Did your insurance company let you know that there would be an audit? Do not worry. It’s just a normal thing to do. Now, if you did something really bad, like using the wrong billing codes or putting modifiers in the wrong places, you could end up in quite a mess.

There are some modifiers in which modifiers 25 and 59 are prominent. They are the highest audited modifiers by the insurer providers. This article will go over these and other modifiers that, when added to your practice, can trigger an audit red flag.

If you want to get through the audit process without being accused of fraud, you need to know exactly what your insurance company is looking for. Give them what they want to show transparency in your practice.

Why do Payers (Insurance Providers) Audit Modifiers?

Modifiers are simple 2-character codes added after the CPT code to provide additional information about services rendered. These are the main keys to accurate billing and proper reimbursement. One of the primary factors that trigger insurance payers to conduct audits are unnecessary addition of modifiers.

Insurance providers have an expectation of proper patient documentation with correct modifiers that support healthcare providers about the treatment they have given to their patients. Insurance providers always check and verify that they settle up with the right payment for services.

Highest Audited Modifiers by Payers

Different insurance providers have different procedures for auditing modifiers, but some of the modifiers are constantly appearing on their systems. We will give you a list of highly audited modifiers, but two of them “modifiers 25 and 59” are at the top of that list.

• Modifier 59
• Modifier 25
• Modifier 50
• Modifier 51
• Modifier 76
• Modifier 91

We have broken down all these highly audited modifiers in detail below.

Modifier 59

It’s not easy to get money out of an insurance provider’s pocket. Modifier 59 is a highly audited modifier among all mentioned modifiers. To get passed through this audit you need to mention that your services were unique and different from others provided on the same day. Don’t write it as; if it is different from others, mention how it is different.

In some cases, healthcare professionals must mention that the procedure or service was different from others that were performed on the same day.

Modifier 59 is a difference maker in the services.

This modifier is added to inform the insurance providers that what you have done was completely different from the normal routine. It acts as an extra piece of information for effective communication with payers in terms of codes.

Example:

You were doing knee surgery on patients. During the surgery session, you found cysts in a nearby area of the knee. You have removed a cyst of patients along with surgery, it was extra work that needed to be paid.

If you removed a cyst during your knee surgery, it’s important to mention the location and size of the cyst. For instance, you removed a cyst from Femur (thigh bone or upper bone to knee). This is considered a separate procedure or service.

Why is Modifier 59 highly audited?

The first and foremost reason that leads modifier 59 towards strict audit is the confusion of insurance providers. They might wonder why there were two codes for a procedure. If you failed to show that the procedures you have done were genuinely separate, the payers may not lay a soft hand on you. You can avoid these audits and protect yourself from the negative impact of this audit by clearly mentioning the treatment points that are involved in each procedure.

Modifier 25

Insurance providers are so choosy and they might say “NAH, that consultation and checkup of patients was just for the sake of procedure, there’s no extra payment.”

When patients visit a healthcare provider or a consultation is given along with a procedure Modifier 25 turns up. Modifier 25 elaborates insurance payers that you have done more than usual, you have done check-up along with procedure on the same day. Professionally speaking, this modifier is used to report Evaluation and Management (E/M) services.

Example:

Your patients come to your office with belly aches. You are accountable for full examination and identify that patients need ultrasound and you charge bills for time spent on identifying and diagnosing the disease.

Why is Modifier 25 highly audited?

You must show beyond doubt that E/M services are truly separate from the procedure. Insurance company auditors are fond of challenging you in these cases, so always up to fight and back up your claim. It’s okay, don’t panic. Write details about the patient’s history and their treatment. Enlist reasons why you order tests and more about what you are thinking. This detail will be helpful for you as a proof in case the insurance providers give you a tough time during a modifier audit.

Modifier 50

Insurance providers are always unpredictable, they might think: “Wait What? Healthcare providers are trying to double dip by charging for two procedures, although they have performed one procedure”. We can expect anything from the insurance provider like: Why both sides (RT & LT) need a procedure. They think like you are playing tricks on them.

If you are accused of entering the same code twice for which you may face an audit trail. Don’t worry, just add modifier 50 as you might have performed the services on both sides i.e. RT and LT. Modifier 50 acts as an indication of the body side for which the procedure is done either its RT (right) or LT (left). 150% of payment adjustments related to patients’ bilateral procedures are applicable.

This modifier acts as a message to insurance providers that you have performed the same procedures on both sides (LT & RT) of the body.

Example:

Modifier 50 conveys to the insurance provider that you have performed the same action on both sides of the patient’s body.

For instance, you have performed a procedure on both right and left knees. You must write down that patients had arthritis in both knees, having equal pain on both sides.

Why is Modifier 50 highly audited?

It’s important to mention both sides(RT/LT) of the procedure clearly, insurance providers might question whether this procedure could be bundled into a single code, particularly when the procedure is so simple. In some cases, patients’ anatomy might restrict you from performing the same procedures on both sides. So this can affect the proper use of Modifier 50.

Clear and detailed documentation is your best companion during modifier 50 audits. Mention that both sides of the body need attention. Write all these details in a professional tone. Use medical terms like “bilateral condition”  to maintain professional rhythm. This can depict that you are not asking for extra money, that’s all you deserve.

Modifier 51

Insurance providers play the role of penny pinchers when it comes to paying you for the surgical procedures that you have performed. They might try to stack all your work in one payment and they might think like that: “OH NO! Healthcare providers are playing with us by replicating their surgeries.” Insurance providers give you a tough challenge for this because it can lead to a higher payout.

Modifier 51 helps healthcare professionals to mention their surgeries, when multiple procedures/ surgeries are done in the same session, these are other than E/M services. You are the one person that is performing multiple surgical procedures in one session. Quite Impressive! Modifier 51 can be used to tell your insurance payer that you have performed multiple surgeries in the same session with the same patient.

Example:

You have performed two surgical procedures: colonoscopy and polyp removal during the same session. You are supposed to use Modifier 51 to identify these two procedures were different from each other and performed in the same session; and you deserve separate charges for both.

Why is Modifier 51 highly audited?

Modifier 51 is a complex modifier that pinches insurance providers toward tough audits. Auditors are in search of any mistake you have made in bundling, where multiple procedures can be a part of a single procedural package.

If you are a cardiologist and have performed a bypass and valve repair on the same day, you must mention why the bypass is needed to improve the patient’s blood flow and also explain that repairing the leaky valve is important to avoid further heart complications. Your payer will ask whether you have billed both procedures separately or as a single package. No need to be confused, justify yourself by providing supporting documentation. Clearly explain why you did each surgery and how it was different from the 1st one.

Modifier 76

Always be ready to justify why you have repeated the procedure. Clearly explain all scenarios under which the procedure is repeated – either the first X-ray was unclear or anything else.

Modifier 76 is in the queue where the same healthcare providers or different qualified healthcare professionals (QHPs) repeat the surgical procedures. It quotes insurance providers about repeated procedures that are performed due to compact reasons.

Example

You did an ECG of a patient and found a horrifying abnormality. You repeated the ECG to cross-check the results. Or might be there’s a case where you took an X-ray of a patient’s chest, but it was so blurry and unable to spot the issue. You were doing it again for some significant reasons.

Why is Modifier 76 highly audited?

Insurance providers always keep keen eyes and seek to audit the Modifier 76. They are very curious to know what’s the reason behind repeating one action twice. Smartly tackle this audit by giving solid reasons about repeating your course of action. For instance, if you repeated the X-ray procedure don’t just mention it as “unsatisfactory”. Maybe it happened because of patient movement or might be due to poor image quality – explain specific reasons. Don’t give your soft spot in the hands of insurance providers that give them reasons to doubt you.

Modifier 91

Insurance providers are in doubt as to why two physicians do the same tests on the same day. They are thinking; “We don’t know the reason why healthcare providers repeated lab tests; it might be to give a boost in the medical bill.” They think it was an unnecessary act, auditors are over-optimistic to give this challenge to healthcare providers.

Modifier 91 backs up you when you perform a clinical laboratory test repetitively for the same patient, on the same day, to manage the treatment of a patient. Sometimes, healthcare providers need to perform many laboratory tests i.e. repeated blood tests to diagnose the ailment property.

Example:

If your patient was suffering from severe chest pain and you decided to take an Electrocardiogram (EKG or ECG) of the patient. Then the cardiologist jumps in and needs another EKG.

Why is Modifier 91 highly audited?

For Modifier 91 insurance providers are more audit-focused to know “why clinical diagnostic tests are repeated on the same day”. Unnecessary lab testing can tweak providers, they might be searching for the medical necessity of each test. You must note down the specific reasons for repeating tests in each case like any changes in symptoms or medication. This way you can easily justify all your answers with evidence.

From modifiers to audits. Continue your learning journey with our in-depth look at Medicaid audit triggers.

Checklist for Success of Your Practice in Audit Done By Insurance Providers

Here are a few quick points that help you and your healthcare practice to get a clean chit from insurance provider audits easily. 

• Properly review your clinic documentation
• See how modifiers are used for services done
• Look for coding outliers 
• Properly mention and check drug unit reporting
• Check diagnosis coding is done properly
• Check telehealth coding
• Audit the insurance payer auditors

“Healthcare Providers” Frame of Thought:

Insurance providers act like detectives; they focus on our records for any reason to cut down our payment. It’s a very consistent battle with them to prove our value and defend every penny we have spent. It’s difficult to scrape together all the money that we deserve.

“Insurance Providers” Frame of  Thought:

We are accountable to our policyholders to ensure that all claims that are accepted or rejected are accurate. Audits are an important part of this process to identify red flags. That’s all we care about our members for appropriate billing and timely reimbursement. We try our best to maintain a balanced and fair payment system for every individual who is involved.

FAQs

Who gets audited by insurance providers?

Anyone who gets reimbursement from insurance providers is supposed to get audited. Are you thinking you might be next in the queue for auditing of modifiers? Some healthcare providers are more likely to get caught in sight of insurance providers. Providers who are constantly dusted with high-paying modifiers on their claim submissions are basically inviting red flags for their practices. It’s just calling insurance providers: Audit My Practice!

Is there any way to avoid an audit?

Avoiding your practice for an audit is like trying to go up in the sky without a hot air balloon. But you can adopt some tips to avoid and minimize the risk of audit. But you can’t have control over audit outcomes.

• Do accurate and complete documentation to avoid audit procedures and claim denials.
• Stick to coding guidelines that prevent errors.
• Audit your practice internally, before your small mistake can lead to a bigger problem.
• Claim your free practice audit.
• Maintain positive collaboration and communication with payers to reduce the negative impact of audits.

Can all payers conduct audits?

From bigger insurance providers to smaller regional payers, everyone can do audits. Insurance providers can keep control of healthcare costs by pinning down the overpayments. They have the power to audit your practice and no barrier can stop their staff from doing audits. Think of it like a financial analysis of your practice – these audits can add value to your revenue cycle.

Conclusion

A happy wrap-up? Maybe not much quite, but pins healthcare providers’ hope on insurance providers. We have understood the storminess of highly audited modifiers. It’s like a rough journey with numerous challenges, unexpected turns, and a never-ending battle with insurance providers. But remember one thing “YOU” and “INSURANCE PROVIDER” both are working towards the same goal: maintaining a balance by ensuring fair reimbursement. To maintain a balance both parties have to do their part:

As a Healthcare Provider:

Make sure to be diligent in documenting patient treatments and following proper medical coding procedures.

As an Insurance Provider:

You need to be more sensible, and practical, and avoid overly destructive audits that will significantly impact both patients and providers.