Major insurers push back on claims involving modifier 25 and 59

Physicians are advised to review their documentation practices in light of reports from DOs experiencing payment denials related to clinical validation edits made by an increasing number of large payers.

DOs began reaching out to AOA for assistance earlier this year when Health Care Services Corporation (HCSC), which operates Blue Cross Blue Shield plans in Illinois, Montana, New Mexico, Oklahoma and Texas, made changes to its automated payment policy rules regarding claims using modifiers 25 and 59.

That edit initiated significantly increased scrutiny by the HCSC insurers of documentation for claims and resulted in payment denials for part of the services provided, according to AOA staff working on behalf of affected DOs.

Multiple specialties affected

The 15 DOs reporting the most problems have practices that focus on osteopathic manipulative treatment, but the HCSC edits do not appear to be specifically targeting OMT. Instead, this broadening scrutiny of claims involving modifier codes is hitting a multitude of specialties, including dermatology and pain management.

AOA staff is concerned that other large payers will adopt similar edits regarding the use of modifier 25, which means that physicians will have to spend more time on clinical documentation if they want to win appeals. Auditors need to see more detailed documentation of the evaluation and management (E/M) services as well as the procedure for a physician to successfully appeal.

“The E/M documentation guidelines for physicians are 20 years old, but the documentation standards payers are enforcing are vastly different from what they were even 10 years ago,” said Mat Kremke, vice president of the American Osteopathic Information Association, which provides physician services to AOA members. “These changes reflect a shift toward value-based care.”

Clinical documentation improvement will streamline reimbursement in most cases, Kremke said.

Tips to improve documentation:

• Write legibly or simply do not handwrite any part of the patient’s medical record. Illegibility often results in claim denial.
• Avoid cutting and pasting notes in the EHR. While the process saves documentation time, it also puts up a red flag to auditors.
• Make sure the documentation supports a separate E/M for the visit. Insufficient notes may result in this part of the claim being denied or reduced.
• Avoid upcoding. Payers are aggressively reviewing claims for the appropriateness of the E/M level.

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‘Looking for the patient’s story’

“Coders and auditors view medical records very differently, and it’s the auditor’s opinion that determines the outcome of the appeal. An auditor is looking for the patient’s story and the physician’s thought process to understand treatment decisions as they pertain to each visit,” said Boyd Buser, DO, AOA past president. Dr. Buser represented AOA physicians in a recent meeting with HCSC to discuss the impact of the rule edits.

“Red flags occur when the documentation repeats the same case notes, either verbatim or nearly identically, and doesn’t reflect any changes and improvements over the course of treatment,” Dr. Buser explained.

The AOA has joined with a medical association staff coalition to jointly address these issues. Members of the coalition include AOA payment policy staff as well as representatives from dermatology, pediatrics, neurology, urology, pain management, ophthalmology, otolaryngology, rheumatology and obstetrics and gynecology associations.