Medical coding is an intricate process. While assigning the correct diagnosis and procedure codes, hundreds of codes must be reviewed and chosen from.
Besides, you cannot afford to be careless during code selection as it can result in repercussions, such as claim denials, payment delays, financial penalties, audits, and legal issues. The same is true for the use of modifiers in medical billing.
Yes, you must ensure a sense of specificity and accuracy while selecting modifiers, as their inappropriate use will also result in adverse consequences. But worry not! This guide will help you out. We will discuss the purpose of modifiers and their types and benefits. We will also mention the most commonly used modifiers.
So, without further ado, let’s get started!
What is a Modifier in Medical Billing?
Modifiers play a significant role in ensuring efficient and accurate medical coding and billing. It is a powerful tool that allows you to document nuanced details while creating medical claims. It can comprise two letters, two digits, or a letter and a digit. Besides, it eliminates the need to report individual codes.
For example, you made procedural modifications based on the patient’s specific condition. No worries, a modifier will solve the issue. Or if you want to inform the payer that all the bundled services for this code were not performed
Thus, a modifier is a code that helps you provide additional information about the performed procedures or services, ensuring clean claim submission, reducing the denial rate, and improving your practice’s revenue cycle.
Types of Modifiers in Medical Billing
Modifiers can be classified based on the coding systems, i.e., the Healthcare Common Procedure Coding System (HCPCS) and Current Procedural Terminology (CPT). However, these two are not the only categories for modifiers. Thus, in this section, we will comprehensively discuss different types of modifiers:
CPT Modifiers
The CPT modifiers are generally two digits long, and the American Medical Association (AMA) holds its rights. However, some performance-measure CPT modifiers are alphanumeric and apply only to CPT category II codes.
This type of modifier in medical billing is used to supply additional information about the healthcare procedures or services reported via the CPT coding system.
HCPCS Level II Modifiers
The HCPCS modifiers are generally two characters long, comprising one letter and one digit. The Centers for Medicare and Medicaid Services (CMS) manages the HCPCS coding system. You can use these modifiers with the HCPCS level II codes to provide additional details about the performed procedures.
NCCI Modifiers
Medicare and Medicaid accept these modifiers to evade Medicare’s National Correct Coding Initiative (NCCI), Procedure-to-Procedure (PTP) edit under specific clinical circumstances. This process of bypassing the edit is known as unbundling. The modifier code 59 (for distinct procedure) is an example of an NCCI modifier.
Informational and Pricing Modifiers
Modifiers in medical billing can also be categorized as pricing and informational modifiers:
Pricing Modifiers
Pricing or payment-impacting modifiers in medical billing are literal to their name and cause a change in pricing for the reported code. Medicare uses a Multi-Carrier System (MCS) that requires coders to place a pricing modifier before the informational modifier.
Besides, on the CMS 1500 claim form, 24D is its appropriate position, i.e., directly on the right of the procedure code on the medical claim. You may encounter payment delays or denials if you fail to add the pricing modifier at its associated place.
Informational Modifiers
An informational or statistical modifier generally comes after a pricing modifier on a medical claim. Even though it is separate from a payment modifier, it still affects the reimbursements.
For example, coders use modifier 59 to override the NCCI PTP edits to receive payment for both procedures. Here, 59 is an informational modifier.
However, note that different payers have varying billing and coding requirements. So, if one payer classifies modifier 59 as an informational modifier, it doesn’t mean all insurance companies consider it the same.
Thus, we recommend you check the specific payer requirements before submitting a claim to avoid payment delays and denials.
Benefits of Using Modifier Codes in Medical Billing
Discussed below are some of the major benefits of using modifiers.
- Modifiers serve as a billing or informational clarification and eliminate the need to list a separate procedure or service code.
- However, the inappropriate use of modifiers may trigger alerts to the authorities, hinting towards non-compliance with the laws and fraudulent activity to get higher reimbursements.
- Thus, healthcare facilities must train their coding and billing teams on the proper application of modifiers to avoid revenue loss or audits.
- Besides, modifiers help you maintain coding specificity, ensuring clean claim submission that leads to appropriate and timely payments.
- Moreover, it helps you optimize reimbursements for complex cases where you unconventionally performed certain procedures or rendered care services.
Commonly Used Modifier Codes in Medical Billing
In this section, we will discuss the commonly used modifiers in medical billing:
Modifier 22 – Additional Procedural Work
Append this modifier when a procedure involves additional work from its typically defined difficulty and effort. It will help you justify the increased reimbursement rate to the insurance payer due to the extra skill, time, and complexity required to perform the procedure.
However, note that you should provide supporting documentation with the claim when using this modifier to justify its use and ensure timely reimbursements.
Modifier 25 – Separately Identifiable E/M Service
It is another commonly used modifier code in medical billing that identifies that a distinct and separate evaluation and management (E/M) service is rendered to the patient by the same physician on the same day. You can use this modifier to get reimbursement against the E/M service and the procedure, as long as the former service was separately identifiable and significant.
Besides, this modifier indicates that the rendered E/M service was beyond the scope of usual post-operative and pre-operative care associated with the procedure.
Modifier 26 – Technical Component (TC)
It indicates the physician only provided the professional component of the service, while another entity provided the technical component. Thus, if you add this modifier, the payer will only reimburse you for the professional component. For example, when a physician only interprets the test results but does not perform the lab tests.
Modifier 33 – Preventive Care
You may add modifier 33 when the purpose of the patient encounter was preventive rather than therapeutic or diagnostic. Adding this modifier will ensure that you are reimbursed separately for the preventive care services by the payer.
Modifier 50 – Bilateral Procedure
When the healthcare provider performs a procedure on both sides of the patient’s body (bilaterally) in the same encounter, you should append this modifier code 50 in the medical claim. So, the payer reimburses the provider appropriately for the additional resources and complexity.
Modifier 51 – Multiple Procedures
Another commonly used modifier code is 51. It identifies the provider performed multiple services/procedures during the same encounter. This code alerts the insurance company that the practitioners should receive a reduced payment rate for subsequent performed services. Simply put, adding this modifier will prevent overpayment issues.
Modifier 59 – Distinct Procedures
You may use modifier code 59 to identify care services or procedures that are distinct and separate from other services/procedures rendered on the same day. Adding this modifier helps you clarify to the payer that the procedure was performed at a different anatomic site to prevent claim denials due to the bundling of services.
Bottom Line
The use of modifiers in medical billing is critical as they provide additional details, like how the procedure was altered to suit the specific circumstance. There are several kinds of medical billing modifiers ranging from HCPCS Level II, CPT, and NCCI to payment-impacting and informational modifiers. Their appropriate use mitigates claim denials.
Some commonly used modifiers are modifier 22 for additional procedural work, modifier 25 for separately identifiable E/M service, modifier 26 for technical components, modifier 33 for preventive care, modifier 50 for bilateral procedure, modifier 51 for multiple services, and modifier 59 for distinct procedures.
However, if you find claim creation challenging, you can get our professional medical coding services and let the experts handle the reporting of appropriate modifiers.
