Is your neurology practice losing $30,000 annually to modifier errors? Modifier mistakes silently kill profits in neurology billing. A missing 59 modifier bundles procedures that should pay separately. An incorrect 25 modifier gets your visit denied. Athenahealth has built-in tools preventing modifier errors.
This guide shows you how to avoid modifier errors. You’ll learn which modifiers neurology uses most. We explain common errors costing thousands. We provide step-by-step Athenahealth configurations. Stop losing money to preventable modifier mistakes.
Critical Neurology Modifiers
Neurology uses modifiers more than most specialties. The same codes mean different things with different modifiers.
Modifier 25: Significant E/M Service
Modifier 25 indicates a significant, separately identifiable E/M service. Neurology uses this constantly. Visits often include both evaluation and testing. Without modifier 25, the visit gets bundled. You lose $100-$200 per claim.
Modifier 59: Distinct Procedural Service
Modifier 59 shows procedures are distinct and separate. Neurology frequently performs multiple procedures in one session. Without modifier 59, payers bundle them together. This modifier is critical for nerve studies and multiple injections. Multiple trigger point injections in different areas require modifier 59.
Modifier 26: Professional Component
Modifier 26 bills only the professional interpretation. Neurologists frequently read EEGs and EMGs performed elsewhere. Modifier 26 ensures payment for interpretation only. Using this correctly prevents compliance issues.
Common Modifier Errors
Understanding frequent errors helps prevent them. These mistakes happen across thousands of practices. Each error costs real money.
Missing Modifier 25
This is the most common neurology modifier error. The physician does a detailed visit and an EMG. Billing staff code both, but forget modifier 25. The payer bundles the visit into the EMG payment. Documentation quality affects modifier 25 usage. The visit must be significant and separately identifiable. Athenahealth can prompt for modifier 25 automatically.
Incorrect Modifier 59 Placement
Modifier 59 must go on the correct code. This confuses many billing staff. The modifier goes on the lesser-valued procedure. Getting this wrong results in denials. When billing multiple procedures, modifier 59 goes on whichever has lower reimbursement. Placing it incorrectly causes rejections. Resubmission delays payment 30-45 days.
Overuse of Modifier 59
Some practices use modifier 59 on every claim defensively. This overuse triggers audits and scrutiny. It suggests the practice doesn’t understand proper application. Audits cost $10,000-$50,000 in defense and recoupment. Modifier 59 should be used only when necessary.
Athenahealth Configuration for Modifier Accuracy
| Configuration Area | Setting | Purpose |
| Charge Entry Rules | Require modifier 25 for E/M + procedures | Prevents missing 25 modifiers |
| Code Edits | Auto-apply modifier 59 to secondary procedures | Ensures correct 59 placement |
| Procedure Templates | Include modifier prompts | Reminds staff of requirements |
| Claim Scrubbing | Block claims with missing modifiers | Catches errors before submission |
Setting Up Charge Entry Rules
Athenahealth’s charge entry rules prevent modifier errors before they happen. These rules validate coding logic in real-time.
Creating E/M and Procedure Rules
Go to the Administration section. Select Clinical Configuration, then Charge Entry Rules. Create a new rule for E/M codes paired with procedures. The rule should require modifier 25 on E/M. Configure the rule to trigger when any E/M code appears with a procedure. Set the enforcement level to “block” rather than “warn.”
Building Modifier 59 Logic
Create rules for common modifier 59 scenarios. Multiple nerve studies need modifier 59 on secondary codes. Multiple injections in different areas are required. The rule should automatically add modifier 59. For nerve studies, modifier 59 goes on codes after the primary. Include anatomical requirements in the modifier 59 rules.
Building Charge Templates
Charge templates streamline billing and reduce errors. Neurology procedures follow predictable patterns.
EMG Study Templates
Create templates for common EMG combinations. A typical EMG includes nerve studies plus needle EMG. The template should include all codes with required modifiers. Include documentation prompts in templates. The template should remind physicians to document the necessity. Configure templates to prompt for laterality and nerves tested.
Office Visit with Procedure Templates
Build templates for visits combining evaluation and procedures. Common combinations include a new patient with EMG and follow-up with injection. Allow template customization for unusual circumstances. Most visits follow standard patterns. Occasionally, unique situations arise. Templates should be starting points, not rigid restrictions.
Using Claim Scrubbing
Athenahealth’s claim scrubbing catches errors before submission. This prevents denials rather than fixing them afterward. Proper scrubbing configuration is critical.
Configuring Scrubber Rules
Go to Administration. Navigate to Revenue Cycle Management, then Claim Scrubbing. Review the default rules that come with the neurology configuration. Activate rules checking for missing modifiers. Rules should flag E/M codes with procedures missing the modifier 25. Set scrubbing enforcement to “error” level for critical rules.
Custom Scrubbing Rules
Build custom rules for practice-specific patterns. If your practice frequently bills certain combinations, create rules. Custom rules address your unique errors. Include payer-specific modifier requirements. Some payers have unique preferences. Configure rules matching each major payer’s expectations. This reduces payer-specific denials.
Training Staff on Modifiers
Technology alone doesn’t prevent errors. Staff need proper education on modifier use. Combine Athenahealth tools with training programs.
Initial Training
Provide dedicated sessions on neurology modifiers. Cover the most common modifiers and uses. Use real claim examples from your practice. Show what happens when modifiers are missing. Explain the financial impact of errors. Staff need to understand these aren’t just technical details.
Ongoing Education
Conduct quarterly refresher training. Repetition reinforces correct practices. Share recent error examples and corrections. Review payer-specific requirements regularly. Payer policies change frequently. Medicare updates policies annually. Commercial payers modify requirements without warning. Keep staff current.
Monitoring Modifier Accuracy
Ongoing monitoring ensures accuracy remains high. What gets measured improves. Track modifier-related metrics monthly.
Key Performance Indicators
Track the percentage of E/M and procedure combinations, including modifier 25. Your target should be 95%+ compliance. Monitor modifier 59 usage rates on multiple procedures. Usage should align with clinical patterns. If 80% of nerve studies use modifier 59, that’s appropriate. If only 20% do, you’re underbilling.
Monthly Audit Process
Conduct monthly audits of 20-30 random claims. Verify modifier usage on each. Check that required modifiers are present. Compare audit findings to Athenahealth configuration. If audits reveal recurring errors, the configuration may need adjustment. Maybe rules aren’t strict enough.
Conclusion
Avoiding modifier errors requires combining technology with training. Athenahealth provides powerful tools to prevent mistakes. Charge entry rules require critical modifiers before submission. Claim scrubbing catches errors at the last moment. Templates standardize correct application. Train staff on neurology modifier requirements thoroughly. Monitor accuracy through monthly audits.
FAQs
What is the most common modifier error?
Missing modifier 25 on E/M visits with procedures is the most common. This happens 15-20% of the time without controls. It costs $24,000-$48,000 annually in bundled claims.
How does Athenahealth prevent errors automatically?
Athenahealth uses charge entry rules requiring specific modifiers. When E/M and procedure appear together, the system demands modifier 25. Claims can’t be submitted without it.
Which procedures require modifier 59 most often?
Multiple nerve studies and multiple trigger point injections require modifier 59. When testing different nerves or injecting different areas, modifier 59 prevents bundling.
Should modifier 25 be used on every visit?
No, modifier 25 is only for significant, separately identifiable E/M services. Brief evaluations don’t qualify. The visit must involve substantial separate work.
How often should practices audit modifier usage?
Conduct monthly audits of 20-30 random claims. Review the charge entry rule effectiveness quarterly. Perform comprehensive annual audits. This catches problems early.
