Clearing CPT modifier mysteries

May 1, 2007

Virtually every modifier came about in response to some abuse by physicians that has been identified by the Centers for Medicare and Medicaid Services.

"One should use modifiers frequently in order to communicate with the insurers so that one is paid properly," says Brett Coldiron, M.D., clinical assistant professor of dermatology and otolaryngology, University of Cincinnati.

Granted, he says, the process can be awkward: "It's sort of like programming their computer. They should be able to figure these things out for themselves, but they can't."

Virtually every modifier came about in response to some physician abuse identified by the Centers for Medicare and Medicaid Services (CMS), he adds. But without them, Dr. Coldiron says a doctor would spend a lot of time "explaining why one should be paid," and not reaping nearly what his or her services are worth.

The important modifiers

This modifier gets frequent use, Dr. Coldiron tells Dermatology Times. If a patient with a history of skin cancer comes in for a total body skin exam which reveals a couple of actinic keratoses (AKs) that need to be frozen and a few lesions that require biopsies, one must indicate with a -25 that one saw the patient for a separate evaluation service on the same day as a procedure, he explains.

"You didn't just destroy AKs and do biopsies - you had to make an evaluation and management judgment that these things needed to be done."

In such situations, he says, "You must discuss at length what you're going to do and how." Accordingly, Dr. Coldiron explains, "It's appropriate to bill a consultation code with a -57 decision for surgery behind it. That way you'll get paid for the consultation the same day you excised the tumor."

Also, he recommends making it clear in one's notes that the procedures involved two different lesions.

"I use this modifier all the time," Dr. Coldiron adds.

However, he says that when one excises a tumor and repairs it with a flap, "You cannot use -59 to get around not getting paid for the excision. The excision of the tumor is included in the flap" under CMS rules.