CPT modifiers inform payers about the distinct services and procedures physicians perform. Outsourcing medical billing to an expert would ensure correct coding of claims using the right modifier. In fact, getting paid for procedures can become more complicated if CPT modifiers are not used correctly. On the other hand, when used appropriately, modifiers help practices collect revenue for services rendered.

Experienced medical coders know the situations that warrant the use of modifiers, which are as follows:

  • The service or procedure has both a professional component (supervision, interpretation, report) and technical component (equipment, supplies, and technical support, for e.g., radiology procedures
  • The service or procedure was performed by more than one physician and/or in more than one location
  • The service or procedure has been increased or reduced – Under certain circumstances a service or procedure is partially reduced or eliminated at the physician’s discretion
  • Only part of a service was performed – a procedure is bilateral, but performed only on one side
  • The service or procedure was provided more than once – excising lesions on different area of one body part through separate incisions
  • Events occurred that were unusual to the circumstances – for e.g., the patient had a negative reaction to anesthesia which resulted in early termination

In certain cases, more than one modifier may be used with a single procedure code; some modifiers can only used with a particular category and some modifiers are not compatible with others. The different categories of modifiers are as follows:

  • General
  • Advance Beneficiary Notice of Noncoverage (ABN)
  • Ambulance Origin/Destination
  • Anatomic
  • Anesthesia
  • Assist at Surgery
  • Chiropractic
  • Physician Quality Reporting System (PQRS)
  • Therapy

In appropriate use of modifiers such as appending a modifier when it isn’t warranted and not appending a modifier when it is needed, will lead to loss of revenue. Incorrectly appending a modifier and receiving payment will attract scrutiny by auditors.

Medical Economics offers physicians the following tips to collect appropriate payment for services rendered while also avoiding compliance risk:

  • Know individual payer rules: Payers revise modifiers annually with some being deleted and others being added. Payers have different rules on modifier use. Payment is affected when providers fail to apply modifiers that are required by individual payers.
  • For instance, take modifier 25 which 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.  An article published by the American Academy of Orthopaedic Surgeons points out that key requirement of a “significant and separately identifiable” E/M service is that the work for the E/M service is “substantially more and different than the typical preoperative and postoperative E/M work included in the minor procedure”.

    However, a recent Medical Economics report says that might not accept modifier 25 for certain services, such as when an E/M code is reported in addition to a code for a pain management injection.

  • Pay attention to clinical documentation: In addition to understanding modifier use, ensuring the required documentation is vital to avoid problems and inappropriate claim denials or underpayments. For instance, to append modifier 25, the documentation should indicate that a significant, separately identifiable E/M service was provided on the same day as a procedure. This means that the clinical documentation must support the history, exam, and medical decision-making for two separate services (www.medicaleconomics.com).
  • Likewise, when appending modifier 22(increased procedural services), the medical record documentation must clearly support the substantial additional work and the reason for the additional work, such as:

    • Increased intensity or time
    • Increased technical difficulty of performing the procedure
    • Severity of the patient’s condition
    • Increased physical and mental effort required

    If the procedure involved increased time, the documentation should specify the total time and how it compares with the typical time for the procedure.

  • Append the modifier to the right code: Correct use of modifiers is crucial to ensure payment for covered services that would be denied if the modifiers were not appended. For instance, modifier 59 (distinct procedural service) identifies a procedure or service that is independent from another procedure performed during the same visit or day. Physicians need to check NCCI edits or specific payer bundling rules touse this modifier correctly. Each NCCI edit table has edits, which are pairs of codes that generally should not be reported together. For instance, when reporting an excisional biopsy and lesion destruction, modifier -59 should be appended to the lesion destruction CPT code.
  • Again,a modifier must not be appended to an unlisted code because modifiers are used to indicate that a service or procedure has been altered by some specific circumstance, but not changed in its definition or code.

With commercial payers factoring modifiers into their reimbursement protocol, correct use of modifiers is necessary to maximize reimbursement and avoid fraud and noncompliance concerns. Partnering with an experienced medical billing and coding company is a practical way to ensure accurate modifier use.