Question:

What are the risks of improper use of modifiers like modifier 59?

Answer:

“Overuse of modifier 59 would result in additional revenue (at-risk revenue) not a loss of revenue. If a claim is properly coded and an edit is triggered requiring a modifier the claim will not process until a modifier is appended or a code is removed. If a biller overrides the claim process to bypass the edit and submit a claim without appending a necessary modifier the claim will edit by the clearinghouse and or payer claims processing system. If a laboratory is over utilizing a modifier that results in overpayment there is a risk. Depending on the frequency that this error occurs and the payment rate for the test there could be little risk but there could also be a significant risk. It is a matter of mathematics. High utilization and high $$$ payment equal higher risk.”

This question was answered in an edition of our Laboratory Compliance Manager. For more hot topics relating to laboratory services, please visit our store or call us at 1.800.252.1578, ext. 2.

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