Proper Modifiers Maximize Reimbursement
By Edwina Sprow, CPC
Vol. 13 No. 8 P. 14
Incorrect modifier usage stands as the No. 2 reason for lost reimbursement in radiology practices, defined as either the wrong modifier being appended to a claim or no modifier being used when required. (The No. 1 reason is selecting the wrong code or incorrect documentation.)
Where a radiology service is performed, who owns the equipment, and who is performing the interpretation all factor into when (and which) codes should be submitted with a modifier. Radiology procedures are defined as global services and fall in the 7xxxx series of the CPT book. For example, the radiology code 71020 (two view chest, frontal and lateral) is considered a global CPT code, as it consists of the professional component and the technical component combined. The relative value units have been calculated to include the expense for the whole package. When charging for only a portion of a service, a modifier must be appended to the code on the CMS-1500 form to indicate a reduction in reimbursement is owed to the service provider.
The most common modifiers in radiology billing are 26, TC, 76, 77, 50, LT, RT, and 59. The following is a brief explanation regarding each modifier:
• 26, professional component: When a radiologist is only interpreting films or imaging/tracing and is not providing the machinery, this modifier should be added to the code on the claim form. Typically, this occurs when a radiologist is reviewing for a hospital, an ambulatory surgery center (ASC), or a doctor’s office that owns the equipment and provides the staff but requires the radiologist to interpret the images and write reports.
• TC, technical component: This modifier covers the expense of the staff, machinery, equipment, and nonprofessional interpretation elements required to provide a radiological film or image/tracing. Oftentimes, a hospital, ASC, or office will use this modifier when submitting a claim for a radiological service performed.
Modifiers 76 and 77 are similar in that they relate to the same radiological service performed on the same date of service; however, the provider of service determines which modifier is selected for the additional service performed.
• 76, repeat procedure, same physician: When a procedure or service must be performed again on the same date of service by the same physician (regardless of the outcome), this modifier should be included with the CPT code on the CMS-1500 form.
• 77, repeat procedure, different physician: This modifier should be included with the CPT code for the same scenario involving modifier 76 but when a different physician performs the repeat procedure. (Note: Medicare considers all physicians in the same group practice with the same specialty to be the same physician.)
• 50, bilateral procedure: This modifier relates to circumstances in which both sides of the body are imaged or a procedure is performed on both sides of the body. Do not use this modifier if the code is written as a bilateral procedure or service, as it is expected to be performed on both sides. Also, “both sides” does not mean front and back (AP/PA and lateral); it refers to right and left sides.
• LT/RT, left side/right side: Depending on the side of the body that is imaged, one of these modifiers is be appended to the code to reflect only one side was imaged.
Keep in mind that some payers may not acknowledge modifier 50 to reflect bilateral sides. If this is the case, two line items will be reported: one with modifier LT and one with modifier RT. Modifier 50 is typically used more often than modifier LT/RT; however, payers generally dictate how these get used. Contact your payers, Medicare administrative contractors (MACs) and Medicaid integrity contractors (MICs) to ensure what they expect, as some MACs and MICs will not take modifier 50 under any circumstance, while others won't take LT/RT.
In general, commercial plans will expect to see modifier 50 if a service is performed bilaterally and the procedure is not written as a bilateral service. If a service is performed on one side or the other, then the payer will expect to see modifier LT or RT. The payer will also expect to see modifier 52 if the service is written as a bilateral service (further explanation below).
• 59, distinct procedural service: Ever since the 2005 Office of Inspector General (OIG) Work Plan noted prevalent error rates for modifier 59, it has been monitored closely. In regard to modifier 59 usage, the Centers for Medicare & Medicaid Services gives the following guidance:
Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier 59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, 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 physician. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.
Modifier -59 is an important NCCI-associated modifier that is often used incorrectly. For the NCCI its primary purpose is to indicate that two or more procedures are performed at different anatomic sites or different patient encounters. It should only be used if no other modifier more appropriately describes the relationships of the two or more procedure codes. (For more information, visit www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/downloads/modifier59.pdf.)
As such, it is important to research all potential modifiers available prior to selecting modifier 59. This modifier will be of most use to interventional radiology coding as well as diagnostic radiology and nuclear medicine coding when multiple services are performed on the same date.
Modifiers 52 and 53, which are utilized less frequently, are to be used when a service is started and not performed to its full extent for any reason. These modifiers yield a partial reimbursement.
• 52, reduced services: Under certain circumstances, a service or procedure is reduced or eliminated at the physician’s discretion. For instance, only a portion of a service may be required, but there is no CPT to best describe this scenario, such as when a code calls for supervision and interpretation and the surgeon provides the supervision while the radiologist provides only interpretation. In such a case, don't forget modifier 26 if providing only the interpretation.
• 53, discontinued services: Under certain circumstances, a physician may elect to terminate a surgical or diagnostic procedure, often due to the well-being of the patient or staff. Do not use this modifier if anesthesia has not yet been administered.
• 25, separate procedure during an evaluation and management visit: If a radiologist performs office visits and/or consultations and performs procedures (not 7xxxx codes) that are separately identifiable on the same date of service, then modifier 25 should be used. However, if the radiologist knew the patient was coming for the procedure on that date of service, then the evaluation and management (E/M) will be considered part of the global package for the procedure. In this case, modifier 25 would not be appropriate, and the E/M would not be chargeable at this visit.
As modifier 25 has been noted on the OIG Work Plan, it is also being closely watched. As such, ensure that the E/M is not associated with the procedure for which the patient is being seen on that date of service. (For a 2008 Radiology Today article that further details the usage of modifier 25, visit www.radiologytoday.net/archive/rt_110308p8.shtml.)
In radiology, several modifiers can be used for one CPT code, depending on the situation, such as modifiers 26, 59, and RT or modifiers 26, 52, and 59.
It is important to note that radiologists should not decrease the fees they submit to payers, as payers will do that themselves when a modifier 52 or 53 is submitted. However, fees should be increased when modifier 50 is submitted, with two units added when reporting on one line item because the payer will not automatically increase its reimbursement if the rates aren’t already increased.
— Edwina Sprow, CPC, a coding specialist for North Scottsdale Family Medicine Associates in Arizona and a member of AAPC, has more than 25 years of experience in the healthcare industry.