Medcal Coding: Modifiers
Modifier
2 character (letters or numbers) appended to CPT or HCPCS Levell II code.
Provides additional informaion about the medical procedure, service, or supply involved WITHOUT changing the meaning of the code.
Modifiers may also provide:
details not included in the code description (anatomic location)
*Payer programs may have modifiers that apply only when your're reporting codes in connection with those programs.
A modifier may be approriate when:
The service or procedure has both professional and technical components.
More than one provider performed the serice or procedure.
More than one location was involved.
A service or procedure was increased or reduced in comparision to what the code typically requires.
The procedure is bilateral.
The service or procedure was provided to the patient more than once.
Proper use of modifiers is important both for:
accurate coding because some modiferes affect reimburesement for the provider.
Omittiing modifiers or using wrong modifiers may:
cause claim denials that lead to:
rework; payment delays; potential reimbursement loss
_____holds copyright in CPT.
The American Medical Association (AMA)
CPT modifiers are
generally two digits, although performance measure modifiers that apply only to CPT Category II codes are aplhapnumeric (1P-8P).
Some of the most commonly used 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
59: Distinct procedural service
HCPCS II codes and modifiers are maintained by the
Centers for Medicare & Medicaid Services (CMS).
HCPCS Level II modifers are
alphanumeric or have two letters.
Examples of HCPCS Level II modifiers
E1: Upper left, eyelid
TC: Technical component; under certain circumstances, a charge may be made for the technical component alone; under those circumstances the technical component charge is identified by adding modifier ‘TC’ to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles
XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure
Modifiers are also categorized by type:
Pricing Modifiers (payment-impacting modifiers or reimbursement modifiers)
Informational Modifiers
Pricing modifier is a
medical coding modifier that causes a pricing change for the code reported.
The Multi-Carrier System (MCS) that Medicare uses for claims processing
requires pricing modifiers to be in the first modifier position, before any informational modifiers.
On the CMS 1500 claim form
the appropriate field is 24D.
You enter the pricing modifier directly to the right of the procedure code on the claim.
Most providers use the electronic equivalent of this form to bill Medicare for professional (pro-fee) services.
Claims that do not have the pricing modifier in the first position may encounter processing delays.