Navigating Coding Modifiers

What ASCs need to be on the lookout for BY SAHELY MUKERJI


oding modifiers—usually two digits—can increase or decrease

reimbursement and cause claims not to be paid properly or denied if used incorrectly or not used when neces- sary. “Modifiers are added to the main procedure code to signify that the pro- cedure has been altered by a distinct factor,” says Stephanie Ellis, RN, pres- ident of Ellis Medical Consulting Inc. in Franklin, Tennessee. “Modifiers are accepted by most payers.” ASC coders might want to use extra

caution when using the following cod- ing modifiers.

Modifiers -33 and -PT: “These mod- ifiers essentially communicate to the payer that the service qualifies as a preventative or screening service and, as such, higher benefit levels, when applicable, should be applied,” says Rebecca Geise, president of NSN Rev- enue Sources LLC in Tampa, Flor- ida. “These modifiers are used most often when screening colonoscopies are scheduled but turn into diagnos-


tic or therapeutic because an issue is encountered, a polyp for example.” If an ASC wants to use these modi- fiers it must make sure that the patient is asymptomatic when coming to the ASC for a colonoscopy because these are for screening tests only, says Paul Cadorette, director of education at MD Strategies in Houston, Texas. “One of the issues that we have with a screening colonoscopy is that when the doctors dictate diagnoses, they dictate symp- toms,” he says. “The physician’s office schedules the procedure as a screen- ing colonoscopy with no mention of the signs and symptoms the patient is expe- riencing. It isn’t until the patient either presents or has the colonoscopy that the doctor documents not only the screen- ing colonoscopy but also signs and symptoms such as diarrhea and rectal bleeding. When the physician lists those symptoms as diagnoses, the patient is no longer considered asymptomatic based on the information contained in the operative report, and this can lead to errors in coding and billing.”

An ASC must take the time to make it clear to a patient before a colonoscopy that if a polyp is found and removed during the procedure, the procedure would not be coded as screening any- more but as a therapeutic procedure and the patient would have to pay his or her portion, Cadorette emphasizes. “In addition, not all patients have screening benefits,” he says. “Under the Patient Protection and Affordable Care Act (PPACA or ACA), if some- one was enrolled in a plan through his or her employer prior to March 23, 2010, their plan could be grandfa- thered. If grandfathered, the plan is not required to provide coverage for these different types of screenings.” Going forward, ASCs must remain

aware of any changes that a possi- ble repeal of the ACA will have with regard to screening services, he says. It also is important to remember that the use of these two modifiers is payer and code type specific. “The -PT modifier is used when billing a colo- noscopy claim to Medicare and the -33 modifier is for use on claims filed to commercial payers,” Ellis specifies. “However, some commercial plans allow use of the -PT modifier.”

Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30