Skip to main content

Modifier codes for Medical Billing: Considerations and Examples

June 26, 2014

Medical coding modifiersIt promises to be another whirlwind year for medical billing and coding, the ongoing conversion to EHR compliances and PQRS for incentives and potential penalties makes it very hard for billers and coders to comply with all the rules and regulations. Though ICD-10 has been pushed for another year, and despite the added functionality ICD-10 codes lend to diagnoses and billing, modifier codes will still be used, as claims will still need to be modified. Fortunately modifiers work equally well with ICD-9 and ICD-10 codes and are remaining unchanged. Even so, change may affect them. It seems a good time to review their structure and utility, and the possible impact new practice systems may have on their usage.

A modifier is a two digit code by which a reporting physician indicates that a performed service or procedure has been altered by some specific circumstance, though without a change to the basic procedure and its defining CPT code. Modifiers can be used with any CPT code. Properly used, modifiers make claims reporting easier: their considered use eliminates the necessity of separating procedure listings to describe modifying circumstances, and accurately applied, lowers the risk of claims rejection by the patient’s insurer. Practices should incorporate modifier code usage in any review of their coding and claims submission procedures.

Modifiers are a critical component of coding and using them incorrectly can result in lost revenue and audits. Knowing your modifiers and their proper usage can reduce the risk of lost income and improve audit compliance.

When to Use Modifiers

Modifiers are used under the following circumstances:

  • When a procedure is performed more than once on the same day.
  • When more than one procedure is performed on the same day
  • When a procedure is a non-covered service
  • When more than one assistant surgeon completes a procedure
  • Provision of a procedure in a specific location, such as an HPSA area, teaching facility, rural area
  • When necessary to differentiate between the professional and technical portions of a procedure done in a hospital setting.
  • When multiple providers share or split work on the same surgical procedure
  • To reflect increase, reduction or discontinuation of a procedure
  • To reflect participation of the provider in a government-funded incentive program, such as PQRI or Electronic Prescribing
  • When a patient falls within a global period from a previous procedure

New Practice Management Systems and Modifiers

Many practices are changing to newer medical billing practice management systems and software to support their conversion to ICD-10, and as part of their EHR conversions. Easily overlooked amid meeting the many challenges these present are the relatively few and unchanging modifier codes. A new system may impose new requirements on the use of modifiers, such as only allowing numeric modifiers, or limiting the number of modifiers for a procedure. It may require different sequencing, e.g., convention has long dictated the listing of modifiers affecting reimbursement go before those that are informational. Will this sequencing be supported within a new claims management system?

Although CMS itself has no modifier code rules, carriers often do, publishing their own guidelines so practices will be able to conform to their claims submissions requirements. If you find these guidelines unavailable, you should contact your payer in writing well ahead of any planned changes to a new practice management system.

Researching changes to modifier code usage in advance may well save you time, money and frustration later on.

Share: Share this article on LinkedIn Share this article via email