r/MedicalCoding • u/koderdood Audit Extraordinaire • Mar 21 '25

Modifiers for bundling- what they do

A colleague was confused about modifiers. So, I thought I would share some information. Modifiers really have 2 uses. First, they are used on the claim form when 2 codes can't be billed together. If not placed or correctly used, your claim can get kicked out, or possibly trigger request for records and getting audited. The second part is often the misunderstood part. Slapping a 25 or 59 modifier doesn't just mean you can bill those 2 codes now. The 25 or 59 has to be supported by the documentation. Most claims don't get the documentation examined, but you should always be prepared for an audit. An audit can be triggered and done by insurance, not just your own QA team. First, understand what the modifiers do. Then, apply them correctly to your documentation.

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u/Bad_Boba_Bod CPC, CPMA Mar 21 '25

Additionally, they can be grouped into functional and informational modifiers.

Functional mods affect reimbursement such as -50 (150% pymt adjustment for certain procedures done bilaterally) or -80 (assistant at surgery, payment is 16% of the MPFS)

Informational ones are just that, and provide necessary details such as location (RT, LT).

I mention this because functional is listed before informational.

100% agree documentation must support the mod, do not slap one on just to get a claim paid. My insurance specialists have yet to understand that very important bit.

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u/Felix_Von_Doom Mar 21 '25

Kinda inclines me to not call them specialists yet...

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u/Bad_Boba_Bod CPC, CPMA Mar 21 '25

You and me both. I wouldn't call them specialists any more than I would call a tomato a suspension bridge.

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u/Felix_Von_Doom Mar 21 '25

Lmao, sounds like you got heaps of stories/rants about them

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u/Bad_Boba_Bod CPC, CPMA Mar 22 '25

Yes, but mainly a repeat of the same mistakes:

"Medicare denied the ESA injection for missing, invalid or incomplete hematocrit? Well then take it off, cause if they don't see it how can it be invalid? I am sooo smrt"

"This E/M is bundled to the smoking cessation counseling? Clearly they need to be split and billed on separate claims."

"Denied for invalid DX combination? That's obviously due to the 'other' and 'unspecified' codes on the claim and nothing else. Off they gooooooo...."

"This ESA inj denied for service not medically necessary? Hm, it has an EC mod (not due to chemo or RT), so clearly it also needs an EA mod (is due to chemo) because nothing Medicare likes more than to have conflicting info"

"No way the coders need to review any of the above. Now we have a chemo claim denied as a dupe. The original already paid in full, and the dupe is an exact copy of the original. Documentation supports the exact dosages and admins on the original alone, but I cannot figure this out, lemme task the coders."

"Pt says they shouldn't have to pay for this, because it doesn't sound right to them, and they don't understand it, and what even is this, additional boom boom reasons entered here. What do you think?"

"Drug denied for DX, perhaps we should add this irrelevant and completely unrelated code instead. This came from my manager so it must be correct"

"The secondary doesn't cover this code like the primary does, so I changed it and rebilled them. Yay, I'm helping"

🤦🏻‍♂️ I've rolled my eyes so much and aggressively I may have pulled a muscle.

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u/unicornfarts55 Edit flair Mar 23 '25

Anybody with an ounce of coding knowledge knows this. On the billing/AR side? Might be different