INAPPROPRIATE MODIFIER USAGE denial AND UNPROCESSABLE CLAIMS

A modifier is a two-position alpha or numeric code that is added to the end of a Current Procedural Terminology (CPT) or Health Care Procedure Coding System (HCPCS) code to clarify the service(s) being billed. Modifiers provide a means by which a service is altered without changing the procedure code. They add more information, such as the anatomical site, to the code. The Multi-Carrier System (MCS), Medicare's claim processing system, denies claims as "unprocessable" for inappropriate modifier use. "Unprocessable" means the claim is missing certain information or the information present is incorrect. Unprocessable claim denials to not have appeal rights, you must correct the claim and resubmit it for a proper initial determination. Your Remittance Advice (RA) identifies unprocessable claims by the Medicare Outpatient Adjudication (MOA) code MA130 in the upper right corner of the claim information. Code MA130 means, "Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Submit a new claim with the complete/correct information." Please note that because no initial determination is made on a claim returned as "unprocessable," the submitter may not ask for a review or appeal. If the use of a procedure code/modifier combination is inappropriate, you will need to make the necessary corrections and resubmit the claim. Please refer to the current versions of CPT and HCPCS coding books for correct reporting of modifiers.

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