Many modifiers are generally used by a practice in dental coding. A few commonly used modifiers in dental billing and insurance reimbursement include Modifier 25 and Modifier-59, among others.
As a definition, this modifier can be defined as a significant, separately identifiable evaluation and management service (E/M) performed by a qualified healthcare professional or dental practitioner and needs to be performed on the same day as the procedure or any other service.
This code informs the insurance company that a dental practice is eligible for both services and needs to be compensated for both. When used as per guidelines, it can be an effective source of generating extra revenue.
Usage of this modifier is permitted for the same dentist performing an E/M procedure or procedure during the same visit. One can consider the case of an oral examination. A healthcare professional examines the patient and conducts a complete intraoral and extraoral examination during a routine visit. If, during this check, the healthcare professional is concerned about a new lesion that has developed, they may recommend testing to be done.
If an oral DNA and CBCT are done, then the practice must support such an E/M recommendation as significant and distinct from the routine procedure. It should also not use this modifier for regular pre-procedure evaluations.
In terms of a definition, this modifier can be considered a distinct procedural service. It can be used when two procedures need to be done during the same visit. Both procedures, however, need to be done at separate locations and are generally not done together.
One can consider the extraction of an erupted tooth, which is code D7140, and a separate procedure in a different quadrant. This modifier should be used when the practice has no other descriptive modifier available for usage. The team should also make sure of clear documentation of the distinct nature of the rendered services.
A few tips for the accurate usage of modifiers by a dental practice are as follows:
Different insurance organizations can differ in their modifier usage. Some organizations accept CPT modifiers, while some recognize CDT modifiers. Some might accept both modifiers, and the dental team needs to be aware of the same.
Hence, the team needs to regularly verify modifier acceptance, documentation requirements, and frequency limits that are mandated by the insurance organization. It is
possible that some Medicaid programs might not accept Modifier -25, but a few private insurance companies can mandate it for combined E/M visits.
A vital point of consideration for ideal modifier usage lies in proper documentation. Every modifier that has been applied needs to be supported with clinical notes. It must include the purpose of providing an additional service, how the service is a necessity and distinct, as well as the time spent on rendering the service. The dental team must ideally have a standard checklist of documentation requirements needed when using modifiers 25 and 59.
The practice must ensure that the billing staff are always updated on changes in guidelines and coding rules. The practice can arrange for periodic training sessions that include briefings on new or updated CDT codes, cross-coding dental to medical, as well as the application and usage of modifiers. Audits conducted by the practice can be utilized as part of the training sessions to promote Efficient Dental Billing and Coding.
The practice must not misuse or take advantage of modifiers for financial gain. Such usage always gets flagged during audits, investigations, and claim rejections. The overuse of modifiers 25 and 59 can be an indicator of unbundling or upcoding. The team needs to avoid billing separately for services that can be combined. It should also not use modifiers to evade edits in the absence of proper documentation.
The dental team must effectively use modifiers to validate and get reimbursed for emergency procedures and post-operative complications. Any extra services conducted during treatment can be billed by using modifiers.
An example can be when a patient comes to the practice within 48 hours due to post-operative bleeding. When offered treatment for the same, the team can use a modifier while offering an explanation why the treatment was not part of routine follow-up.
There are chances of a dental procedure or treatment getting submitted as a medical claim. This can be applicable for a hospital-based dental service. There are also occasions when a dental practice needs to administer necessary solutions like sedation or a biopsy.
On these occasions, a CPT modifier can be used in medical claims that ensure compliance with insurance company policies. The team needs to maintain a CDT-CPT cross-coding guide to appropriately use modifiers.
The practice must deploy a dual checking system to monitor the usage of modifiers on every claim. There should be quality checks that can identify missing or inappropriate modifiers, or when claims need a modifier but it is not available. The team can make use of software that has coding alerts or flags that can detect typical modifier errors.
The American Dental Association releases annual updates on CDT codes, and that includes modifier implications as well as CPT modifiers. The practice can also be a part of dental coding forums and other related associations.
A few scenarios are mentioned herewith:
Code D7510 is applicable for incision and drainage. Code D0140 is applicable for a limited examination. In these cases, modifier-25 can be used when an examination can be deemed necessary to diagnose and determine an appropriate treatment recommendation.
Modifier-25 can be used for a tooth extraction (D7140) while Modifier-59 can be used on the second instance. The reason can be extractions that are performed in non-connected quadrants.
Modifiers constitute a complex but beneficial component of CDT codes. They help provide a reference to procedures conducted by the practice. They also ensure smoother communication and reimbursement with the insurance company. The practice must ensure that the teams are periodically trained in the usage of modifiers while also adhering to compliance guidelines. Modifiers, when used accurately and effectively, can help the practice run smoothly and profitably.
