Two Characters Can Impact Your Reimbursement: The Importance of Using Modifiers By Deion Whorton, Sr

Two Characters Can Impact Your Reimbursement: THE IMPORTANCE OF USING MODIFIERS

By Deion Whorton, Sr.

It is important for physicians and their staffs to know when it is applicable to append a modifier to a CPT or HCPSS code. Using the correct modifier is crucial in order to be reimbursed at the correct rate. Failure to append a modifier to a code can also delay payment.

Modifiers are used to supply additional information or to report an adjustment to a procedure or service provided by a medical professional. Depending on the situation, modifiers can increase or decrease the reimbursement rate for services rendered.

There are two types of modifiers associated with medical billing. The first type of modifier used in medical billing is CPT modifiers. These modifiers, in numeric format, were adopted by the American Medical Association. The second type that is used in medical billing is HCPCS modifiers. Unlike CPT modifiers, there are hundreds of HCPCS modifiers and they are in alpha or alpha numeric format. These modifiers are often used when reporting a surgical procedure.

It is important to report a HCPCS modifier when the procedure is not performed bilaterally (this will be discussed later in this article). There are HCPCS codes that are used to indicate a provider’s credentials and the location where services are rendered. Government insurance carriers typically require providers to append these modifiers, if applicable. Every insurance carrier is different regarding the use of HCPCS modifiers. It is imperative that the billing and coding team knows when it is appropriate to append the appropriate modifier.

Below are examples of the commonly used CPT & HCPCS modifiers, along with examples of when it is appropriate to use these modifiers:

Modifier 24- Unrelated Evaluation and Management Service by the same physician or other qualified healthcare professional during a postoperative period- This modifier should be used for a visit that has occurred during the postoperative period that is not related to a surgery. This modifier should be used if a patient sees a medical provider after contracting nasopharyngitis within a few weeks after an appendectomy.

Modifier 25- Significant, Separately Identifiable Evaluation and Management by the same physician or other healthcare professional on the same day of a procedure or another service. This modifier is only appended to an E/M code when another service is provided during a visit. This modifier is likely to trigger an audit with the insurance carriers if used in excess. Insurance carriers are known to pend these claims and request medical records. This modifier should be used if the original purpose of the encounter was for evaluation and management. If an OB/GYN requests an ultrasound during the office visit, the provider can bill for the office visit and the ultrasound. Modifier 25 must be appended to the evaluation and management code. If the purpose of the visit is strictly for an ultrasound, you should not bill an office visit.

Modifier 33- Preventative Service- This modifier is appended to services that are considered preventative care. The payer will pay 100% of the allowable when used appropriately. Internal and family medicine providers will append this modifier to well visits and any immunizations that are recommended. A gastroenterologist provider may use this modifier if they perform a colonoscopy due to family history or age.

Modifier 50- Bilateral Procedure- This modifier is appended to a procedure code when the procedure is performed on matching organs. Examples of a matching organs are ears. If a pediatric patient has recurrent episodes of otitis media in both ears, the patient may require tympanostomy tubes to prevent fluid from accumulating around the ear drums. The modifier should be appended to the appropriate code describing the insertion of the tympanostomy tubes. There may be additional codes reported if there is fluid prior to the tubes being inserted. If so, the applicable modifier should be used based on the documentation. Some insurance payers may require you to append the code twice and append RT and LT modifiers.

Modifier 57- Decision for Surgery- This modifier is appended to an E/M code when a physician decides the patient needs surgery. The surgery is generally done within 24 hours after evaluation. This modifier is typically appended to emergency room and initial hospital care evaluation and management codes. If a patient presents to the emergency room and it is determined that he or she has appendicitis, the patient will need emergency surgery. The patient will more than likely be admitted based on this finding. The reported codes on the claims will be the appropriate E/M code with the appended modifier and the applicable CPT code for the appendectomy.

Deion Whorton Sr. is the CEO of PCS Revenue Cycle Management. He is passionate about helping physicians and healthcare professionals increase profitability within their organization. PCS Revenue Management is a member of the BCMS Circle of Friends.