One of the most common reasons medical claims are refused is the absence of modifiers or the use of incorrect modifier combinations. Accurate treatment coding is essential, but it is also critical to add modifiers when applicable and to use the proper one for the code you are using. When your claim is refused, it not only delays payment but may result in non-payment.
Misapplying medical billing modifiers may also result in an audit, resulting in significant fines, and audits can go back many years. Medicare audit authorisations might be as much as $10,000 per incident. That implies that if you charge a modifier improperly on a claim, you might be fined $10,000 for each instance. We examined the most widely used modifiers, 59, 51, 26, and TC, and their abuse in this post. You may go over your code rules and see whether you’re making the same error.
Misuse of Modifier 59
Modifier 59 is the most commonly abused modifier among developers. Modifier 59 is a ‘Distinct Procedural Service.’ It is typically used to imply that two or more operations were done on distinct body parts during the same visit. This modification should also be used only when no other, more relevant modifier exists to explain the connection between two procedure codes. Unfortunately, it is more frequently used to prohibit one service from combining or merging with another on the same claim. It should never be used to prevent services from being packaged or to circumvent the insurance carrier’s edit process. Modifier 59 should be replaced with another modifier that more correctly defines the charged services.
Misuse of Modifier 51
Multiple surgeries/procedures are categorized as Modifier 51. Many procedures were conducted within the same surgical period on the same day. This modifier can be abused in a variety of ways. First, it can be misused when a method is better accurately represented using an add-on code. It should also not be used with an evaluation and management (E/M) service. Finally, you may employ it improperly for the wrong operation, especially if you charge Medicare claims. Modifier 51 should not be used when two or more physicians execute distinctly separate, unrelated procedures on the same patient on the same day.
Modifiers 26 and TC
The professional component (physician’s interpretation or report) of a diagnostic, laboratory, or pathology service is denoted by modifier 26, whereas modifier TC represents the technical component. It’s critical to understand when to bill worldwide and when to break down a code into professional and technical elements. Payments for a process’s technical and professional components may be made separately if, for example, a facility offers the technical component of a service/procedure. At the same time, an independent physician performs the professional component.
The physician charges the procedure code with modifier 26 added, but the institution bills the exact particular process with modifier TC. On the other hand, if a physician offers both the professional (supervision, interpretation, report) and technical components of a service (equipment, supplies, and technical assistance), that doctor would submit the global service, the process code without the TC or 26 modifications. Understanding how to correctly utilize modifiers 26 and TC is essential for filing clean claims and avoiding rejections for repeated billing.
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