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2020: Abuse, misuse, and misunderstandings of modifiers -25, -59, and -62

Sonal Patel (sonalpatel@nexsenpruet.com) is a Health Care Coding & Compliance Consultant at Nexsen Pruet LLC in Charleston, SC.

There is no easy way to say this, so I will state the simple facts. Over the years, the misuse and misunderstandings of modifiers in healthcare coding have led to the many spotlights set forth by the Office of Inspector General’s (OIG) Work Plan. The sheer volume of misuse and misunderstanding has often led to cases of identified abuse.[1] Moreover, with known intent thrown in the mix, this erroneous usage becomes fraud, according to the definitions set forth by the False Claims Act.[2]

Healthcare coding and compliance industry professionals must continue providing education and best practices on appropriate modifier usage on services rendered by physicians and other qualified healthcare professionals. These concentrated efforts will allow medical practices to retain their reimbursement levels the first time claims are processed and will further bypass scrutiny in a post-payment audit, should one occur.

This article highlights the three modifiers already on the OIG’s radar during the writing of this article in April 2020.

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