Some people read mystery novels, some people can read body language but medical coders can read claims. Some claim lines are simple to read. The patient comes into a physician office, has an office visit for asthma treatment. A single CPT® code and a single diagnosis code is all she wrote. If the patient also received a nebulizer treatment at the visit with albuterol, then the story is more interesting and it needs a modifier.
Missing CPT® modifiers
What if that claim was submitted like this, without modifiers?
Either the office visit or the nebulizer treatment would be denied, depending on how the payer’s claims editing system works.
The correct way to submit the claim:
Here’s a Dermatology example I saw recently. The claim was submitted as:
Checking NCCI edits, 11100 is a component code of 17000, but may be submitted with a modifier. The documentation supported two separate lesions, one was biopsied and one destroyed. The code with the highest RVU is submitted first with no modifier, and the second is submitted with modifier 59 because it was a bundled service.
The correct coding is:
The case of the misplaced modifiers
Staying in Derm, I reviewed this claim recently:
- 17003-51 × 2
The documentation confirmed that a malignant lesion and three pre-malignant lesions were destroyed. The service with the highest RVUs should be submitted without a modifier. Since the second service is bundled per NCCI, it needs modifier 59, not modifier 51. And, add-on codes don’t require modifiers. The correct coding is:
- 17003 × 2
Using modifiers correctly gets your claim paid the first time.
Using modifiers incorrectly results in one of two bad outcomes: you get paid for services you were not entitled to be paid for or your claim is denied, partially or in full. Both of these outcomes need to be avoided!
Watch Using modifiers correctly: every claim line tells a story to learn how to avoid misplacing and missing modifiers on physician claims.