Audits

When performing a service during the global period, or the days after you perform a procedure, you need to use the correct modifier(s).  Otherwise, the insurance company will think that the service was just part of the follow-up care, which is included in the global surgical package. That means they won’t want to reimburse you. If they do reimburse you, and the RAC sees it, they may suspect an overpayment and begin an audit.

The modifiers that RACs really crack down on, aka audit triggers, include:

• Modifier 25: Significant, separately identifiable evaluation and management (E/M) service by the same physician or other medical professional on the same day of a procedure or other service

• Modifier 24: Used after surgery to bill an unrelated E/M service by the same physician during the postoperative period.

• Modifier 79: Used for an unrelated procedure or service performed by the same physician during the global period.

• Modifier 78: Indicates an unplanned return to the operating room by the same physician after the initial procedure for a related one during the global period.

• Modifier 57: Indicates that an E/M service resulted in the initial decision to perform surgery, either the day before or the day of a major surgery. It’s used only for procedures that are considered major surgeries (90-day global period).

• Modifier 59: Identifies a distinct procedural service routinely reported in a dermatology setting to indicate that the services/procedures, though not normally reported together on the same date/claim, are appropriate under the circumstances.

• Modifier 76: Repeat procedure by the same physician/qualified healthcare professional indicating a procedure(s)/service(s) was repeated subsequent to the original service(s)/procedure(s)

• Misuse of ABN modifiers GA, GX, GY, GZ:

  • GA - Waiver of Liability Statement Issued as Required by Payer Policy, Individual Case

  • GX - Notice of Liability Issued, Voluntary Under Payer Policy

  • GY - Item or Service Statutorily Excluded, Does Not Meet the Definition of Any Medicare Benefit

  • GZ - Item or Service Expected to Be Denied as Not Reasonable and Necessary

Modifier 25 is one of the most commonly used modifiers in dermatology. It’s also one that is often scrutinized. This modifier is used to indicate that on the day of a minor procedure, your patient’s condition required a significant, separately identifiable E/M service that went above and beyond the pre- or post-operative care that’s generally associated with the procedure or service performed. 

Learn more about modifier 25.

You may think it’s obvious why you needed to remove your patient’s mole that ended up being benign. She had a history of skin cancer, so you needed to take every mole seriously. But if you don’t document the reasoning correctly, the carrier or RAC might think that you just removed it for cosmetic reasons, which is not covered.

Whether you’re performing a low-level E/M service or a major surgery, you need to document the reasons behind all your decision-making. 

Remember to write everything clearly and to be as specific as possible in your patient’s medical record. For example, if you treat a rash on your patient’s left leg, don’t just write “leg.” Specify that it was the left one.

• Learn more about medical decision-making.

• Learn more about the medical record.

Let’s say you removed a benign mole just because your patient hated how it looked. Because the procedure was solely for cosmetic purposes, you can’t try to bill it as a covered service. 

When it comes to non-covered services, pay close attention to:

• Use of modifier 59. This is for distinct, independent services performed by a single provider, in one day. However, you can’t just add this modifier to a non-covered service that’s performed on the same day as a covered one. If it’s not covered, it’s not covered. Modifier 59 won’t override the non-covered policy.

• Advanced beneficiary notice of noncoverage (ABN) (PDF)

• National coverage determinations (NCD) and Local Coverage Determinations (LCDs)