Modifier 59 Errors

EXAMPLES OF MODIFIER 59 ERRORS

Your organization is losing money. The OIG HHS reported that nearly 42% of Medicare claims for E/M services are incorrectly coded resulting in $6.7 billion in overpayments. A recent review of E/M services by the CERT (Comprehensive Error Testing) contractor revealed that the most common error found for E/M services is the lack of documentation to support the level of E/M billed. This led to downcoding of the billed E/M services. Overpayments or downcoding, you’re leaving money on the table and putting your organization at risk.

CPT® (PROCEDURE) DOCUMENTATION TRENDS: MODIFIER 59 ERRORS

Where procedures are applicable, there is an increased number of cases in which the documentation supported reporting additional CPT® codes. Across all specialties, the data is showing a 5% opportunity for the reporting of additional procedural services. In our snapshot, primary care specialties show a higher rate of 13%, whereas for the specialists show only a 2% opportunity. Practices should review their EMR systems as well as provider workflows to ensure all services performed are billed.

The overall accuracy rate for procedural services is only 82%, leaving ample opportunity to improve documentation. The documentation for the majority of the records reviewed showed evidence that the procedural service or test was performed, however, lacked specific requirements such as a detailed interpretation or procedure details. The most common of these services include EKGs, injections, and lab services.

Another common error trend is the inappropriate use of modifier -59. This modifier is used to specify circumstances that necessitate more than one procedure being performed on the same date of service. During our audits, we see a trend in which this modifier is used to unbundle services inappropriately. National Correct Coding Initiatives define when codes may and may not be reported together and should be followed. Additionally, with the advent of modifiers XP, XE, XS, and XU, modifier -59 may no longer be the most specific and should be used only if there is no more appropriate modifier available.

We reviewed the OIG HHS report, regional CERT reviews, and examined auditing trends from Healthicity. And it’s easy to see what a lot of organizations are getting wrong and why auditing is a necessary and critical part of your compliance plan.

Download this free eBrief, How NOT to Leave Money on the Table in 2018, to learn how to use tools to identify learning opportunities, measure your providers against national trends, and improve your bottom line.