By CAREL VISSER

It is widely accepted that the national denial and rejection rate runs as high as 30 percent of all insurance claims submitted to insurance companies for adjudication. Rejected claims have data and/or formatting problems and can be resubmitted when corrected. Denied claims have been accepted for processing and had a negative determination outcome. These claims cannot simply be resubmitted and have to be sent back as appeals or reconsiderations. In both cases it is a costly and time-consuming exercise. One of the chief causes of rejections and denials is the incorrect use or lack of modifiers. Correct use of modifiers can speed up claim processing and reimbursement.

What are Modifiers

Modifiers consist of two numbers, two letters or a letter and a number. They are appended to either a Current Procedural Terminology (CPT) code or a Healthcare Common Procedures Coding System (HCPCS) code to further explain the procedure or service, giving more detail to the code. This cuts down on the number of CPT and HCPCS codes required. There are two levels of modifiers. Level I modifiers are developed and maintained by the American Medical Association and consist of two digits. They can be applied to CPT and HCPCS codes. Level II Modifiers are developed and maintained by The Centers for Medicare and Medicaid Services and consist of two letters or a letter and a number. There are approximately 358 Level II modifiers. It is possible to use multiple modifiers. The correct order of modifiers is very important to ensure approval of the claim. A word of caution; overuse of certain modifiers, modifier 22 for example, can trigger audits.

CPT  Modifiers

This article will deal with CPT modifiers only. Level II modifiers will be dealt with at a later stage. There are 36 CPT modifiers consisting of two digits each. A selection of these and their correct usage is explained below.

Modifier 22 - Increased procedural services

When a procedure requires more work than is typically required, modifier 22 can be appended to show this increase in work. Documentation must be added to support the extra work. Do not use this modifier with evaluation and management services.

Modifier 24 - Unrelated evaluation and management (EM) service by the same physician or other qualified health care professional during a postoperative period

There are three possible global periods for surgical procedures - Zero day Postoperative Period, 10 day Postoperative Period and 90 day Postoperative period. If a physician is required to perform an EM during the postoperative period of a procedure that is totally unrelated to the procedure performed, then modifier 24 is attached to the EM service to ensure payment.

Modifier 25 - Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service

If an EM service is performed on the same day as a procedure, then modifier 25 is added to the EM to ensure the EM and procedure are both paid instead of being regarded as a bundled service.

Modifier 50 - Bilateral procedure

When an identical procedure is performed on both sides of the body in the same encounter, then modifier 50 is added to the procedure code. This negates the need to bill the procedure with modifier LT and then to repeat the procedure with the modifier RT. Caution must be taken that the procedure code does not already have a bilateral service in the title (CPT code 27158 – Osteotomy, pelvis, bilateral (eg, congenital malformation))

Modifier 51 - Multiple procedures

Modifier 51 is added to CPT codes when multiple procedures are performed which are not components of the first procedure performed by the same physician at the same encounter. Code 51 is not used on EM services. Medicare does not recommend using modifier 51. Do not use modifier 51 on ‘add-on’ codes. This modifier should be used sparingly.

Modifier 58 - Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period

If a procedure or service is planned to be performed during the postoperative period, is more extensive than the original procedure or service, or for therapy following a surgical procedure the modifier 58 can be appended to the staged or related CPT code.

Modifier 59 - Distinct Procedural Service

Modifier 59 is used when there are multiple distinct procedures other than EM services performed by the same physician at the same encounter. Modifier 59 should only be used when there is no other modifier available that would better explain the procedure.

Modifier 76 - Repeat procedure or service by same physician or other qualified health care professional

In cases where a procedure needs to be repeated by the same physician or other qualified health care professional, modifier 76 can be appended to indicate that the procedure needed to be performed again. Do not use this on EM services.

Modifier 79 - Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period

This modifier is used when a physician is required to perform a procedure or service that is not related to the original procedure carrying a global period during the postoperative period.

Modifier 95 - Synchronous Telemedicine service rendered via a real-time interactive audio and video telecommunications system

Synchronous Telemedicine service is defined as a real-time audiovisual interaction between a physician or other qualified health care professional and a patient located at a site distant from the physician or other qualified health care professional. The nature and time spent on the consultation must be comparable to the service if it was held face-to-face. Modifier 95 may only be appended to services listed in Appendix P of CPT.

Modifier 99 - Multiple modifiers

If multiple modifiers are required, modifier 99 may be appended to the CPT code and the individual modifiers are listed as part of the description of the service.

Carel Visser, is the COO of Florida Business Systems which provides medical billing and revenue management services. He is a qualified medical biller and coder dealing directly with day to day business and providing training to companies in medical billing and revenue management skills. Email cvisser@flbsystems.com  

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