Wednesday, March 23, 2016

Documentation is required when billing modifier 24

Based on widespread probes of office evaluation and management (E/M) services, First Coast has discovered that the 24 modifier for E/M services, when billing within a global surgery period, has been billed incorrectly at least 60 percent of the time. Clinical review of documentation demonstrates that modifier 24 was either not supported for the encounter, or was improperly applied (i.e., a different modifier should have been submitted).

To address this widespread improper billing, First Coast implemented a pre-payment edit on April 16, 2012, applicable to office visit E/M claims (codes 99201-99205 and 99212-99215) billed with the 24 modifier.

For claims containing modifier 24 received on or after April 16, 2012, First Coast began developing to the provider to provide supporting documentation that justifies the use of the 24 modifier. Providers must respond within the specified timeframe included in the development letter. Failure to submit the documentation timely may result in a claim denial.


Also effective April 16, 2012, First Coast no longer accepts:

• Telephone requests via the interactive voice response or a customer service representative to add or change the 24 modifier on a previously denied claim.
• Written or fax requests (processed on or after April 16) to add or change the 24 modifier without supporting documentation. The provider will be sent a written notification that their request could not be completed.

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