnAnother effective stress management technique is to increase your control of a situation in advance. You can start by planning tomorrow the night before and sticking to your routine. This way you know what to expect in the morning.nn10. Do more of the work you enjoy.nNot everyone is privileged enough to do what you love for a living. Even if you are chasing your dreams and following your passions, there will still be tasks you’re not fond of doing. In either case, focus more on the work that you actually enjoy doing.nnFor example, if you’re a chef, then you obviously have a love for cooking. Instead of spending your days doing administrative tasks, outsource or delegate those tasks so that you can spend more time in the kitchen or at the market finding fresh ingredients.nnWhen you do, you’ll feel more fulfilled, inspired, challenged, and productive.nnOriginal