Can a Billing Partner Help Improve Your Revenue

Can a Billing Partner Help Improve Your Revenue

Author : Akhil Singhal Post Date : September 16, 2021 Total Views: 367

Increasing the number of new patients while retaining current patients is vital to the success of any physician’s practice. But, unless that practice receives steady, profitable cash flows throughout most revenue cycles, they may be unable to stay operational.

Even before the COVID-19 pandemic, the dilemma of whether to do in-house medical billing or outsource medical billing beleaguered many physician-owned practices. Now that the healthcare industry is inundated with COVID patients and people suffering long-COVID symptoms, physicians are discovering the numerous benefits of relying on billing partners. According to Grand View Research, the medical billing partner market is expected to exceed $19 billion by 2026. That’s a nearly 12 percent annual growth rate!

How Can a Billing Partner Improve Medical Revenue?

Ensures Accurately Coded Claims

What is fueling this rush by physicians to find the best medical billing partner they can depend on for superior service? One of the leading reasons behind the skyrocketing billing partner market involves the necessity for filing claims correctly. Unless claims are coded accurately and error-free, they will be returned and the physician will suffer an interruption in cash flow.

An estimated 80 percent of medical claims and billing documents contain at least one error that prevents physicians, clinics and hospitals from getting paid. With over 80,000 diagnostic and procedure codes to comb through, medical assistants and physician staff simply don’t have the time to consistently submit 100 percent accurate claims. Unfortunately, the cycle of submitting claims, getting back rejected claims, finding and fixing errors and resubmitting them can force providers to wait for months before receiving payment.

A professional medical billing partner provides trained, knowledgeable billing and coding specialists who’s job is to do one thing: submit correct claims the first time. This allows physicians and their staff to focus solely on patients and running the office as efficiently as possible.

Handles the Collections Process

One of the most time-consuming tasks of a physician’s practice is collecting past due payments. Doctors can tell you from experience that simply sending past due notices is ineffective for settling a past due bill. Moreover, when doctors decide to sell a debt to a collection agency, they lose most of that revenue.

Billing partners take care of collecting past due payments. They employ individuals who specialize in collecting debts by working one-on-one with patients, verifying addresses of patients who have moved and informing patients of payment options available, such as credit cards, other types of insurance or local social agencies.

Increases Revenue by Adhering to Insurance Regulations

Major insurance companies, including Medicaid and Medicare, are constantly changing guidelines regarding what treatments they cover, patient eligibility and how much they will pay for certain procedures. Trying to keep up with the constant deluge of modifications to insurance rules is literally a full-time job that a busy physician’s office finds difficult to manage properly.

A medical billing partner stays up-to-date in real time to changes made by health insurance companies. This means claims won’t be rejected for including obsolete or incorrect data. In addition, many updated insurance guidelines for Medicaid or Medicare come from changes made by the federal government. Continuous noncompliance with federally mandated adjustments may result in losing compensation provided by Medicaid and Medicare.

Is Outsourcing Medical Billing Right for Your Practice?

Consider the following summary of the benefits of hiring a medical billing partner:

  • Significantly improves cash flow and revenue by eliminating costly errors and claim returns
  • Reduces overhead expenses
  • Less expensive than purchasing and constantly upgrading medical billing software (software cannot manage debt collections nor handle problems best suited for human-to-human contact)
  • Professional medical billing partners provide detailed monthly reports regarding claims sent, collections, payments and other important items
  • Allows physicians and staff to spend more quality time with patients
  • Ensures physician practices comply with ever-changing federal insurance regulations

Call today to learn more about how a medical billing partner can give the advantages you need to make your practice a long-term success.

Optimize your operational efficiency and revenue with our state of art RCM Technology Platform. Schedule an online demonstration now.

Optimize your operational efficiency and revenue with our state of art RCM Technology Platform. Schedule an online demonstration now.

Optimize your operational efficiency and revenue with our state of art RCM Technology Platform. Schedule an online demonstration now.

Optimize your operational efficiency and revenue with our state of art RCM Technology Platform. Schedule an online demonstration now.

Optimize your operational efficiency and revenue with our state of art RCM Technology Platform. Schedule an online demonstration now.

Optimize your operational efficiency and revenue with our state of art RCM Technology Platform. Schedule an online demonstration now.

Optimize your operational efficiency and revenue with our state of art RCM Technology Platform. Schedule an online demonstration now.

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Inhouse Billing Vs. Outsourced Billing

Inhouse Billing Vs. Outsourced Billing

Author : Akhil Singhal Post Date : September 8, 2021 Total Views: 975

Many small medical practices still do their billing in-house. The success or failure of your billing team can make or break your practice as a business. However, it can be one of the most difficult functions your staff performs. You might have a crack team of billing analysts who are also great at collections. Chances are, though, that you will get better results with a company that specializes in billing and collecting millions of dollars a month for various clients.

In this article, we talk about the difference between in-house and outsourced billing, discuss the pros and cons of each and give you a look at the cost and savings associated with an outsourced solution. If you aren’t ready to hand over 100% of your billing operations, you can start with a hybrid approach, such as seeking assistance with collections and simplifying your billing system.

Whatever you decide, OmniMD has solutions that can help your front desk and back-office crew minimize mistakes, improve efficiency and increase patient satisfaction.

In-House Vs Outsourced Billing Comparison

In-house medical billing typically consists of billing clerks entering medical codes into billing software that interfaces with insurance companies and other payers. It also involves handling various aspects, such as reporting, required to close the revenue cycle.

When you outsource your medical billing, you or your business manager engages with a third-party company that specializes in billing, collections and other aspects of the revenue cycle. Ideally, this gives physicians and staff members more time to focus on patients and day-to-day operations.

Let’s take a deeper dive into the pros and cons of both options to give you a clearer picture of which one would work for you.

In-House Medical Billing

Many physicians or other practitioners decide to keep their billing in the hands of their staff. You may feel more comfortable having oversight over revenue and collections, and that’s understandable.

You may not want to trust a third party with your patient information or the part of your business responsible for bringing in the money. However, there are pros and cons of using EHR billing software versus customized billing solutions from a third party. You might be surprised what you would find if you crunched the numbers, taking into account the total cost and savings of each option. Additionally, you should consider factors such as accurate billing and timely entry of payment requests.

You may feel you have effective billers who enter data and collect payments efficiently. Therefore, switching to an outsourced solution may seem counterintuitive. With in-house personnel, you can walk down the hallway to check on a billing issue. When you outsource this function, you have to contact the billing company,

However, there’s a price for this convenience. When you pay billing analysts and billing clerks directly, you also have numerous administrative costs that are lower or nonexistent when you go with an outsourced billing provider.

Many practices are still feeling the crunch of government regulations that resulted in lower reimbursements. If you want to save money, you can’t just cut salaries or hire less qualified people. However, if you transition to an outsourced billing company, you may realize significant cost savings.

In-house billers often lack the necessary support to perform at their highest level on every task. Additionally, small offices may only have one or two people doing the billing. If someone quits or gets sick, you’re going to see a major reduction in revenue until you are once again fully staffed.

Pros and Cons of In-house Billing


  • Maintain control
  • Proximity
  • No need to invest in a new system


  • Administrative burden
  • Higher staffing and support costs
  • Subject to turnover and other employee challenges

Outsourced Medical Billing

By outsourcing your medical billing, you access the bench strength of a large billing department. So, if you are a small practice, you don’t have to worry about decreased revenue due to an employee falling ill, going on vacation or seeking other employment. Instead, there’s always someone to fill in the gap to keep your revenue stream steady.

When you hand your billing over to a third party, you pay a small percentage of your collections. Therefore, the company only gets paid if they bring in revenue. This motivates outsourced billing providers to work with maximum efficiency. An outsourced billing team, such as that available at OmniMD, is also going to work harder to recover aged collections.

Many physicians spend as much as an entire day on paperwork. That’s a lose-lose situation. Every minute a health care provider isn’t with a patient costs your practice money. Additionally, most doctors aren’t trained in billing and administrative tasks nor do they find the work satisfying. This may put your office at further risk of missing payments or letting a superbill fall through the cracks.

On the downside, patients and staff members may find using a third-party billing company inconvenient. Since outsourced billing takes place off premises, it requires extra effort to monitor and provide the necessary information needed to establish effective billing practices. Therefore, it’s important to choose a vendor with great collaboration and communication skills.

Choose a company with proactive business practices and automated reporting and other functions. Choosing a company such as OmniMD gives you virtually endless opportunities to customize your billing software and enjoy a transparent relationship that improves your revenue collections, billing efficiency and staff and patient satisfaction.

When considering both options, outsource billing appears to have fewer shortcomings than hiring billing clerks and analysts on premises. Plus, having less oversight can be both a pro and a con for physicians who want to concentrate on the practice, not paperwork.

Outsourcing Pros and Con


  • Reduces billing errors and denied claims
  • Improves cash flow
  • Ensures billing compliance
  • Maximizes use of office space for medical business
  • Puts physician focus back on patient care
  • Reduces employee count and administrative responsibilities
  • Improves revenue cycle management
  • No-cost regulatory-compliance
  • Update your billing technology and simplify data entry


  • Give up some control
  • Not located on premises

Cost Savings Example With Outsourced Billing

Billing specialists can make six-figure salaries, while it costs around $4,000 or less for billing services. There are many other costs that you can reduce or eliminate by outsourcing the billing for your practice, including the following:

  • Billing Staff Salaries
  • Billing Software Cost
  • Hardware costs
  • Continued Education Training Cost (will be less when you outsource)
  • Ancillary Costs
  • (Office Space/Office Supplies, Patient Statements, Others)

Carrying collections in the form of bad debt is a reality for many practices. When you outsource your billing, you gain access to persistent collections specialists. While in-house collection efforts typically yield a 60% collection rate, that figure jumps to 68% when you partner with an effective medical billing provider.

Let’s say you have $2.5 million in uncollected debt. Your in-house collections team may recover $1.5 million, or 60% of the debt. Meanwhile, focused specialists at a third-party provider might collect $1.7 million, or 68% of bad debt that otherwise becomes a write-off.

Taking a Hybrid Approach

There may be sensitive accounts or services that you want to bill for directly. It’s perfectly acceptable and you can achieve the same boost in collections and savings while keeping a portion of the billing in-house. Find a company that will work with you to meet the needs of your practice.

Are You Shopping for Billing Solutions for a Billing Company?

OmniMD also provides billing solutions for billing companies. If you want to implement intuitive, consistent forms for all of your medical billing clients, partner with our team for end-to-end medical billing services that allow your staff to manage all your customers with a single sign-on. OmniMD has your solution. We will integrate data from all of your legacy systems, including EHR, Practice Management, and Patient Portals.

Want to know why more physicians and practices choose OmniMD? Request a demo today!

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Guide to Patient Satisfaction in 2021

Guide to Patient Satisfaction in 2021

Author : Akhil Singhal Post Date : September 1, 2021 Total Views: 849
In this guide to patient satisfaction, we’ll take a look at some of the most common pain points for patients and how you can address them. Clients are more demanding than ever as their financial burden increases, and concerns over the spread of diseases such as COVID-19 make patients reluctant to go to a medical provider, even for urgent care. So, the more your practice can do to ease the minds of patients and keep interactions positive, the better patient satisfaction and outcomes will be.

You can prevent your loyal patients from changing service providers by eliminating common pain points. By addressing the following issues, you can provide convenient, seamless, and quality medical care that delights your clients:

  • Billing concerns
  • Inefficient appointment setting
  • Lack of automation for new patient registration
  • Poor communications of diagnostic, treatment, and medication information

Let’s start with some high-level goals.

High-Level Goals to Improve Patient Satisfaction

As you formulate a plan to tackle each of the challenges below, keep the following high-level goals in mind:

  • Strive to improve access to care and meet patients online for critical communication.
  • Listen to what your patients tell you when diagnosing problems with satisfaction at your practice, and conduct regular customer satisfaction surveys to keep on top of your client’s changing needs.
  • Talk to your healthcare professionals to find out what they need to access information and streamline the treatment process.
  • Adopt technology, such as OmniMD, that allows your team to create an effective virtual experience during treatment, appointment setting, follow-up care, and other touchpoints.
  • Offer training for medical professionals new to virtual communication.
  • Place your patient at the center of your business and work everything us around them.

Billing Concerns and Solutions

Efficient billing practices help you enter claims to payers quickly for a faster revenue turnaround. They also make life easier for patients, who ultimately want to know how much the service will cost. Too often, patients are unable to get a straight answer regarding billing prior to a visit. In many ways, this is driven by unknown factors that come up during an examination. However, there are still several things you can do to address billing concerns.

To improve patient satisfaction when it comes to billing, consider the following suggestions:

  • Adopt technology that includes a patient portal. This technology gives patients access to their information, sends appointment reminders, and allows you to communicate with clients efficiently. By including an FAQ section and glossary describing billing codes, you can help them understand the billing without calling your office.
  • Add a chat feature to make it easy for patients to ask questions about their procedures. Patients often have questions about their financial responsibility since bills typically contain multiple payment amounts. Giving them a lifeline as they examine the bill can help your patients remain calm and cool while working to understand the billing process.
  • Train your billing team to promptly answer customer questions and politely address complaints.
  • When it comes right down to it, patients tend to be more trusting of medical procedures than the billing process. You can maintain consistent pricing and educate each patient on the cost of service while they’re still in the office. This approach avoids misunderstandings and hard feelings.

OmniMD Medical Billing Software and Medical Billing Services offer a comprehensive solution that makes it easy to verify insurance eligibility, simplify your billing template, send bills and accept payments electronically, and improve your patient satisfaction rates through an effective billing process.

Patients also need understanding and better communication when it comes to appointment scheduling, discussed in the next section.

Appointment Scheduling Pain Points and Solutions

Taking an appointment may seem simple. However, there are several factors that make the process complicated. It only takes one emergency visit to derail appointments for the rest of the day for one or more providers. With the right scheduling software, you can set better expectations for wait times and move things around more easily when necessary.

If your front desk still uses an appointment book to manage appointments, you’re missing out on the functionality of automated appointment setting software.

Here are a few questions to help you determine whether your appointment setting technology meets the needs of your front desk team and patients:

  • Does your system allow patients to schedule their own appointments online?
  • Does your appointment software automatically schedule reminders that reach clients via text, email, or their preferred communication channel?
  • Can your staff see appointments for each provider at a glance?
  • How easy is it to create an appointment in your current appointment scheduling system?

Automation does more than make it easier to set appointments and check patients in. Patients can choose the right professional to help them with their particular condition. Combined with a call center that can manage appointments after hours, appointment setting software can streamline the front desk experience.

Best of all, you can customize your settings to allow for same-day appointments for emergencies and access reporting that shows counts for various procedures and appointment times by day, week, or month.

Medical appointment software adds a ton of value to your practice, including:

  • Setting and managing recurring appointments
  • Printing schedules for physicians and other practitioners
  • Tracking activity to improve wait times and other metrics that boost patient satisfaction
  • Accessing one-click co-pay acceptance to improve your revenue stream

So, making the right choice when it comes to your medical appointment software can mean the difference between a waiting room full of annoyed patients and efficient appointment-setting practices that make your patient’s loyal customers.

New Patient Registration Improvements

Patients often complain about the new patient registration process for the following reasons:

  • Too many forms
  • Duplicate information on forms
  • Takes up too much time during the office visit

With the right automation tools, you can streamline the new patient registration process by moving it online. Patients should not have to re-enter their name, insurance information, and contact information on multiple forms.

Paper-free new patient processing makes sense. It can also help you save time and money and alleviate patient dissatisfaction. Explore the solutions offered by OmniMD, such as pre-visit data capture, context-aware forms, and data validation for consistent data.

Making Diagnostics, Reports, and Medication Information Available

Implementing a patient portal allows your clients to retrieve prescription information, diagnostics results, and other reports impacting their health. Making this information available online can also help healthcare providers prioritize urgent cases. By improving medical care and outcomes, online diagnostic tools, reporting, and medication management further improve customer satisfaction.

Providing immediate access to lab results can help practitioners come to a conclusive, accurate diagnosis faster. This means that the patient receives the right treatment earlier in the progression of diseases and disorders.

After treatment, patients may have questions regarding symptoms, complications, and other concerns that come up during the recovery process. Allowing patients to send a message directly in the patient portal can provide updated information for physicians looking to recommend additional treatment or alleviate patient concerns. Alternately, limited engagement can slow recovery periods and put the patient at risk.

Find out how vigorous engagement with patients through a patient portal facilitates care transitions such as diagnosis, treatment, and aftercare.

Request a demo today!

OmniMD offers numerous tools that can help your practice retain patients through improved engagement. Contact us today for a free consultation on how our tools can streamline your practice.

Optimize your operational efficiency and revenue with our state of art RCM Technology Platform. Schedule an online demonstration now.

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How to Use Modifiers 59, 25, 91

How to Use Modifiers 59, 25, 91

How to Use Modifiers 59, 25, 91

Author : Akhil Singhal Post Date : August 13, 2021 Total Views: 736
If you run a healthcare organization from a small physician’s office to a large hospital, your billing department uses codes to document procedures, medication and techniques used to treat clients. Entering the wrong code can result in improper billing and claims denials. Even if you get it right, the codes themselves often don’t accurately reflect the level of care provided.

Medical codes transform services, procedures and equipment into a universally understood language. However, your billing clerk may need to include more information to ensure that your organization receives the proper compensation. In addition, modifiers help clarify the services provided to insurance companies and billing personnel.

A medical modifier consists of two numbers or letters added to CPT or HCPCS Level II codes. Modifiers provide essential information about the service or procedure without impacting the main code. This blog provides guidance on using modifiers 59, 25 and 91.

When Should You Use Modifiers?

Tack on a modifier to the appropriate CPT code when you need a better description of services provided to clients. It’s important to avoid adding modifiers merely to increase reimbursement. You also cannot use modifiers to bill for procedures bundled with other services.

Working with modifiers requires care and due diligence. The descriptions aren’t always as clear as you might hope. Also, using the wrong modifier can result in suspicion or claim denials on the part of an insurer.

However, modifiers are critical to proper billing for your organization’s products and services. They further clarify a CPT code to document important information. These supplemental descriptions paint a more detailed story regarding services. In this blog, we’re concentrating on three of the most commonly miscoded ones.

CPT modifier 59: Distinct Procedural Service

Medical practitioners use modifier 59 to distinguish distinct procedural services. This commonly misused modifier indicates multiple procedures on different parts of the body during a single visit. Unfortunately, coders often use it to separate services bundled in another code. When used to prevent bundling and increase the total bill, adding modifier 59 becomes part of fraudulent billing practices.

Coders should also avoid using modifier 59 to bypass controls on the insurer’s claims processing system. Therefore, it’s important to use 59 only when there’s no more appropriate code to describe multiple procedures.


  1. A dermatologist performs a Photo Dynamic Therapy session on a patient’s scalp and face.
  2. Then, the machine is used to treat other parts of the body.
  3. The coder enters 9656796567 – 59 into the claim system.
  4. Modifier 59 indicates the second procedure, which required new positioning on a unique body region.

This is a valid use of modifier 59.

Modifier 25: separately Identifiable Evaluation and Management

Modifier 25 is a separately identifiable evaluation. Further, it’s performed by the same doctor or caregiver on the same day. Therefore, medical professionals can use modifier 25 to amend applicable CPT codes when the patient’s condition requires multiple evaluation and management (E/M) services.

Avoid using modifier 25 in the following circumstances:

Avoid using the 25 modifier to bill for postoperative E/M related to a prior surgery.

  • Don’t add modifier 25 for an E/M service not followed by a procedure.
  • Instruct coders not to append 25 for minimal same-day procedures unless you can show the service was “significant, separately identifiable.”


  1. A patient attends a cardiac appointment complaining of chest pain while exercising. The patient is hypertensive and has high cholesterol. The cardiologist orders a stress test on the same day.
  2. The billing clerk enters an E/M visit (99214) and a cardiovascular stress test (93015).
  3. Usingmodifier 25 with the E/M code accounts for the significantly separate procedures.

Modifier 91

Use modifier 91 to indicate a test performed multiple times on the same day. If you use the tests for separate specimens for unique results, apply modifier 91 to clarify the billing.

When to avoid using modifier 91:

  • Don’t append 91 if re-running lab tests to confirm previous results.
  • Avoid modifier 91 if retesting due to problems with the equipment or specimen.
  • Don’t use the 91 modifier when another code includes a test series or for procedures that require a one-time result.


  1. A high blood pressure patient takes a plasma renin activity test (84244 Renin) while lying down.
  2. The doctor performs the same test in multiple positions to determine whether the position contributes to hyperaldosteronism or other conditions.
  3. Repeat renin tests are scheduled for the afternoon, but the patient is standing up this time.
  4. The 91 modifier can be added to the second renin (84244) procedure.
  5. This results in two sets of lab tests for the same day on the same patient.

Understanding how to use modifiers correctly can help ensure that your claims are processed smoothly and without incident. Refer to the CPT code book for information on other modifiers.

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Modifier 22 Everything you need to know

Modifier 22 Everything you need to know

Modifier 22 – Everything You Need to Know

Author : Akhil Singhal Post Date : July 29, 2021 Total Views: 935
Current Procedural Technology (CPT) allows a certain range of complexity. However, sometimes the procedure conducted goes beyond this range. In such scenarios, modifier 22 comes in handy.

But, what is modifier 22? It is described in the CPT guidelines as a benchmark that classifies increased procedural service. The CPT code book’s Appendix A explains that a modifier comes to play when the work needed for a particular procedure goes beyond what is typically required.

Using it correctly helps in reimbursing a physician and ensures this group of professionals is compensated for any additional time they are involved in tackling unseen difficulties and other unanticipated complications.

But it is imperative to note, proper reimbursement goes beyond just integrating a modifier to a service code. According to professional coders, there are many other factors and requirements that come into play.

In this regard, this guide seeks to explore how procedural coding works and when to use modifier 22.

How does Modifier 22 Work?

Modifier 22 finds its application mainly in surgical procedures. And they come in handy when the provider of the procedure performs substantially more work while discharging their services.

But with no preset criteria set by CPT to determine that the procedure has exceeded the range of complexity, coders may have to come with their interpretations.

Though, the aforementioned scenario is not recommended. This is because CPT codes are not subjective. By treating them as such, may raise red flags with payers who will deem a coder’s modifier 22 as incorrectly attached to all procedures.

Even worse, the payers will start taking a keen look into claims made through modifier 22.

So, what do you do if you want the modifier you wish to attach to a CPT code work smoothly? First, as a coder, you have to conduct in-depth research and try to understand the situations that are best suited for the use of modifier 22. Set a range of complexities that a payer will concur with, therefore, ensuring the module 22 claims proceed smoothly without hiccups.

Situations that are Justifiable to Use Modifier 22

While modifier 22 is attached to the CPT code for multiple procedure claims, the main aspect to consider in their application is that they should be used rarely and in the most challenging procedures. Some of the situations that warrant the use of modifier 22 include:
• Excessive hemorrhage (blood loss) associated with the procedure.
• Great levels of trauma that cause extreme difficulties or complications when a surgeon is performing the procedure.
• Complex services that have been included and go beyond the complexity range documented in the CPT code.
• Existence of other genetic mutations such as tumors, malformation, or pathologies that directly interfere with the surgical procedure in question.
• Other factors such low birth weight and morbid obesity, just to mention a few.

Cases where Modifier 22 Cannot be used

There are some instances that are inappropriate to use modifier 22. They include:
• In cases where there is no documentation of a procedural service exceeding the range of complexity set by CPT code.
• If there is an alternative of performing the same procedure more effectively and documented in the CPT code guideline.
• If the procedure was not performed by a specialist.

Does Difficulty Alone Guarantee use of Modifier 22?

A surgical procedure that requires a physician to put in additional work due to complications may justify the application of modifier 22 combined with the surgical procedure code. Nevertheless, to attach modifier 22 to the CPT code, there must be clear evidence that the procedure is extremely difficult.

According to CPT changes compiled by American Medical Association in 2008, modifier 22 can be used when some additional factors and complexities call for extra physician technical skills, thereby significantly increasing their work and time on the table.

Why is Documentation Important?

Documentation is vital when coding a modifier 22. It helps to clearly indicate additional work performed by a surgical physician as a result of unanticipated complications.

A good example cited by the American Urological Association (UA) entails an overweight patient who is scheduled to undertake a radical nephrectomy combined with regional lymphadenectomy. Documentation in such a scenario comes in handy. The surgeon in question must document things like lysis of adhesion as a result of previous surgery and clearly document additional surgical time even before initiating radical nephrectomy, which would be caused by the sense that the patient is morbidly obese.
More importantly, the documentation should entail:
• An Explicit methodology of the procedure.
• Any unexpected factors that lengthened the time of the procedure.
• Pre-existing conditions and additional diagnoses.
• Any extra effort spent performing the procedure.
• A clear statement detailing the nature of the unexpected service taking into account pertinent supporting portions of the surgeon.
• If applicable, they must include progress notes, pathology reports, and office notes just to mention a few.

Bottom Line

If you think that Modifier 22 provides an easy way to reap additional reimbursements, then you’re not entirely correct. Before payers agree to reimburse a claim with a modifier 22, they will require detailed evidence of complexities beyond the preset range encountered. Always remember it is not always a guarantee you will get extra payments because a modifier 22 is coded on a claim.

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Modifier 59 – Facts to Learn

Modifier 59 – Facts to Learn

Modifier 59 – Facts to Learn

Author : Akhil Singhal Post Date : April 15, 2021 Total Views: 879

What is a Medical Coding Modifier?

A medical coding modifier is two-character letters or numbers appended to a CPT® or HCPCS Level II code. Modifiers indicate additional information about the procedure, service, or supply altered by some specific circumstance without a change in its definition or code. They won’t add information or change the outline of service to improve accuracy or specificity.

There are instances when coding and modifier information issued by the CMS differs from the AMA concerning the utilization of modifiers. A clear understanding of Medicare’s guidelines and regulations is vital to assign the suitable modifier(s).

There are numerous instances when a modifier use may be the most appropriate, for example:

  • A service or procedure has both professional and technical components.
  • More than one location is involved.
  • A service or procedure is increased or reduced in comparison to what the code typically requires.
  • More than one provider performs the service or procedure.
  • The procedure is bilateral.
  • The service or procedure is provided to the patient greater than once.

Let us go through some of the most used modifiers in the medical coding & billing industry!

Modifier 59 – Facts to Learn

At times, it is imperative to point out that a procedure or service was distinct or independent from other non-evaluation and management (E/M) service(s) performed on the same day. Modifier 59 indicated usage is for procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances.

It is the most pronounced modifier that affects National Correct Coding Initiative (NCCI) processing

The Medicare NCCI includes edits describe when two Healthcare Common Procedure Coding System (HCPCS) / Current Procedural Terminology (CPT) codes should not be reported together.

A Correct Coding Modifier Indicator (CCMI) of “0” designates the codes should never be reported together by the same provider for the same beneficiary on the same date of service. If these are reported on the same date of service, the column one code is eligible for payment and the column two code is denied.

A CCMI of “1” signifies the codes may be reported together only in defined circumstances, which are identified on the claim using specific NCCI associated modifiers.

CCMI of “9” NCCI editing does not apply.

This modifier may be stated to emphasize that a procedure or service was distinct or independent from other services performed on the same day.

One of the common misuses of this modifier is related to the piece of the definition that allows its use to describe a “different procedure or surgery.”

The code descriptors of the two codes of a code pair edit usually signify different procedures, even though there may be an overlap. The edit indicates that the two procedures should not be collectively reported if performed at the same anatomic site and same patient encounter as those procedures would not be “separate and distinct.”

Modifier is most frequently used are for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures performed at different anatomic sites not ordinarily performed or encountered on the same day and cannot be described by one of the more specific anatomic modifiers.

Appropriate Use Cases of Modifier 59:

  • A different encounter.
  • Different procedure or surgery.
  • Different anatomical site or organ system: If two procedures are performed at separate anatomical sites or at separate patient encounters on the same date of service separate incision or excision
  • Separate lesion or separate injury (or area in injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual
  • Used for two services described by timed codes provided during the same encounter only when they are performed sequentially.
  • A diagnostic procedure which precedes a therapeutic procedure only when the diagnostic procedure is the basis for performing the therapeutic procedure.
  • No other appropriate modifier is available. Evaluate other modifiers such as the RT/LT identifying right and left, F1 – F0 to identify fingers, T1-T0 to identify toes, and E1-E4 to identify eyelids
  • Evaluate additional modifiers to determine appropriate usage

The CMS established 4 new HCPCS modifiers to provide greater specificity in situations where modifier 59 was previously reported.

  • XE – “Separate encounter, a service that is distinct because it occurred during a separate encounter;” use this modifier only to describe separate encounters on the same date of service
  • XS – “Separate Structure, a service that is distinct because it was performed on a separate organ/structure”
  • XP – “Separate Practitioner, a service that is distinct because it was performed by a different practitioner”
  • XU – “Unusual Non-Overlapping Service, the use of a service that is distinct because it does not overlap usual components of the main service”

Inappropriate Use Cases of Modifier 59:

  • When appended with an E/M  If submitted on E/M codes 99201-99499, E/M codes are processed as though a modifier were not present (i.e., the code pair will be subject to NCCI editing and has an indicator that does not allow bypass)
  • To report a separate and distinct E/M service with a non-E/M service performed on the same date
  • When other valid modifiers exist to identify the services, like RT, LT, E1-E4, TA, etc.
  • When clinical documentation does not support the separate and distinct status
  • When used to indicate multiple administration of injections of the same drug
  • When the NCCI tables lists the procedure, code pair with a modifier indicator of “0”

Important Tips for Coder and Biller

  • Bill all services performed on one day on the same claim
  • Report each service on a different line
  • Apply 59 to the subsequent procedures (if applicable)
  • More than one line with modifier 59 appended to the same procedure code requires submission of supporting information/documentation on the claim
  • Use modifier 59 to identify procedures or services not normally reported together, but is appropriate under certain clinical circumstances
  • Claims reporting modifier 59 on multiple lines for the same procedure code without a narrative or documentation to support the additional lines will receive rejection code 969/standard code 16 (Claim/service lacks information or has submission/billing error(s), needed for adjudication)

The key is that a provider’s clinical documentation must support the use of modifier 59 (or any other modifier).

Use Case 1:

Column 1 Code / Column 2 Code – 17000/11100

CPT Code 17000 – Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); first lesion

CPT Code 11100 – Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed.

Single lesion Modifier 59 may be reported with code 11100 if the procedures are performed at different anatomic sites on the same side of the body and a specific anatomic modifier is not applicable. If the procedures are performed on different sides of the body, modifiers RT and LT or another pair of anatomic modifiers should be used, not modifier 59.

Use Case 2:

Column 1 Code / Column 2 Code – 29827/29820

CPT Code 29827 – Arthroscopy, shoulder, surgical; with rotator cuff repair

CPT Code 29820 – Arthroscopy, shoulder, surgical; synovectomy.

Partial CPT code 29820 should not be reported and modifier 59 should not be used if both procedures are performed on the same shoulder during the same operative session because the shoulder joint is a single anatomic structure. If the procedures are performed on different shoulders, modifiers RT and LT should be used, NOT modifier 59.


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