Modifiers 52 & 53

The usage of Modifiers 52 & 53 is very clear and straightforward but still many claims have these modifiers applied incorrectly opening up the possibility of a recoupment later on.

52 Modifier - Reduced Services.

In many instances a procedure or service is reduced at the discretion of  a physician.

We need to apply the 52 modifier to that CPT code, when the physician is performing a reduced procedure rather than the entire procedure, as denoted by the CPT code and when that reduced procedure does not have a specific CPT code for billing. The 52 modifier should not be applied to a CPT code, when the procedure that was planned had to be discontinued / terminated for any reason whatsoever. In these instances we need to use modifier 53 to indicate that the procedure was discontinued.

If the reduced procedure is surgical, the claim needs to submitted with an Operative report and a separate report detailing how the reduced procedure differs from the normal procedure.

For procedures that are non-surgical, a report detailing how the reduced procedure differs from the normal procedure needs to be sent alongwith the claim.

Example :

The provider is planning on performing pure tone audiometry, air only, for a patient on only one ear. There is no CPT code for this test when performed on one ear, while we have CPT code 92552 pure tone audiometry (threshold), air only, for both ears ( bilateral procedure ). 

In this instance since the provider plans to perform the test for one ear only, this becomes a reduced procedure. Hence we need to append modifier 52 to CPT code 92552.

53 Modifier - Discontinued Procedure.

In many instances a surgical or diagnostic procedure may need to be terminated / discontinued due to various reasons.

A procedure that was initiated may need to be terminated / discontinued due to various reasons, in such cases we need to apply Modifier 53 to the CPT code. A procedure may be discontinued / terminated due to various reasons, such as the patient not being able to tolerate the procedure. The 53 modifier basically indicates that the procedure was initiated but not completed.

If the discontinued procedure is surgical then a Operative report needs to be sent alongwith the claim. 

For procedures that are non-surgical, a report detailing how the discontinued procedure differs from the normal procedure needs to be sent alongwith the claim.

The 53 modifier cannot be used, if a Procedure is discontinued by the Physician before administering anesthesia or surgical preparation in the operating room.

Example :

Colonoscopy was initiated on a patient. Polyps were removed by hot biopsy from the descending colon. The provider then attempted to move the colonoscope past the splenic flexure but due to a tortuous colon / blockage the colonoscope could not advance past the splenic flexure. The procedure was hence discontinued.

In this instance the physician had initiated a Colonoscopy by Hot biopsy CPT 45384, but the procedure was discontinued as the colonoscope could not move past the splenic flexure. Hence we need to append mofifier 53 to CPT code 45384.

Hemodialysis & E & M visits

In general when Hemodialysis is billed alongwith an E&M procedure, the Hemodialysis procedure alone is paid while the E&M procedure is denied.

This is because the Hemodialysis procedure has an E&M component built into it and hence the additional E&M procedure is denied. The Evaluation and Management services related to dialysis treatment for ESRD are included in the Dialysis codes and so are not separately reimbursable.

However an E&M can be billed if it is for a separate and distinct service.

For example if a Physician treats a separate and unrelated condition, than the E&M code can be billed with modifier 25, the important point to note is that the documentation should substantiate that the E&M is for a separate and identifiable service apart from the Dialysis procedure on the same day.

Services that are generally included into the Dialysis code are the Physician's evaluation, treatment plan, phone calls, counselling, physician laboratory visits and overall management of the patient.

Key Indicators

Knowing whether your practice is doing well financially is important for the successful running of any practice. Many practices flounder and go bankrupt because they were not monitored properly, leading to their financial ruin.

There are some key indicators which would guide us to make major course corrections where necessary, to bring the practice back on track. Monitoring these key indicators on a regular basis, will ensure that your practice remains financially healthy and continues to run smoothly.

Visits :
The number of Patient visits per month is a straightforward indicator, that is directly proportional to the monthly revenue.

New Patients :
Practices need to ensure that the percentage of New Patients to the total monthly visits is on the increase or steady, on a monthly basis, this would ensure that Old Patients dropping out are compensated by the New Patients, otherwise we would see a drop in the monthly revenue of the practice. When we see the percentage of New Patients decreasing on a monthly basis, this should serve as a warning for us to make course corrections in our practice.

Payor Mix :
An analysis of the Payorwise monthly collections will help us to identify which Payors contribute the most to the revenue of the practice and which payors will significantly impact the practice when their reimbursements change.

Days in AR :
Practices need to know how many days it takes, for them to collect one days charges. The days in AR reflect how quickly and efficiently the practice is able to work the AR and get paid. Higher the Days in AR could be due to a whole host of problems such as Charge / Demographic entry errors, Coding errors,  delayed claim submission, not working the clearing house reports, improper handling of denials and poor AR management. Practices should aim to keep the days in AR under 40.

AR aging :
The AR bucketwise aging is an indicator of how the AR is distributed across different buckets. We can have upto 70% AR (70% of Average monthly charges) in the 0-30 day bucket, upto 15% AR in 30-60 day bucket, upto 10% AR in the 60-90 day bucket, upto 5% AR in the 90-120 day bucket and upto 25% AR in the 120+ days bucket. High AR in the 0-30 day bucket could be due to Charge entry errors, Demographic entry errors, Coding errors or delays in claim submission, high AR in the later buckets could point to improper denial / AR management.

Gross Collection Rate :
The ratio of Actual Collections to Total Charges for a month would be a good indicator of how well we are collecting against the total charges billed. But this ratio needs to be reviewed based on your contractual adjustments. So if you are overbilling your allowed amount by 180 % then a Gross Collection Ratio of 45-50 % is fine.

Net Collection Rate :
The ratio of Actual Collections to Net Charges (Total Charges Less Adjustments) for a month would be a more accurate indicator, than the Gross Collection Rate, of how well the practice is collecting its receivables, since this ratio measures Actual Collections against Actual Collectables, practices should aim for a ratio of 95% or higher.

Preventive Services

Medicare has been reimbursing certain Preventive Services such as Annual Wellness Visits, Cardiovascular Disease Screenings, Diabetes Screening Tests, Screening Pelvic Exam, Glaucoma Screening, Smoking and Tobacco Cessation Counseling e.t.c for some time now.

Recently Medicare has started covering for Screening and Behavioral Counseling to reduce Alcohol misuse and Face-to-Face Behavioral Counseling for Obesity.

Alcohol misuse :

Effective for claims with dates of service October 14, 2011, and later, CMS shall cover annual alcohol screening, and for those that screen positive, up to four, brief, face-to-face behavioral counseling interventions per year for Medicare beneficiaries, including pregnant women.

Obesity Therapy :

Effective for claims with dates of service on or after November 29, 2011, CMS will allow coverage for Face-to-Face Behavioral Counseling for Obesity, 15 minutes, G0447, along with 1 of the ICD-9 codes for BMI 30.0-BMI 70 (V85.30- V85.39 and V85.41- V85.45), only when submitted with one of the following place of service (POS) codes: 11 – Physician’s Office, 22 – Outpatient Hospital, 49 – Independent Clinic or 71 - State or Local Public Health Clinic.

For more information on Medicare preventive services, visit http://www.cms.gov/PrevntionGenInfo on the CMS website.
For more information on Medicare Learning Network® (MLN) preventive services educational products, visit  http://www.cms.gov/MLNProducts/35_PreventiveServices.asp on the CMS website.

Source CMS

Referral vs Authorization

A Referral is not the same as an Authorization. 

In general a referral is required when a PCP refers a patient to a specialist in-network provider for consultation, while an Authorization also known as Prior Authorization, is approval from the Insurance plan for the performance of certain specific medical procedures and services, based on medical necessity.

A typical scenario would be a PCP referring a patient to a in-network Nephrologist. A referral would be required without which the Insurance plan will not pay. If the Nephrologist performs only an evaluation, the referral alone would suffice, but if the Nephrologist chooses to administer a Procrit injection, than this procedure ( which is on the Prior authorization list of the Insurance plan ) would require a Prior authorization for the Insurance plan to make payment.

Referral :

• A referral is required when a PCP refers a patient to a specialist
• HMO Plans in general require a referral while PPO plans do not require a referral
• A referral is valid for a certain period and for a certain number of visits
• A referral is not required for Emergency services
• A referral is not required for Routine / Preventive services
• Without a referral the insurance plan will not pay

Prior Authorization :

• A Prior authorization is required when a provider plans on performing a procedure which is on the Prior authorization list of the Insurance plan
• A Prior authorization needs to be obtained from the Insurance plan before the performance of the medical procedure
• A Prior authorization is provided by the Insurance plan when they are satisfied as to the medical necessity of the procedure
• A Prior authorization is not required for Emergency services
• Without a Prior authorization the Insurance plan will not pay for procedures that are on its Prior authorization list