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CREDIT BALANCES – THE NEW RED FLAG FOR YOUR PRACTICE

What physician wants to give any money back to an insurance carrier?  Few consumers realize that unlike other business owners, physicians don’t get to set their own prices for services rendered.  Rather, they are on a “take it or leave it” reimbursement system.  So, frustration runs high when a provider is informed that there has been an overpayment on an already heavily discounted service.  These overpayments, result in credit balances.

There seems to be an uptick in the number of practices that are contacted by the State Department of Revenue and told that they are the target of a credit balance audit.  This article, Juggling the Credit Balance Dilemma, is a good overview of why this is happening and the penalties you face if you don’t resolve credit balances.  We hope you take a minute to read the article and then make sure your practice is in compliance.

Is Mod 59 a Magic Bullet?

Coding

Mod 59 codingWe’ve noticed an increase in the usage of modifier 59 (mod 59).  Oh we all want a magic bullet.  The code that will get every charge reimbursed the first time.   Although modifier 59 may get the claims paid it might not be the correct usage of the code.  After all there are no magic bullets.

Mod 59 does have a purpose. We asked a certified professional coder to explain when it should and shouldn’t be used.  Here is an explanation that you may find helpful.

Mod 59 is used on services that are commonly bundled and/or are not normally reported together. However, there are certain circumstances can be reported and paid separately.

WHEN SHOULD I USE MOD 59?

Adding mod 59 indicates that a procedure or service is distinct or independent from other non-E/M services performed on the same day.  You can use modifier 59 when

  1. the procedure is performed in a different session or patient encounter;
  2. there is a different procedure or surgery;
  3. there is a different site or organ system; or
  4. a separate incision/excision and separate lesions or separate injuries not ordinarily encountered or performed on the same day by the same individual.

For billing, bill all services performed in one day on the same claim.  Add mod 59 to the subsequent procedure if the other procedures are not normally reported together and is appropriate for the clinical circumstances.

NO ON MODIFIER 59

If a service is typically included in the performance of the primary procedure then the procedure is bundled and should not be reported with mod 59.  Modifier 59 should never be used when another more appropriate modifier exists to clarify the services performed and when the documentation does not support the separate and distinct status.

The Medicare National Correct Coding Initiative (NCCI) has also addressed the use of mod 59.  One function of NCCI PTP edits is to prevent payment for codes that report overlapping services except in those instances where the services are “separate and distinct.” Modifier 59 is an important NCCI-associated modifier that is often used incorrectly.  For more detailed information, click here for a copy of the related mod 59 article from the NCCI.