Medical billing professionals often have to use modifiers to affect the description of a diagnostic process, treatment plan, or other service performed for a client. This also includes things like prescriptions or other medical supplies that may have been provided to a patient as part of an effective treatment plan.

What Are CPT Code Modifiers?

A CPT code modifier is a two-digit code that is specifically linked to a CPT code that needs a further description of the diagnostic, evaluation, and management or procedures performed for a specific patient. It differs from the HCPCS Codes used by some public health institutions.

What Are HCPCS Codes?

HCPCS codes are used by public health institutions like the Centers for Medicare and Medicaid Services. Unlike CPT codes they are comprised of a letter that is then followed by 4 digits. HCPCs are most often used for things like medical transportation services, or other outpatient payment system services. This includes things like providing a patient with things like special medical equipment or performing orthotic procedures and orthotic treatment devices.

What Is An HCPCS Modifier?

An HCPCS modifier is often used by Medicaid Services or Medicare or specialist commercial payors, for specialty services and devices. Some will even use two alphanumeric characters, and two digits or a single alpha digit.

Different CPT Modifiers For Different Circumstances

There are several different types of CPT modifiers that might be called for depending on the situation. The following are a few common examples of scenarios when a CPT modifier might be needed. This includes diagnostic procedures as well as specialty treatments, and the use of specific medical supplies.

The Provider Owns A Technical Piece Of Equipment

This includes things like radiological devices and other specialized diagnostic equipment, where the provider performs maintenance and other upkeep measures.

The Diagnostic or Treatment Was Carried Out By More Than One Practitioner

There are some treatments and sophisticated diagnostics that need to be administered by more than one physician or by a team of technicians from different disciplines. This might also include things where there was an assistant surgeon, physician, or support technician needed to complete the treatment or diagnostic process.

The Service Was Reduced Or Increased In Duration

There are some diagnostics or treatments that may take longer than normal. A prime example of this would be treating scar tissue or other dermal abnormalities that can vary in size and severity. It might also be that a complication occurred in the treatment or diagnostic process, which required halting or postponing the immediate treatment.

A Procedure Or Diagnostic That Was Administered More Than Once

There are some diagnostics and treatment plans that need multiple applications. A CPT code modifier will then indicate the successive treatments to make it clear to all the parties and payers involved that it is not a duplicate billing error.

Note Potential Revisions

In all of this, it’s also important to keep in mind that a lot of payer institutions, insurance providers, and public health institutions revise their CPT code modifiers on an annual basis. This includes some codes being removed or new CPT code modifiers being added. This includes things like Medicare discontinuing the SG modifier, which used to be used to indicate that a claim was for a facility, yet there are still some Medicaid and Workers’ Compensation payers that do still require it. This means that you need to stay diligently informed of individual payer and institutional preferences at all times.

While some payers require modifiers, others don’t care whether modifiers are applied because their contracts pay based on the revenue codes or the procedure codes. Using a modifier for these claims usually doesn’t affect payment. What affects payment is failing to apply modifiers that are required by the individual payers.

Some employer-sponsored medical insurance providers have their own CPT codebook that is integrated with their CMS platform. These codes can also change over the course of a given year or if the employer happens to change their CMS platform or change to a different insurance provider.

There are also a variety of government payers including the Department of Labor, Medicaid, and TRICOR that have some of their specific CPT code modifier regulations associated with specific classifications and procedures.

What Are Some Of The Most Common CPT Code Modifiers?

Several common CPT code modifiers might be needed depending on the patient’s needs as well as the diagnostic or treatment plan needed to achieve successful treatment outcomes. The following are some of the more common CPT Code modifiers and instances where they might need to be used.

CPT Modifier 22 For Increased Procedural Service

This CPT Code modifier is often used to describe an increased workload associated with a diagnostic or treatment procedure. It often requires additional documentation of the service to keep from delaying the claim process.

CPT Modifier 25 Significant, Separately Identifiable Service

This CPT Code modifier is often used when there are a significant, separate yet identifiable evaluation and management service performed by the same physician on the same day of service. You often see this when two separate diagnoses are made on the same day or during the same appointment. Though each diagnosis might have required different measures or testing procedures.

CPT Modifier 26 Professional Component

This CPT Code modifier typically has a global definition. This includes things like an orthopedist using an x-ray as part of a larger diagnostic process, though the X-ray itself was taken elsewhere.

CPT Modifier 50 Bilateral Procedure

This code modifier is somewhat common in that it’s used to note a procedure that took place on both sides of the body. Though it should only be used if the word “Bilateral” doesn’t already appear in the original code definition.

CPT Modifier 51 Multiple Procedures

This is a CPT Code modifier that is often used to note that multiple procedures were performed by the same physician during a single clinical session. When using CPT Code Modifier 51, it’s also important to list the procedure with the highest reimbursement rate first without the modifier. Then additional procedures are listed in order of reimbursement value with the modifier.

How Does A CPT Code Modifier Affect The Reimbursement Rate?

It’s important to note that different modifiers can affect the reimbursement rate for different diagnostics and procedures. For example, the use of CPT Code Modifier 22, sees the payer providing the physician or diagnostician with 110% of the normal reimbursement rate. Whereas CPT Code modifier 50 indicates that the same procedure was performed twice and pays at 150% of the original reimbursement rate.

It’s important to avail yourself of the different reimbursement rates that each payer assigns to specific CPT Code Modifiers. Different payers may have different requirements and contract schedules that need to be periodically updated.