Recent statistical reports convey that the rate of claim denials from Blue Cross and Blue Shield is way high for chiropractic practices, particularly in the usage of modifiers. Many medical billing outsourcing companies that provide chiropractic practices realized that their claim denials are due to inappropriate use of the 25 and 59 modifiers. Either it was due to incorrect usage of modifiers or the utilization of modifiers was more than the required average.
Moreover, Illinois Chiropractic Society (ICS) on reviewing several claims, in a press note, delivered that the denials of claim are because of the impact the new code-editing feature created; otherwise, the information provided for claims are all good to go. In this way, the prominence of modifiers has been highlighted. Through this blog, you can know how to use the modifiers 25 and 59 accurately in Chiropractic medical billing, effectively.
Where do you use modifiers 25 and 59 in a claim form?
The usual way of specifying Chiropractic modifiers in a claim form is they go along with CPT codes to convey the insurance company that a usual service type has not been billed. Using the right modifiers appropriately can bring down the denials rate and increase reimbursements. In case CPT codes are billed without adding modifiers, there are high chances that the insurer may reject the claim with a detailed explanation on the explanation of benefits (EOB) column with another service.
Chiropractic manipulative treatment (CMT) and CPT codes
CMT codes impose treatment for influencing joint and neurophysiological functions, which covers five spine regions indeed: cervical region, thoracic region, lumbar region, sacral region, and pelvic region.
Let us look into the related CMT CPT codes now.
- For spinal 1&2 regions, the code is 98940
- For spinal 3&4 regions, the code is 98941
- For spinal 5 regions, the code is 98942
- For more than one extra spinal region, the code is 98943
How to use modifiers 25 and 59 when submitting Chiropractic medical billing claims?
There are specific guidelines you may have to follow while reporting modifier 25 with CMT codes.
- CMT codes have a pre-manipulative patient evaluation.
- In case you wish to specify additional evaluation and management (E/M) services, it should be done individually using modifier 25. Note that this has to be provided only if the patient’s health condition needs it. Therefore if you are billing both manipulation and E/M codes for the same visit, modifier 25 should be attached by default to the E/M code.
- Before submitting claims, providers should look for which category you are using modifier 25, i.e. whether it is commercial or federal.
- Due to the E/M service can be caused by a similar type of conditions or symptoms, based on which the CMT services are provided there is no need of specifying it under different diagnoses.
The Centers for Medicare and Medicaid Services (CMS) developed an editing program for the National Correct Coding Initiative (NCCI), which is used by carriers and third-party administrators to avoid improper payment when specific codes are submitted along. In such cases, along with other modifiers, modifier 59 is also an exception to the NCCI edits.
Sometimes, the physician may have to mark a procedure or service that is quite different from other non-E/M services carried out on the same day. Modifier 59 is used to denote such procedures or services that are not reported usually together.
A new subset was released in the year 2015, by CMS, for the 59 modifiers, which are XE, XS, XP, and XU to be used in place of 59 modifiers wherever.
- Modifier XE can be used for a separate encounter when there is a distinct service and occurred during a particular meeting.
- Modifier XS can be used for a separate structure when there is a distinct service and performed on an individual organ or structure.
- Modifier XP can be used for a separate practitioner when there is a distinct service and performed by a different practitioner.
- Modifier XU can be used for an uncommon overlapping service when there is a specific service, and it does not overlap the standard components used in the main service.
Ultimately, both modifiers 25 and 59 are critical to save your claims from denials and get quick reimbursements in Chiropractic medical billing services. Outsourcing Chiropractic medical billing and coding is the best and practical option to achieve optimized results and profits for your business. 24/7 Medical Billing Services is one such company that provides the necessary CMT billing and coding services with top-notch quality.