Hospitals are not getting’ the urgency of using modifiers
HCFA coding edits will catch some providers off-guard
Last July, the Health Care Financing Administration (HCFA) in Baltimore began requiring hospitals to report 37 modifiers — both common procedure terminology (CPT) and HCFA common procedure coding system (HCPCS) Level II — to cover outpatient services for surgical procedures, radiology, and other diagnostic procedures.
A "soft" memo received by providers in June, however, indicated that HCFA will not be editing for the modifiers. Does that mean hospitals can take a breather until they receive another memo?
No, says Andrea Clark, RRA, a national health information management consultant based in Baltimore. "There is no other effective date," she says, adding that her information came directly from HCFA. "This is the grace period. Hospitals are not getting it. They don’t understand that they need to go forward with this. I know compliance is a big issue, but this is a requirement from Medicare and is part of compliance." HCFA plans to begin coding edits sometime in the summer, Clark says. "If hospitals don’t go forward, they’re really going to be surprised when HCFA turns on the edits."
Lots of confusion
One problem is the mixed messages providers are receiving from their fiscal intermediaries (FIs). As Clark explains, FIs in one state are saying they will accept the modifiers while FIs in other states are say ing they won’t. "You have the FIs saying different things even though HCFA is the Grand Poobah. If the modifier is on [the claim], it shouldn’t be rejected."
Providers also are trying to adapt their information systems so they will accept the modifiers. Vendors have primarily risen to the challenge and have added data elements to their systems that allow the addition of the modifiers, she says.
Some providers are demanding compliance from new systems. "I know some of our local hospitals have just gone on new patient accounting systems," says Nora McNeil, president of Code Quest in Toms River, NJ. "One of their requirements in their contracts was that the systems would be able to accept modifiers."
How well their systems adapt to the changes depends on how well they interface, McNeil says. For example, providers are reporting that the modifiers are not always hitting the UB-92 claim form even if they appear on the screen.
"Providers have to sit down and decide what’s going to be the best way [to add the modifiers] within each facility, depending on their system capabilities," she states.
Determine responsibility
Not every hospital is using the same personnel to work on the problem, either. "It depends on which hospitals you go to," McNeil says. "Some hospitals up in Syracuse have an MIS person who has set up the use of modifiers. Some of it is being coded in the coding department. Some of it is being set up in the chargemasters. Other hospitals haven’t even attempted to do it.
"Hospitals need to determine who is going to be responsible for creating the charge, whether it’s going to be a clinical person through hard-coded chargemaster or coding staff," she adds.
Clark says she has yet to see a client get a modifier to go through on the chargemaster. "There hasn’t been any movement when it comes to the chargemaster, and if there has been movement, it’s been very slow. A lot of my clients haven’t even begun to look at radiology or the medicine section."
Some facilities aren’t prepared to use the modifiers, anyway, McNeil says. "They don’t have anyone in-house who knows how to use the modifiers and knows what the impact is going to be. They’re all trying to deal with medical necessity rejections right now anyway."
She says she is also concerned that providers aren’t ensuring that their systems can accept more than just one two-digit modifier on each service. "I hope they are looking ahead."
Then there is general confusion about how certain modifiers, such as "-59," are being used.
"[Providers] have no clue how -59 is used," Clark says. "I’m providing a lot of education based on the Correct Coding Initiative Unbundl ing Edits, and teaching that the modifier is used for going across the edits and showing that there was a separate distinct procedure on the same day."
Some of the modifiers have changed, too. As of Jan. 1, two new modifiers replaced modifiers -52: reduced services, and -53: discontinued services for ambulatory surgery procedures, she says. Modifier -52, is not being eliminated, however. It is now used for partially reduced or eliminated services at the physician’s discretion — not for surgical procedures.
Hospitals need to pay close attention because this is only the first wave of modifiers, Clark warns. "More will be popping up all over the place."
Prepare for modifier reporting
Clark recommends that hospitals begin preparing for modifier reporting as soon as possible. Here are her suggestions for preparation in the following acute areas:
1. Information systems
• Modify internal financial data abstracts/ fields to accept modifiers for Medicare outpatient services.
• Ensure research information systems, vendor modifications, and support capabilities regarding modifier reporting and application for Medicare outpatient services.
• Test and verify acceptance and transfer of CPT code(s) with appended modifier(s) to the Medicare UB-92 claim form.
• Develop hospital departmental report writing capabilities in conjunction with this requirement.
2. Patient financial services
• Review, modify and add all chargemaster line items reflecting Medicare outpatient modifier reporting requirements, such as for radiology and other diagnostic services.
• Request education from health information department to understand appropriate application of modifiers.
• Synchronize charge tickets to reflect all changes instituted through the chargemaster, such as those specific to radiology and other diagnostic services.
• Educate appropriate provider staff regarding new requirements and appropriate charge line item reporting.
• Pay attention to Medicare memos and transmittals and communicate this information to the appropriate departments.
3. Health information management
• Research encoder vendor modifications and support capabilities regarding modifier modification and reporting.
• Update data abstracts/fields to allow for reporting of at least two separate modifiers per CPT code.
• Validate interface capabilities between the health information system and patient financial services system.
• Educate outpatient coding staff regarding appropriate modifier usage.
• Report modifiers, when appropriate, for surgical procedures (CPT code range 10,000-69,999) to include Medicare ambulatory surgery, emergency department, endoscopy suite, and hospital-based clinics.
[Editor’s note: For more information, contact Andrea Clark at (410) 747-6081. Contact Nora McNeil at (732) 864-9100.]
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