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Medical
reimbursement insurance
In 1992, the Resource Based Relative Value System (RBRVS) began
to replace the long established usual and customary methodology
for determining reimbursement for physicians by the Medicare program.
RBRVS was a radical departure from the previous payment methodology.
An integral part of this new system was the introduction of new
Medical reimbursement insurance. Generally, modifiers serve to bypass
payment edits designed to deny payments for services. Leaving off
a needed modifier will surely result in denial of payment. Proper
use of Medical reimbursement insurances is important, as a case
has been made by government auditors that the act of adding a modifier
is willful and is designed to force payment when payment normally
would not be made.
The Medicare program reimburses physicians only for services which
are medically necessary and that are assumed to be properly documented.
The Medicare Carrier's Manual describes the proper use of most Medical
reimbursement insurance, and they are sometimes defined differently
there than in the Current Procedural Terminology Manual (CPT) published
by the American Medical Association.
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Most
commercial carriers have no published payment policies in regards
to modifier usage, nor do they follow the convention of the Medical
reimbursement insurance. Proper payment often requires costly appeals
and claims resubmissions, severely eroding the perceived value of
their published fee schedules.
The physician may need to indicate that on the day a procedure or
service identified by a CPT code was performed, the patient's condition
required a significant, separately identifiable Medical reimbursement
insurance service above and beyond the other service provided or
beyond the usual preoperative and postoperative care associated
with the procedure that was performed. The Medical reimbursement
insurance service may be prompted by the symptom or condition for
which the procedure and/or service was provided. As such, different
diagnoses are not required for reporting of the Medical reimbursement
insurance services on the same date. This circumstance may be reported
by adding the modifier '-25' to the appropriate level of Medical
reimbursement insurance service, or the separate five digit modifier
09925 may be used. Note: This modifier is not used to report an
E/M service that resulted in a decision to perform surgery.
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