Wednesday, February 07, 2018

Blues Plans Issuing Denials for Certain Modifiers

By Julie Lenhardt

ACA has recently heard from members in a few states that some Blue Cross Blue Shield plans are automatically denying claims that contain the -25 and -59 modifiers. The states we have heard from to date include Illinois, Oklahoma and Texas. The Blues plans in these states are owned by Health Care Service Corporation (HCSC), an umbrella company that also owns the Blues plans in Montana and New Mexico.

ACA has since learned that during the fall, HCSC instituted a code-auditing enhancement to its claims system to "improve auditing of professional and outpatient facility claims that are submitted...by clinically validating modifiers submitted on such claims." For many chiropractic clinics, this means E/M codes and CPT code 97140 (as well as a few others) may automatically be denied. However, it is important to note that this is not occurring only with chiropractic claims--the code-auditing enhancement applies to all claims with the specified modifiers submitted by any health care professional or outpatient facility.

In some cases, the denials state the modifiers are used inappropriately. In other cases, providers have received letters stating their utilization of the modifier is higher than average. In either case, ACA recommends that chiropractors who receive a denial based on the -25 and/or -59 modifiers appeal the denials if they feel their usage of the modifiers is appropriate.

Before submitting the appeal, review the claim to ensure the modifiers were used appropriately. For example, modifier -25 should be appended to E/M codes performed on the same date as CMT, "if the patient's condition requires a separately identifiable E/M service, above and beyond the usual pre-service and post-service work associated with the procedure."1 Some specific examples of when it is appropriate to bill for both a CMT and E/M code on the same date of service are:

  • New patient visit;
  • Established patient with new condition, new injury, aggravation or exacerbation;
  • Or periodic re-evaluation to assess if a treatment change is needed.

Likewise, it is appropriate to bill for 97140 and CMT performed on the same date of service using modifier -59, but only if each service is performed to a separate body region. If the modifiers are used appropriately and the decision is made to appeal the denial, ACA has customizable template letters for modifier -25 denial for E/M billed with CMT or a modifier -59 denial for 97140. The appeal letters should be submitted with the appropriate documentation that demonstrates the services provided were separately identifiable procedures and clearly shows medical necessity for the services.

Additionally, the claim form should have the correct diagnosis pointers for 97140 and CMT on the same date of service. It is also recommended the X modifiers are used in place of modifier -59--these modifiers are a subset of modifier -59 and provide greater detail on the specific need for modifier -59.

Julie Lenhardt is ACA senior director of payment policy.

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1 comments on article "Blues Plans Issuing Denials for Certain Modifiers"

Ashley Monplaisir

5/7/2018 12:54 PM

So when an appeal is issued using the letters you recommend along with clinical SOAP notes and diagnosis pointing show separate areas of the spine, but it is still denied in error, what is the next course of action???

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