Use of Modifiers in Medical Coding and Billing

Modifiers in medical coding and claim submission

The use of modifiers in coding and billing can be crucial in obtaining proper reimbursement for services.  Proper coding also allows for the remittance of accurate patient encounter data, which is increasingly important in value-based healthcare. Using modifiers can also be an area of risk if not properly documented.  They may result in denied or delay payment, and in some cases the use of “risky” modifiers may increase compliance scrutiny if not submitted with appropriate documentation and detailed operative notes to substantiate the claim.

Additionally, not all payers recognize modifiers or apply them consistently across regions.  Even if claims have been submitted per correct coding initiative edits, these may not bypass local coverage determinations if payers are not setup to receive them.  This can be especially prevalent in split billing where payers may not recognize the professional component (PC) split from the technical component (TC) or facility billing. This is common when procedures are paid for in a global fee or bundle.

What is a modifier?

A modifier is a two digit code which is typically appended to a CPT code, and is used to describe unusual or specific circumstances.  They are generally used when a more specific CPT code does not exist to describe the encounter and services rendered.  EKG codes include those for global billing but also for the professional component only.  When such codes are available, modifiers are not appropriate.

There are two levels of modifiers contained in HCPCS:

  • HCPCS Level I – These are also known as CPT modifiers, as they modify codes contained in the CPT manual
  • HCPCS Level II – Level two codes are primarily used for DME and supplies as well as temporary placeholder codes.

The CPT modifiers accompany CPT codes in submission to payers.  Level two codes are generally appended to HCPCS level II codes and have alpha characters associated with them.  Examples include “LT” and “RT” to designate left and right side.  Level I and II modifiers can be used with either Level I (CPT) and Level II (HCPCS II) codes as is applicable.

Part II – E&M Modifiers will cover what modifiers are used for and the various groupings of modifiers used.

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