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Role of Modifiers in Medical Billing Services

When we talk about medical billing services, it includes assignment of codes as well. And where there are medical codes, there are modifiers too. Modifiers are one of the essential elements of medical coding. It represents the whole method of the procedure along with the code and paves a way for seamless revenue flow.

Current Procedure Terminology or CPT codes will not completely reflect the medical, diagnostic and surgical procedures. In that case, modifiers should be added without fail for accurate and complete medical billing service. A CPT modifier is a code that allows a healthcare professional to indicate that a procedure or service has been altered in some or the other way.

However, the original code or the definition won’t change. Under certain circumstances, modifiers help medical billing services to separate procedure listings which accurately describe that the modification is not necessary.

How do Modifiers work in Medical Billing Services?

  • CPT modifiers help to describe why a particular procedure was necessary and also indicate the location of the body where the procedure was performed.
  • On the other hand, the information includes the number of procedures performed, how many healthcare professionals or surgeons were involved, if any additional services were performed and if any unusual events occurred.
  • Actually, CPT modifiers are two character numeric codes. But in few cases they can also be alphanumeric. They also stick to the end of the CPT codes with a hyphen.
  • There are few circumstances where more than one modifier is necessary for the procedures. A “functional” modifier represents the functional impairment and has a significant impact on reimbursement. So it’s essential to add this modifier initially. Any “informational” modifier which does not affect reimbursements should be added later.
  • The American Medical Association has many CPT coding resources and a vast array of available codes along with intricate rules for applying modifiers.
  • The goal of many companies who deliver medical billing services is to provide experienced, comprehensive billing for timely claims processing and accurate reimbursements.

Why do Modifiers matter a lot?

  • Serving as an informational or a billing clarification, the application of modifiers removes the necessity of separate service or procedure listing.
  • The use of inaccurate modifiers or using the modifiers incorrectly is considered to be a fraudulent activity and non-compliant with the laws.
  • This would result in future audits and also revenue loss. So it’s really essential to be conversant with the CPT modifiers list.
  • Healthcare professionals and medical billing companies can refer to modifiers guide to find accurate modifiers for medical billing services.
  • Many guides list Level I (CPT-4), Level II (non-CPT-4 alpha numeric), and Level III (local) modifiers. Referring to such guides is important because it helps to understand the modifiers in the medical billing list.
  • While Level I and II modifiers are defined in the HCPCS, Level III modifiers are defined by the Fiscal Intermediary and requires the approval of Centers for Medicare and Medicaid Services before adding them.

CPT Code Modifiers:

  • Category I CPT codes describe diagnostic, medical and surgical procedures in five digit numerical sequences.
  • Additional information to Category I CPT codes is provided by Category II CPT Codes that helps to streamline administrative work and track the performance of certain procedures and tests.
  • Category II CPT Codes will not always provide complete information about the specifics of a procedure.
  • The codes will never provide the complete essential information of the procedure keeping the patient’s privacy in mind.
  • In its place, modifiers come into the picture by providing detailed information in an efficient and standardized way.
  • CPT modifiers  indicate either one or a combination of the following:
  1. Why was a procedure necessary?
  2. Was a service or procedure provided more than once?
  3. Were multiple procedures performed?
  4. What was the location of the body where the procedure was performed?
  5. Was there one or more than one physician involved in the service or procedure?
  6. Does the service or procedure have a technical component or professional component?
  7. Did any unusual event occur during the service or procedure?
  8. If any additional service or procedure was performed
  9. If the service or procedure was discontinued
  10. Any other information that is important for claiming reimbursement
  • Few CPT modifiers can be used only with specific type of procedure or service.
  • Modifier–LT is used only while describing a procedure on an appendage or organ paired in the body, whereas modifiers -21, -24, -25, and -27 can be used only for evaluation and management.

Functional and Informational Modifiers for Medical Billing Services:

  • Modifiers and their use are declared and governed by a number of rules. It’s really crucial to know the restrictions, formats and guidelines when using the medical modifiers as missed codes in the claims can result in denials or rejections.
  • Even though CMS-1500 and UB-04 have a place for four modifiers, CMS and other insurance companies will target the first two.
  • Modifiers are required to be ranked in different categories to make sure that there are no coding inaccuracies while filing the claims form.
  • Modifiers those affect reimbursements or revenue payments are known as functional modifiers. Modifiers those provide detailed and additional information, are known as informational modifiers.
  • Usually, pricing modifiers are used to determine the reasonable charges or fee for the services and are considered to be a part of the seven digit procedure code by the Centers for Medicare and Medicaid Services. Statistical modifiers that affect pricing are attached to a procedure code.
  • Of course, modifiers after a CPT or HCPCS codes will not guarantee reimbursements. There has to be a clear understanding and knowledge of the rules, regulations, policies and guidelines to be capable of assigning the accurate modifiers.
  • Sometimes, medical documentation will be requested in order to support the assigned modifiers. It is the responsibility of healthcare providers to stay informed of certain requirements while submitting the claims.
  • Very large number of medical billing errors while providing medical billing services lead to claim denials because of inaccurate use of modifiers.
  • An expert medical billing services team will know how to use these modifiers. They also study how they impact practice reimbursements by understanding payer considerations.

 

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