Modifiers In Medical Billing

Medical billing and coding involves several phases and implementing them successfully is really essential for physicians for submitting accurate claims for their services. Accurate billing is executed by reporting right ICT-10 and HCPCS codes. Leading billing companies have experienced coders who not only acknowledge its need but also help healthcare providers to bill procedures s correctly.

Modifiers are essential tools in the Coding process and elaborate how things should be paid and further qualify a CPT code. The judicious application of modifiers obviates the necessity for separate procedure listings that may describe the modifying circumstance.

Modifiers are appended to CPT and HCPCS codes to provide additional information about a medical procedure or service for processing a claim, without changing the meaning of the code. In other words, many medical and surgical procedures and services are complex and modifiers indicate a service did not occur exactly as described by its CPT or HCPCS code descriptor, but the situation did not change the code that applies. Modifiers explain why the physician or other qualified healthcare professional provided that service or procedure.

?When to use Modifiers:

• ??Here are examples of situations when modifiers are used:
• ?To provide additional information about services that were provided unusually
• ?To denote when not all the services in a bundle are not performed
• ?The service or procedure has both professional and technical components
• ?More than one provider performed the service or procedure
• More than one location was involved
• A service or procedure was increased or reduced in comparison to what the code typically requires The procedure was bilateral
• The service or procedure was provided to the patient more than once
• Not appending modifiers or using the wrong modifiers can cause claim denials and result in rework, payment delays, and revenue loss.

Advantages of Using Modifiers

The use of modifiers in medical billing helps in

• Avoiding claim denials by submitting clean and accurate claims
• ?Submitting claims with a higher level of coding specificity and obtain the right reimbursements
• Getting improved reimbursements for services that have been rendered concurrently or in an unusual manner depending on the specific nature of the case

HCPCS MODIFIERS:

CMS updated and copyrighted HCPCS level II modifiers and alphanumeric, with a letter being the first character of the code. Like CPT modifiers, provide some example of HCPCS modifiers. ?Types Of Medical Coding Modifiers:

?Different types of medical modifiers are used

CPT Modifiers:

AMA, annually copyrighted and updated, CPT generally comprise two digits

? Role of a Modifier in Medical Billing:

Modifiers are appended to CPT and HCPCS codes to provide additional information about a medical procedure or service for processing a claim, without changing the meaning of the code. In other words, many medical and surgical procedures and services are complex and modifiers indicate a service did not occur exactly as described by its CPT or HCPCS code descriptor, but the situation did not change the code that applies. Modifiers explain why the physician or other qualified healthcare professional provided that service or procedure.

Not appending modifiers or using the wrong modifiers can cause claim denials and result in rework, payment delays, and revenue loss

??????Examples of CPT modifiers:

• ?25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service
• 26 Professional component
• ?52- Reduced services
• ?53 Discontinued procedure
• ?55 Postoperative management only
• ?56 Preoperative management only
• 59 Distinct procedural service

?HCPCS Modifiers: HCPCS Level II modifiers are copyrighted and updated by the CMS and are alphanumeric, with a letter being the first character of the code. Like CPT modifiers, provide additional information about a procedure or service without redefining the service provided. Here are some examples of HCPCS modifiers:

• ?AA Anesthesia services performed personally by the anesthesiologist
• ?AD Medical supervision by a physician: more than four concurrent anesthesia procedures
• ?E1 Upper left, eyelid
• ?LT Bilateral procedure only performed on one side of the body
• ?TC Technical component
• XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
• ?QN- Ambulance service furnished directly by a provider of services

MODIFIER 59

CPT Manual defines modifiers 59 as a “Distinct procedural service.”

The 59 modifier considered the most misused modifier by coders. Normally, it is used to indicate that two or more procedures were performed during the same visit to different sites on the body. It is too often used to prevent a service from bundles or conjoined with another service on the same claim.it should not be used strictly to prevent a service?from being bypass the insurance carrier’s edit system.

?Indications for use of modifier 59:

• ?Different session or encounter on the same date of service
• ?Different procedure distinct from the first procedure
• ?Different anatomic site
• ?Separate incision, excision, injury or body part

MODIFIER 25

Modifier 25 is used when a minor procedure (one with a 0- or 10-day global period) and a significant and separately identifiable evaluation and management (E/M) service are performed during the same session or day.

?According to Medicare:

?Modifier 25 is used to facilitate billing of E/M services on the day of a procedure for which separate payment may be made.

• ?It is used to report a significant, separately identifiable E/M service by the same physician on the day of a procedure.
• The physician may need to indicate that on the day a procedure was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the usual preoperative and postoperative care associated with the procedure that was performed.
• Different diagnoses are not required for reporting the E/M service on the same date as the procedure or other service.
• Both the medically necessary E/M service and the procedure must be appropriately and sufficiently documented in the patient's medical record to support the claim for these services.
• This circumstance may be reported by adding the modifier 25 to the appropriate level of E/M service.

MODIFIER 91

Modifier 91 is?used when multiple, serial laboratory tests are needed in the course of treatment of a patient?(e.g., repeat blood glucose tests). Modifier 91 is used when a clinical laboratory test must be repeated on the same date of service and the results are used to assist in managing the treatment of a patient.

?WHEN TO USE MODIFIER 91:

• Used for a rerun of a laboratory test to confirm results
• Due to testing problems for the specimen
• Due to testing problems of the equipment
• When another procedure code describes a series test
• ?When the procedure code describes a series of test
• ?For any reason when a normal one-time result is required

?Using Modifiers in Medical Billing:

?As modifiers tell a story of what is being done, they may affect the way payment is made.

In addition to being classified under the CPT or HCPCS categories, modifiers are also categorized as pricing modifiers (also called payment-impacting modifiers or reimbursement modifiers) and informational modifiers. A pricing modifier impacts pricing for the code reported. Modifiers not classified as payment modifiers are informational modifiers. As informational modifiers may also affect whether a code gets reimbursed, they may also be relevant to payment.