Most of the time, CPT codes fail to reflect the complete, diagnostic, surgical and medical procedures as well as services. In such a scenario, a modifier serves its purpose and clearly provides additional information to ensure reimbursements.
Before diving into further discussions let it be clear that: a modifier indicates that the medical services or procedures have been altered in some way. It may also provide more information about the service that a patient received more than one time. However, the original code or definition has not changed.
Types of Modifiers:
The types of modifiers are:
Level I or CPT modifiers
Current Procedural Terminology (CPT) modifiers consist of two numeric digits. These codes are copyrighted & updated annually by the American Medical Association (AMA).
Generally, a modifier is used to describe the who, what, how, why, or where of a situation. The same is true for medical billing and coding modifiers. Such modifiers are used to describe additional information on medical procedures such as:
- Whether multiple procedures were performed?
- Why was a particular procedure necessary?
- Where was the procedure performed?
- How many surgeons or doctors were involved in a medical procedure?
Medical coders and billers describe the additional procedural information in the format ‘CPT code modifier’ and then forwarded it to the insurance agencies.
Below are the most common CPT modifiers:
- Modifier 22 – Increased procedural services.
- 23 – Unusual anaesthesia.
- 24 – Unrelated evaluation and management service by the same physician or other qualified healthcare professional during a postoperative period.
- 25 – Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professionals on the same day of the procedure or other service.
- 52- Reduced services.
- 53- A discontinued procedure.
- 55- Postoperative management only.
- 56- Preoperative management only.
- 57- Decision for surgery.
- 59- Distinct Procedural Services.
- Modifier 76 – report repeat procedure performed on the same day by the same healthcare provider.
- 99- Multiple modifiers.
Level II or HCPCS Modifiers
Level II or HCPCS modifiers consist of two characters— either Alphabets or Alphanumeric. It’s pertinent to mention here that these modifiers are updated by the Centre for Medicare & Medicaid Services(CMS).
The HCPCS modifiers are used to provide additional information on specific items used to deliver non-physician services. Before forwarding to the payers, all of this information is represented in the format ‘HCPCS code modifier’.
For instance, A0428-QN is used to represent “basic life support ambulance service, non-emergency transport, furnished by the provider of services.”
Here is the list of most commonly used HCPCS modifiers:
- AA- Anesthesia services performed by anesthesiologists.
- AD- Medical supervision by a physician, more than four concurrent anaesthesia procedures.
- AH- Clinical Psychologist (CP) Services. [Used when a medical group employs a CP and bills for the CP’s service].
- AJ- Clinical Social Worker (CSW). [Used when a medical group employs a CSW and bills for the CSW’s service].
- QN- Ambulance service furnished directly by a provider of services.
- GZ- Item or service expected to be denied as not reasonable and necessary.
- GY- Item or service statutorily excluded or does not meet the definition of any Medicare benefit.
- GW- Service not related to the hospice patient’s terminal condition.
Reasons For Using Modifiers
As we have already discussed, modifiers play an important role in altering the codes for various medical situations. They are used when the healthcare providers perform the medical procedures in a slightly different manner but without changing their definition/nature.
Here’s why modifiers are used in medical billing:
- The medical procedure was more complicated than expected.
- Healthcare providers need to perform another procedure during the same one.
- Prevent the denials by filing medical claims with accurate and precise modifiers.
- Get complete and right payments for the healthcare services provided to the patients even in an unusual manner. It all depends on the specific nature of the case.
- Plug the revenue loss due to the high percentage of claim denials.
How Does a Modifier Affect Payment?
Do you know using incorrect modifiers are one of the major obstacles in getting reimbursed? When medical billers file the claims to the insurance companies with missing or incorrect modifiers. Then claims get denied and medical practitioners lose their hard-earned revenue for a long time period and sometimes permanently.
In addition to using accurate modifiers, it is crucial for physicians to provide proper medical documentation. That supports the use of the assigned modifier. In case, you fail to document the medical services and procedures. Or the clinical documentation doesn’t contain the required information about patients and adequate definition of the procedure or service. Then you can face several challenges in terms of denied, partial or delayed payments.
Additionally, correct modifiers are not only crucial from the financial aspects. But they are also important from the compliance perspective. Because, in order to avoid healthcare fraud, abuse and other legal troubles. Make sure that your billing and coding staff don’t commit any error while using modifiers.
Furthermore, medical practitioners should always keep in mind that just because a service is “covered”. It does not necessarily mean that service is “reimbursable”. Therefore, you must have a complete understanding of Medicare’s rules to assign modifiers correctly.
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