What is a Modifier in Medical Billing?

Efficient medical billing processes rely heavily on accurate coding to generate a claim that insurance companies and public health institutions will rapidly reimburse. This involves several key phases for the clinician providing service, as well as any administrative staff who are facilitating the claims process.

If medical coding is incorrect it becomes incredibly difficult, if not impossible for the provider to submit a claim and get paid for the services they provide. This includes diagnostics, therapeutic services, treatments, surgeries, medical supplies used, and even medical equipment that the patient is given access to.

Inputting the correct ICD-10, CPT, or HCPCS codes into a claim is just the start of the process. Many codes also use one or more code modifiers for certain situations. These too need to be coded correctly and applied to pertinent specific codes.

If the wrong modifier is used, even if the primary code is generally considered to be correct an insurance company could reject, or deny the claim. At the very least they will put reimbursement on hold as they query your practice for more information pertaining to the claim. When this happens once, it can be inconvenient.

When it happens more than once, it can cause significant delays to your practice’s revenue stream. If it happens too frequently, the insurance company or the public health institution might red-flag your practice for an audit.

This is why so many thriving practices have experienced coders on staff or outsource their medical billing services to a third-party company that is knowledgeable about medical coding and the accurate application of code modifiers.

The Importance of Code Modifiers in Medical Billing

The majority of medical coding modifiers have two characters. They can be letters or numbers depending on the code they are modifying. Code modifiers can be used to alter or add further detail to a CPT code or an HCPCS Level II code.

The American Medical Association and Centers for Medicare & Medicaid Services specifically define a code modifier as a “Means to report or indicate that a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code.”

This means that code modifiers are appended to CPT and HCPCS codes to provide additional accurate information pertaining to a medical procedure, treatment, or diagnostic service. They play a critical role in generating a claim, which expedites processing it through the payer’s system. All without having to change the primary meaning of the original code.

Code modifiers are found everywhere in the medical and mental health industry. This includes a lot of medical therapies, surgical procedures, diagnostics, and even mental health services. Code modifiers are tools that help transmit complex data about a service that might not occur exactly as described by its CPT or HCPCS code descriptor. Many providers end up using code modifiers to help them explain why the service needed to be provided in the manner it was.

Common Situations When Code Modifiers Should Be Used

There are a lot of different cases and scenarios where a code modifier should be or needs to be used in order to generate the most accurate claim possible. This includes things like:

• Providing additional information about a rarely used treatment
• Providing additional information about an uncommon diagnostic technique
• To note when a bundled service was partially performed
• To indicate a service or procedure has both professional and technical components
• To note that when more than one provider performed the diagnostic, therapeutic service, or procedure
• To indicate that a service was performed in more than one location
• If a diagnostic, therapeutic service, or procedure was longer or shorter in comparison to what the code typically requires
• If a bilateral procedure was performed
• To indicate a service or procedure was provided to the patient more than one time

It’s important to bear in mind that failure to use an appending modifier or using the wrong modifiers can easily lead to claim denials or rejection. This often requires the provider to resubmit the claim, clarify the claim, or risk nonpayment for services rendered.

Types of Medical Coding Modifiers

Understanding the Different Types of Code Modifiers in Medical Billing

Most CPT Modifiers are copyrighted and then updated annually by the American Medical Association. Oftentimes, CPT modifiers are added to the end of a CPT code via a hyphen. Some of the most common are:

• 25 which indicates a significant, separately identifiable evaluation and management service that was performed by the same physician or other qualified healthcare professional on the same day of the procedure or other service
• 26 Professional component
• 52 Reduced services
• 53 For use of a previously discontinued procedure
• 55 Postoperative management only
• 56 Preoperative management only
• 59 Distinct procedural service
• HCPCS Level II modifiers are also copyrighted and updated by the CMS. Though these codes are alphanumeric, with the first character of the code modifier being a letter. Similar to CPT modifiers,
• HCPCS Level II modifiers provide additional information about a procedure or service without redefining the service provided. Some of the most common HCPCS Level II modifiers used in behavior therapy are:
• AD Medical supervision by a physician: more than four concurrent anesthesia procedures
• TC Technical component
• QN- Ambulance service furnished directly by a provider of services

How to Use Code Modifiers Correctly

It can be challenging for providers of any scale to stay on top of the current crop of code modifiers used in medical billing. Though it’s particularly challenging for small practices and solo practitioners who have to wear several different hats.

One of the best ways to ensure that the most-accurate code modifier is being used is to outsource your medical billing services to a third-party service like Operant Billing Solutions. This gives you the peace of mind that comes from knowing a medical billing and coding expert is combing through every square inch of your claim to ensure its accuracy.

If there are any incongruities or the wrong modifier was accidentally used by a clinician, the coder can correct the information before it is sent to the insurance company or public health institution. This gives providers more time to treat patients, while also helping to maintain a consistent revenue stream.