Quick Reference — To correct MODIFIER claims

Make necessary corrections and resubmit the claim.

Note: If after acting on this error, the claim remains in a hold status (HOLD or MGRHOLD), the claim requires additional review or work.

1. On the Claim Edit page, scroll down to the Claim Notes section at the bottom of the page.
2. Click the EOB link at the end of the claim note to display the payer message.
   Review the EOB to determine which charge or charges need modifiers. Note the charges that have not been paid. The coding/modifier on the denied charges must be corrected.
3. There are two ways to research modifiers: using athenaCodesource or by clicking the magnifying glass icon that appears next to each procedure code on the Claim Edit page.
4. Currently, athenahealth does not provide coding advice to our clients, but please consult the Code and Knowledge Base in athenaOne for additional information.

Note: At least one change must be made to the claim before it can be resubmitted. It is not compliant to resubmit a claim without changes only to see whether the claim will be paid if you resubmit it to the payer.

1. Display the Claim Action page: Select a claim from the Workflow Dashboard, Claim Worklist, or click the Claim Action Page link on the Claim Edit page.
2. Review the claim information.
3. Actions — If the claim needs to be resubmitted to the payer, select Add Kick Reason.
4. Make any necessary changes to the claim details.
5. Kick reason — Enter DRPBILLING.
6. Claim note — Enter a clear, detailed note for athenaOne users, describing what actions have just been taken.
7. Click Submit.

Note: At least one change must be made to the claim before it can be resubmitted. It is not compliant to resubmit a claim without changes only to see whether the claim will be paid if you resubmit it to the payer.

1. On the Claim Edit page, scroll down to the Claim Notes section at the bottom of the page.
2. Review the claim notes.
   1. If athenahealth has researched the denial with the payer, a detailed description is included.
   2. If there is an EOB or letter from the payer, click the link to review it.
3. If further clarification is needed, contact the payer directly.
4. Applies to — Select the correct insurance type.
5. Status — Select DROP.
6. Kick reason — Enter DRPBILLING.
7. Claim note — Enter a clear, detailed note for athenaOne users, describing what actions have just been taken.
8. Click Save.

The athenaOne Rules Engine uses athenaCodesource to check the effective and termination dates of a procedure code against the claim's from and to dates.

If a procedure code was not valid on the date of service, the claim is assigned HOLD status for the reason: "Rule #3864 Invalid Procedure Code for Date of Service." This message appears in the Claim Notes section of the Claim Edit and Claim Action pages.

1. Display the Code Check page: On the Main Menu, click Claims. Under RESOURCES, click Code Check. The tool appears in the Task Bar.
2. Select a Function — Select CPT/CCI.
3. Enter all the CPT codes on the claim in the fields provided. Do not enter modifiers that are on the claim.
4. Select the CCI version that matches the date of service on the claim.
   You can click the CCI version link to display a table of dates and versions to help you determine the version.
5. Click Submit. An analysis of the coding of that specific claim appears in the Workspace.
   Note: The analysis reveals only bundling issues on the claim and includes modifiers that can resolve the bundling issues. Any modifiers that you use must be supported by the medical record. Because the analysis addresses only bundling issues, there may be other reasons why a modifier is recommended.
6. Determine which modifier to use. For every code that has a MISMOD message, click the M link to the right of the code description. A list of possible modifiers and their descriptions appears in a new window.
   Note: You can use only modifiers that appear in your modifier table in athenaOne. If a modifier is not in your table, please add it to the table before trying to correct the claim.
7. To print the MedAssets analysis, right-click the page and select Print. To return to the claim, right-click and select Back.

The athenaOne Rules Engine uses athenaCodesource to check the effective and termination dates of a procedure code against the claim's from and to dates.

If a procedure code was not valid on the date of service, the claim is assigned HOLD status for the reason: "Rule #3864 Invalid Procedure Code for Date of Service." This message appears in the Claim Notes section of the Claim Edit and Claim Action pages.

1. Display the Code Check page: On the Main Menu, click Claims. Under RESOURCES, click Code Check. The tool appears in the Task Bar.
2. Select a Function — Select CPT/CCI.
3. Enter all the CPT codes on the claim in the fields provided. Do not enter modifiers that are on the claim.
4. Select the CCI version that matches the date of service on the claim.
   You can click the CCI version link to display a table of dates and versions to help you determine the version.
5. Click Submit. An analysis of the coding of that specific claim appears in the Workspace.
   Note: The analysis reveals only bundling issues on the claim and includes modifiers that can resolve the bundling issues. Any modifiers that you use must be supported by the medical record. Because the analysis addresses only bundling issues, there may be other reasons why a modifier is recommended.
6. Determine which modifier to use. For every code that has a MISMOD message, click the M link to the right of the code description. A list of possible modifiers and their descriptions appears in a new window.
   Note: You can use only modifiers that appear in your modifier table in athenaOne. If a modifier is not in your table, please add it to the table before trying to correct the claim.
7. To print the MedAssets analysis, right-click the page and select Print. To return to the claim, right-click and select Back.

After you determine that one or more modifiers are supported by the medical record and you decide which modifiers to use, add the modifiers to the claim:

1. On the Claim Edit page, locate the CPT code that needs a modifier.
2. Enter a comma (,) after the code, and then enter the modifier.
3. Repeat for other procedures that may need modifiers.
4. At the bottom of the Claim Edit page, click Save Claim.