Duplicate claims are something healthcare practices must avoid at all costs when it comes to medical coding for Medicare.

1. Avoid Duplicate Claims
with Appropriate Medical
Coding
Duplicate claims are something healthcare
practices must avoid at all costs when it comes
to medical coding for Medicare
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When it comes to medical coding, frequent errors could bring about significant consequences.
And we aren’t talking about unpaid claims alone.
Duplicate claims are something healthcare practices must avoid at all costs when it comes to
Medicare. Too many of these and other errors could result in the MAC (Medicare
Administrative Contractor) enforcing program integrity actions against them. But while many
practices and hospitals are aware of this, they are faced with the perplexing situation of having
to report claims for various medically necessary instances of the same treatment or service.
How could one possibly avoid duplicate claims here?
They can be avoided, through the use of the right modifier and adding the supporting
documentation in the patient’s record.
Modifier 59
While submitting claims for legitimately required multiple instances of some procedure, service,
or item, the appropriate modifier must be appended in subsequent line items to indicate the
repeat service, item or procedure.
 Modifier 59 Distinct Procedural Service is accepted by the CMS (Center for Medicare &
Medicaid Services) for identifying various anatomic sites, encounters and services.
XE, XP, XS, XU Modifiers
From January 1, 2015 the CMS has set up four new modifiers for defining modifier 59 subsets
more clearly so that distinct services that encompass another service could be more clearly
defined, in the following terms:
 XE - Separate Encounter, service considered distinct because of its occurrence in a
separate encounter

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 XP - Separate Practitioner, service considered distinct for having been carried out by a
separate practitioner
 XS - Separate Structure, service considered distinct for having been carried out on a
separate organ or structure
 XU – Unusual Non-Overlapping Service, service considered distinct for not overlapping
the usual aspects of the main procedure
As mentioned above, these modifiers should not be used on the same modifier 59 claim line,
but in subsequent line items. The CPT states that modifier 59 must be used only when other
descriptive modifiers cannot clearly state the reason for the existence of distinct procedural
circumstances.
Modifier 76 and Modifier 91
The other modifiers that can appropriately explain duplicate claims are:
 Modifier 76 – Repeat procedure or service carried out by the same physician following
the original procedure or service
 Modifier 91- Repeat conducting of laboratory clinical diagnostic tests. This modifier
must be added only in the event of additional test results medically required on the
same day
Supporting Medical Record Documentation
As mentioned before, modifiers must be accompanied by sufficient documentation - proving
the services, procedures or items being billed - added to the medical record of the patient.
Here are some important points to remember regarding the medical record documentation:
 Documentation needs to fully support using the modifier for separate services

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 Medical records could be needed for validating modifier use
 Amendments or additions to documentation would not be entertained following the
denial of a claim
 Even if one of these modifiers is added to a claim line during first submission, it does not
ensure reimbursement.
CPT Codes Requiring Medical Records with X Modifiers
Here are some CPT codes requiring medical records when they are submitted with the X
modifiers:
Medicine 92960
Digestive System 44005, 45378, 45381, 49000, 49320
Musculoskeletal System
20600, 20604, 20605, 20606, 20610, 20650, 20670, 20680,
22214, 22224, 22425, 22505, 22520, 22521, 2252, 2253,
22524, 22551, 22552, 22554, 22585, 22600, 22610, 22612,
22614, 22630, 22633, 22634, 22800, 22802, 22803, 22804,
22830, 22842, 22845, 22846, 22848, 22850, 22851, 22852,
22855, 23700, 24300, 25259, 26340, 27570, 27860, 28110,
28230, 28232, 28310, 28725, 29805, 29806, 29807, 29821,
29822, 29823, 29824, 29870, 29884
Cardiovascular System 36215, 36216, 36217, 36218, 38220
Urinary System and
Reproductive System
52000, 52310, 57100, 57268, 58555, 58660
Nervous System and ENT
System
63005, 63012, 63030, 63035, 63042, 63045, 63046, 63047,
63048, 63055, 63058, 63057, 63075, 63076, 63081, 63082,
69210, 69990
Integumentary System
11055, 11056, 11057, 19120, 19125, 19260, 19290, 19291,
19295, 19301, 19303, 19307, 19316, 19318, 19325, 19328,
19330, 19340, 19357, 19361, 19370, 19371, 19380

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How to Deal with CARC OA18 Denials
Now if you come across that situation where your claim gets denied with CARC OA18 code, it is
important that you don’t rush to appeal. Make sure you have appended the appropriate
modifiers to the applicable claim lines. Only then should the claim be resubmitted. Don’t
resubmit whole claims when only partial payment is made. You should only resubmit the
denied lines.
Sometimes your claim may get denied on the pretext of duplicity even if you have included the
appropriate modifier. This may be because of medically unlikely edits (MUEs). These refer to
maximum service units usually reported for a medical procedure, service or item on a single
service date for a beneficiary.
How Outsourced Medical Coding Can Help
With professional medical billing and coding services, the risk of errors such as duplicate claims
and other mistakes is significantly reduced. As you’ve seen, coding is a minefield which is why
hospitals and physicians struggle with it. With professionals dedicated to this task, there is
much lesser chance for claims to get denied. AAPC-certified coders can handle medical coding
involving the major coding systems including ICD, CPT, MRA, HCC, HCPCS and CDT.