Why is using modifiers crucial to healthcare

The patient has a history of hypertension and high cholesterol. After the physician completes an office visit, it is determined the patient needs a cardiovascular stress test that same day. Modifier 91 Modifier 91 should be used when repeat tests are performed on the same day, by the same provider to obtain reportable test values with separate specimens taken at different times, and only when it is necessary to obtain multiple results in the course of treatment.

When billing for a repeat test, use modifier 91 with the appropriate procedure code. A patient with high blood pressure who has been on a low-salt diet may receive a plasma renin activity PRA test Renin in the morning in the supine position. Because physicians may use variations in PRA levels due to time of day and patient position to evaluate certain conditions such as hyperaldosteronism they may order repeat renin in the afternoon with the patient standing upright for a period of time.

Coding example — 91Report the second with modifier to indicate that the lab performed two separate renin assays for the same patient on the same day. The documentation in the patient's medical record must support the reason why extra hemodialysis sessions were given beyond the frequency. Use of modifier is attestation that additional hemodialysis sessions do not meet medical justification requirements and not paid separately. When reporting this modifier, report with condition code G0 zero when multiple medical visits occur on same day in same revenue centers.

Incarcerated Beneficiary Modifier The incarcerated beneficiary modifier may be used to report services for individuals who are in custody including, but are not limited to, individuals who are under arrest, incarcerated, imprisoned, escaped from confinement, under supervised release, on medical furlough, required to reside in mental health facilities, required to reside in halfway houses, required to live under home detention, or confined completely or partially in any way under a penal statute or rule.

For outpatient claims, providers shall append this modifier on all lines with a line item date of service during incarceration period. All associated charges should be billed as non-covered. Laboratory Modifier Laboratory modifiers are used when laboratory code s are separately identifiable and payment is not included in another service. Do not report if the hospital only provides outpatient laboratory tests to the patient and no other hospital outpatient services on the claim.

Documentation is on file showing that the laboratory test s was ordered individually or ordered as a CPT-recognized panel other than automated profile codes , G, G, and G Information only. Attestinging documentation is on file. Modifier Description CO Outpatient occupational therapy services furnished in whole or in part by an occupational therapy assistant CQ Outpatient physical therapy services furnished in whole or in part by a physical therapist assistant Mod GN Outpatient Rehabilitation Therapy Services delivered under an outpatient speech language pathology plan of care Mod GO Outpatient Rehabilitation Therapy Services delivered under an outpatient occupational therapy plan of care Mod GP Outpatient Rehabilitation Therapy Services delivered under an outpatient physical therapy plan of care Mod KX Outpatient Rehabilitation Therapy Used to indicate the services rendered are medically necessary.

Preventive Modifiers Preventive modifiers are used to indicate service s rendered were preventive. Performance and payment of a screening mammography and diagnostic mammography on same patient, on the same day. Reported on diagnostic mammography code and no modifier reported on screening mammography.

Mod GH Preventive Diagnostic mammogram converted from screening mammogram on same day. Only a diagnostic mammogram code reported with modifier appended. Mod PT Preventive Colorectal cancer screening test; converted to diagnostic test or other procedure.

Appended to diagnostic procedure code that is reported instead of the screening colonoscopy or screening sigmoidoscopy HCPCS code within the surgical range of CPT codes or HCPCS codes GG on the claim for services furnished on the same date of service as the procedure.

Do not report on additional services furnished during visit. This should only be used when documentation indicates work performed is substantially greater than typically required by technical difficulty, severity of patient's condition or increased intensity and time. May be used with diagnostic and radiology procedures as well as with surgical procedures.

It should be used to report bilateral procedures that are performed at same operative session as a single line item. Modifiers RT and LT are not used when modifier 50 applies. A bilateral procedure is reported on one line using modifier This is not required on Medicare claims as the system will apply payment reduction appropriately; however, providers are allowed to add this modifier when appropriate. Mod 52 Surgical Procedure Reduced or elimination of a procedure for which anesthesia is not planned.

This modifier should be used to permit payment for a surgical procedure during postoperative period of another surgical procedure when subsequent procedure was planned prospectively at time of original procedure, a less extensive procedure fails and a more extensive procedure is required or a therapeutic surgical procedure follows a diagnostic procedure e.

Failure to use modifier when appropriate may result in denial of subsequent surgery. Mod 59 Surgical Procedure Distinct procedural service. It does not replace modifiers 25, 27, 50, 77, 78, RT and LT; and should only be used when there is no other modifier fitting this description. Indicates procedure requiring anesthesia was terminated due to extenuating circumstances or circumstances that threatened well-being of patient after patient had been prepared for procedure including procedural pre-medication when provided , and patient had been taken to room where procedure was to be performed, but prior to administration of anesthesia.

Indicates a procedure requiring anesthesia was terminated after induction of anesthesia or after procedure was started e. This modifier may also be used to indicate that a planned surgical or diagnostic procedure was discontinued, partially reduced or cancelled at physician's discretion after administration of anesthesia. Use on surgical codes only to indicate that another procedure was performed during postoperative period of initial procedure, was related to first, and required use of operating room.

Payment is limited to amount allotted for intraoperative services only. Failure to use this modifier when appropriate may result in denial of subsequent surgery. The physician may need to indicate that a procedure or service furnished during a postoperative period was unrelated to original procedure. A new postoperative period begins when unrelated procedure is billed. Report when facility pays for actual blood or blood products, in addition to paying for processing and storage costs.

Do not report on TOB 13X for adjunctive or related SRS treatment but billed on a different date of service and within 30 days prior or 30 days after the date of services for either CPT code or The use of this modifier was required for CYs and and the data collection period for this modifier was set to conclude on December 31, Modifier should not be used by CAHs Mod ER Surgical Procedure Effective January 1, , hospitals are required to report new HCPCS modifier "ER" Items and services furnished by a provider-based off-campus emergency department with every claim line for outpatient hospital services furnished in an off-campus provider-based emergency department.

Effective January 1, , hospitals are required to use this modifier to report imaging services that are X-rays taken using computed radiography technology. MM Mod KX Surgical Procedure Reported by providers billing for single or dual pacemakers as an attestation that the service documentation is on file verifying the patient has non-reversible symptomatic bradycardia. MLN Providers billing an initial treatment strategy for solid tumors with HCPCS codes , , , , , or must append this modifier.

CR Mod PN Surgical Procedure Effective January 1, , non-excepted off-campus provider-based departments of a hospital are required to report this modifier on each claim line for non-excepted items and services.

Providers billing a subsequent treatment strategy for solid tumors with HCPCS codes , , , , , or must append this modifier. For medically necessary pacemaker insertion in conditions not addressed in NCD A service that is distinct because it occurred during a separate encounter.

A service that is distinct because it was performed by a different practitioner. The use of a service that is distinct because it does not overlap usual components of the main service. Waiver of Liability Modifiers Liability waiver modifiers will deny services as not reasonable and medically necessary.

Modifier is used to signify a line item is linked to the mandatory use of an ABN when charged both related to and not related to an ABN must be submitted on the claim. Line item must be submitted as covered, and Medicare will make the determination for payment.

This modifier should be used to report when a voluntary ABN was issued for a service. Lines submitted as non-covered will be denied as beneficiary-liable. Mod GY Waiver of Liability Item or service is statutorily excluded or does not meet the definition of any Medicare benefit. Lines submitted as non-covered and will be Patient Responsibility PR. Cannot be used when ABN is given. Lines submitted as non-covered will be denied as provider-liable.

User License Agreement and Consent to Monitoring. Consent to Monitoring Warning: you are accessing an information system that may be a U. Non-covered miles beyond closest facility are billed with HCPCS procedure code A "non-covered ambulance mileage per mile, e.

Patient pronounced dead after ambulance called. BLS transport by a volunteer ambulance provider. Item provided without cost to provider, supplier or practitioner, or credit received for replacement device e. Partial credit received for replacement device. Investigational clinical service provided in clinical research study that is in an approved clinical research study.

Routine clinical service provided in a clinical research study that is in an approved clinical research study. Biosimilar drug modifier for Sandoz.

Drug or biological acquired with B drug pricing program discount CR Drug or biological acquired with B drug pricing program discount, reported for informational purposes CR Medical direction of 2, 3 or 4 concurrent anesthesia procedures involving qualified individuals. Performance Measure Exclusion Modifier due to medical reasons. Performance Measure Reporting Modifier. Surgical care only. Postoperative management only. Two surgeons. Surgical team. Principal Physician of Record.

Physician Assistant, Nurse Practitioner or Clinical Nurse Specialist services for assistant-at-surgery, non-team member. Indicates service has been performed in part by a resident under direction of a teaching physician. Identifies telehealth services furnished for purposes of diagnosis, evaluation, or treatment of symptoms of an acute stroke.

Emergency reserve supply for ESRD benefit only. Any medically necessary extra hemodialysis sessions beyond the monthly maximum. Any not medically necessary extra hemodialysis session beyond the monthly maximum.

Arteriovenous graft or other vascular access not including a vascular catheter in use with two needles. Unfortunately, out-of-date encounter forms are common. Although updating these forms can be time-consuming and tedious, it is an essential link between your work and getting paid for that work.

This means there are no longer grace periods for deleting old codes from your claims. Reporting codes that are not effective for the date of service means denied claims, while failure to incorporate new codes or new coverage rules results in lost revenue opportunities.

It only takes a few steps to update your forms. First, review the codes that are currently on your forms for deleted and revised codes, and update these accordingly.

Once you've done this, you're ready for a simple check each year for new, revised and deleted codes. Payers are becoming increasingly concerned about the issue of medical necessity. Claims for services that don't meet medical necessity requirements are typically denied straight out; if they're paid in error, the reimbursement may be recouped in the future.

So how do you substantiate the medical necessity of the services you provide? While it may involve coders and billers, this process must begin with you, the physician. You are in the best position to identify the rationale for a test or other service. In practical terms, that means selecting the ICD-9 code or codes that are valid for the visit or other service and linking them to the associated CPT code or codes.

Incorporating this into your daily routine is simple once your encounter forms are up-to-date. If you have a paper system, simply number each ICD-9 code and associated CPT code on the encounter form with the same number. For example, your patient presents for his regular visit for diabetes monitoring and reports symptoms suggestive of angina. As part of the first step in the workup, you do an ECG in your office. You indicate number 2 for the ECG e.

If you use an EHR, you're probably aware of the need to associate a CPT code with an ICD-9 code because the system may not let you close the record before this is done. This process ensures that each CPT code has an applicable ICD-9 code and that the reason for each service is accurately communicated to your staff and ultimately to the payer.

When you don't make the association of the codes clear, you increase the chance that applicable diagnoses may not be identified and that your staff may make incorrect assumptions. In the example above, if diabetes is the only diagnosis noted on the encounter form, your staff may assume it is the indication for the ECG or assign a screening ICD-9 code.

In either instance, the assumption is incorrect and your reimbursement could be affected. Staff members commonly complain that they receive incomplete encounter forms and that they must take valuable time to determine the service provided or the reason for the service before entering the charges.

Provide related codes to begin with, and the problem vanishes. Often, code becomes the default code because physicians think extensive documentation will be needed for coding anything higher and they believe is safe.

To determine whether you're losing revenue opportunities by undercoding, gather data from your billing system to determine your coding patterns. You'll need to know the number of times each physician has billed a through a during the selected time period. Once you have your data, you can compare it with national norms and then calculate your potential for lost revenue. A coding frequency comparison spreadsheet updated with Medicare data the most recent available is available online in the FPM Toolbox.

I recommend gathering several years of data to see if there are any outliers or problems. Doing this will also highlight other opportunities for improvement, such as the need to recruit new patients to the practice. Remember that the risk for an audit is higher when the distribution of codes within a practice doesn't look reasonable.

If a single code is predominant in a physician's profile, the assumption is that the physician isn't really coding for individual encounters. Download in PDF format. Modifiers can be the difference between full reimbursement and reduced reimbursement — or denial. While some payers differ in their use of modifiers, taking the time to learn the rules will pay off. In the last five years, payers have increased their recognition of modifiers when processing claims, which makes it even more important to learn them and use them correctly.