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Common Claim Denials

Common Claim Denial Problems & How To Use Modifiers

Let’s face it. Billing is complicated. Doctors, we know you went to school to learn about the eyes. Nowhere did it say you had to sign up to manage billing. Office staff, you might have a better idea how to manage billing but there’s always room for improvement. Billing staff, well you’re the lucky ones. Whether doctor or staff, we all know billing is an integral part of running a successful practice. One way or another you need to learn the best practices for billing procedures so you can not only get paid more but get paid faster.

To help you and/or your billing department brush up on their billing knowledge, we’ve decided to put together a few quick tips. We’re focusing on the most common denial problems and offering a “how-to” on modifiers that ensure you get paid for the full extent of the exam.

Common Denial Problems

1. Matching Patient Name & Number

One of the most common denial problems is also one of the simplest. Claims often get denied because the patient’s name and number do not match. Ensure the most basic of information is correct before you submit the claim. Taking it a step further, the patient’s name must match his/her proper name. Should he/she use a nickname, you must check that the proper name and the name on the claim match.

2. Using Policy Holder’s Information

This denial problem is commonly found with children or when multiple people are listed under one policy holder for a specific insurance profile. To prevent a denial, you need to ensure you use the policy holder’s information when necessary instead of the patient’s info. For example, when the mother is listed as the policyholder, she needs to also be listed on the claim rather than listing the patient (ie the child).

3. Policy Dates

While it may seem like common sense, a lot of practices forget to ensure the insurance policy is in effect on the date of service. Prior to submitting the claim, verify the insurance policy date.
If you find your practice struggling with eligibility, maybe it’s time to talk to FoxFire’s billing experts. With our claim management software you can check eligibility in real-time, screening patients prior to their appointments or directly at the time of service.

Using Modifiers to Collect More Money for What You’re Already Doing

Providers often miss out on collecting for multiple procedures because they are either unaware of the ability to use modifiers or they are not using modifiers properly. We’re tackling the three most common modifiers and “how-to” use them properly to get paid more for what you’re already doing.

Please note: FoxFire Systems Group does not assume any responsibility for accurate coding. The information provided is for educational purposes only.

1. Modifier 25

Modifier 25 is defined as “significant, separately identifiable evaluation and management (E/M) service by the same physician* on the day of a procedure”.

Procedures in modifier 25 references minor procedures with zero to 10 days of post-operative care, such as foreign body removal, intravitreal injections etc.

*Medicare regulation states that physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician


  • Modifier 25 indicates that on the day of a procedure, the patient’s condition required a significant, separately identifiable E/M service, above and beyond the usual pre and post-operative care associated with the procedure or service performed.
  • Use Modifier 25 in the rare event of an E/M service the day before a major surgery that is not the decision for surgery and represents a significant, separately identifiable service.

Example: A patient needs foreign body removal during a routine exam. Using modifier 25 the doctor can get paid for the procedure as well as the office visit.

2. Modifier 24

Modifier 24 is defined as “unrelated evaluation and management (E/M) service by the same physician* during a post-operative period”.

Unrelated often refers to the un-operated eye or another anatomical part of the eye that is irrelevant to the surgery.

*Medicare regulation states that physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician


  • Modifier 24 can be used on an unrelated E/M service beginning the day after a procedure, when the E/M is performed by the same physician* during the 10 or 90 day post-operative period
  • Modifier 24 can be used when documentation indicates the service was exclusively for treatment of the underlying condition and not for post-operative care.
  • Modifier 24 can be used when the same physician provides unrelated critical care during the post-operative period.

Take special care noting whether the “unrelated E/M service” is truly unrelated. You cannot use this modifier when the E/M is for a surgical complication, infection, wound treatment, etc that clearly relates to the initial procedure.

Example: A patient has cataract surgery and is within the 90 day post-operative window but comes in for a 6-month diabetic check. This service has nothing to do with the surgery. You can still get paid for this procedure even though you are still within the post-operative period.

Both Modifier 24 and Modifier 25 can be used at the same time if, for example, the following occurs:
A physician performs a surgery. During an unrelated E/M visit during the post-operative period, the provider may determine the necessity for another procedure separately identifiable to the original E/M service and unrelated to the original surgery. Referring to the previous example above, the patient with recent cataract surgery (within the post-op period) comes in for a 6-month diabetic check and ends up needing a foreign body removal.

3. Modifier QW

Modifier QW is used for a CLIA waived test.


  • Modifier QW can be used for any test on the CMS list that CLIA standards are waived for.

Example: If a doctor performs a tear analysis for dry eyes they can use the modifier QW. This lets Medicare know that it’s a CLIA waived test and the doctor can get paid for performing it.

There is a lot of information available if you are interested in learning more about billing and coding. While we have outlined some key points above, we highly suggest investing time into learning proper billing procedures or relying on someone such as FoxFire to handle the billing for you.

If you are feeling a little lost or overwhelmed, talk to our billing experts and learn how we can help simplify the process. Speak to a representative today and see how we can help your practice.

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