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


“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.”

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