Understanding Commonly Used Modifiers and Their Impact on Reimbursements
What are Modifiers?
According to the AMA and the CMS, a modifier provides the means to report or indicate that a service or procedure has been performed and altered by some specific circumstance but not changed in definition. It may also provide more information about the service that has been performed more than one time or services that have occurred unusually.
Modifiers can be used to denote when not all the services in a bundle are not performed.
Advantages of Using Modifiers
The use of modifiers in medical billing helps in
Avoiding claim denials by submitting clean and accurate claims
Submitting claims with a higher level of coding specificity and obtain the right reimbursements
Getting improved reimbursements for services that have been rendered concurrently or in an unusual manner depending on the specific nature of the case
Types of Modifiers:
Level I Modifiers. Level I modifiers or CPT Modifiers comprises of two numeric digits and is copyrighted & updated annually by the American Medical Association (AMA)
Level II Modifiers. Level II modifiers or HCPCS modifiers can be made of either Alphabets or Alphanumeric. These modifiers are copyrighted and updated by the Centre for Medicare & Medicaid Services(CMS)
Common Modifiers in Medical Billing:
GQ – Modifier GQ is used to code for services delivered via an asynchronous telecommunications system. Asynchronous telecommunication is when a physician collects & stores medical history, images & pathology reports and forwards them to senior or specialist physicians to get an opinion on the diagnoses & treatment. It can be used by providers participating in federal telemedicine demonstration programs
GT or 95 – Modifier 95 can be used to code all of the diagnosis, evaluation, or treatment of symptoms via Telemedicine. 95 can be attached to any CPT codes. Modifier 95 can be used only when the service is offered via an interactive audio & video telecommunication system. Modifier GT is being appended in place of modifier 95 only when directed by the insurance payer
G0 – Modifier G0 is used to code for telehealth services offered to diagnose or treat the symptoms of an acute stroke
Modifier 24 – Modifier 24 is appended to unrelated evaluation or management (Unrelated E/M) service offered during the post-operative period of a major surgery performed within 90 days by the same physician. This modifier cannot be used to bill for procedures.
Modifier 25 – Modifier 25 is very commonly used in Pediatrics. It is appended to all E/M services performed on the same day as another major surgery by the same physician.
Modifier 26 – Modifier 26 is used to bill the professional component when a service has both professional & technical components. Such components are observed in radiology services where the physicians note on the scans is considered as the professional component whereas the machinery used is counted as a technical component.
Modifier 27 – Modifier 27 is used when a patient is offered multiple E/M service at various outpatient facilities such as the emergency department, pharmacy, primary care clinics on the same day, by the same or different physician
Modifier 51 – Modifier 51 is used to bill for multiple procedures or surgeries offered by the same provider during the same surgical session. Diagnostic imaging services provided during the surgical session is also included
Modifier 59 – Modifier 59 is used to denote distinct procedural services i.e., services or procedures which are different or impartial from the rest of the non-evaluation & management services performed on the same day
Modifier 76 – Modifier 76 is used to report repeat procedure performed on the same day by the same physician and is also consequent to the original procedure
If modifiers are missing or not used correctly, claims can be denied or rejected by insurance payers. Healthcare practices tend to suffer from aged accounts, write-offs, and revenue leakage if they do not have a firm grip on the use of modifiers.
At Medical Billing Wholesalers, our team of specialty-specific billers and coders are trained on and understand the use of modifiers. Each month, we undertake an exercise to understand the reasons behind each claim denial and earmark the claims denied for coding related issues for further analysis. We endeavor to address coding denials iteratively and fix the issues in a structured manner. This means that very few claims are denied on account of coding issues such as incorrect usage or non-usage of modifiers and, consequently, our customers experience decreased denial rates improved collections, and accelerated cash flow.
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