Whar are Modifiers in Medical Billing and their uses

A complete explanation of Modifiers and their uses in Medical billing

1. Name: Muhammad Aqib Javed Scholar of MPH University: Khyber Medical University Contact email: [email protected]

2. Modifiers Introduction: A medical coding modifier is two characters (letters or numbers) appended to a  CPT  or HCPCS Level II code. The modifier provides additional information about the medical procedure , service, or supply involved without changing the meaning of the code . On the CMS 1500 claim form, the appropriate field is 24D .You enter the modifier directly to the right of the procedure code on the claim.

3. When or why is appropriate to use a modifier? The service or procedure has both professional and technical components. More than one provider performed the service or procedure. More than one location was involved. A service or procedure was increased or reduced in comparison to what the code typically requires. The procedure was bilateral. The service or procedure was provided to the patient more than once.

4. Types of Modifiers: CPT Modifiers(Informational Modifiers) CPT modifiers are generally two digits, They are not primarily for determining payment, unlike payment modifiers, These modifiers are added after pricing modifiers on a medical claim, CPT Category II codes are alphanumeric. Examples: 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. 26: Professional component. 59 : Distinct procedural service at the same day.

5. HCPCS Level II Modifiers (Pricing Modifiers) HCPCS Level II codes and modifiers are maintained by the Centers for Medicare & Medicaid Services (CMS). HCPCS Level II modifiers are alphanumeric or have two letters . examples  E1 : Upper left, eyelid TC : Technical component XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service

6. Modifier KX and Modifier 53 KX: It indicates that the provider providing a particular service according to the medical condition and service is met according to the payer's policy . Documentation: When using the modifier KX, the provider must have documentation supporting that the service meets coverage criteria. For example, If a physical therapist provides an additional treatment that exceeds the usual limit, they might use the modifier KX to show that the extra service is medically necessary and meets the insurer’s criteria . 53 Indicates the physician elected to terminate a surgical or diagnostic procedure due to the patient's well-being . Or terminate the procedure due to failed service.

7. Modifier 59: Distinct procedural service To be used only on procedure codes, never E/M services. The procedure code was a distinct or separate service from other services performed on the same day. It is an anatomical modifier (there is no other available anatomical modifier to show that the procedure was a separate service from other services performed the same day. It is a multiple procedure modifier. *IMP… When using modifier 59, append it to the first CPT code .

8. General Modifiers and their use: 59 Distinct Procedural Service identifies procedures/services not normally reported together, but appropriately billable under the circumstances 63 Procedure Performed on Infants less than 4 kg 66 If a team of surgeons (more than two surgeons of different specialties) is required to perform a specific procedure, each surgeon bills for the procedure with a modifier "-66" 74 Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC) Procedure after administration of anesthesia 76 Repeat Procedure by the *Same Physician; use when it is necessary to report that repeat procedures performed on the same day

9. Con… 22 Increased Procedural Service requiring work substantially greater than typically required 24 Unrelated evaluation and management (E/M) service by the same physician* during a postoperative period 25 Significant, separately identifiable evaluation and management (E/M) service by the same physician* on the day of a procedure 27 Multiple Outpatient Hospital E/M Encounters on the Same Day (Not required by CMS and not to be used by physicians for reporting of multiple E/M services) 52 Reduced Service reports a partially reduced or eliminated service or procedure.

10. Con… 90 Reference (Outside) Laboratory 99 Multiple Modifiers are required on one line of service 57 Indicates an Evaluation and Management (E/M) service resulted in the initial decision to perform surgery either the day before a major surgery (90-day global) or the day of a major surgery 58 Indicates a staged or related procedure or service by the same physician* during the postoperative period 77 Repeat Procedure by another physician 79 Unrelated procedure by the same physician during the postoperative period

11. Con… GY Statutorily excluded service - If the service provided is statutorily excluded from the Medicare Program, the claim will deny whether or not the modifier is present on the claim GZ The provider or supplier expects a medical necessity denial; however, did not provide an Advance Beneficiary Notice of Noncoverage (ABN) to the patient Q5 Service furnished by a substitute physician under a reciprocal billing arrangement Q6 Service furnished by a fee-for-time compensation arrangements physician

12. Con… AQ Services provided in a Health Professional Shortage Area (HPSA) CR Emergency health care needs of beneficiaries and providers affected by Hurricane Katrina and any future disasters GA The provider or supplier has provided an Advance Beneficiary Notice of Noncoverage (ABN) to the patient and has a signed copy on file GO Services delivered under an outpatient occupational therapy plan of care

13. Mostly used for Lab billing QW The QW modifier is used in laboratory procedure coding, specifically to indicate that a test was performed by a Clinical Laboratory Improvement Amendments (CLIA)-waived laboratory. GV Used when the service is related to the hospice condition but provided by an unaffiliated provider. Like consultation from a Cardiologist. GW Service not related to the hospice patient's terminal condition e.g. A hospice patient with terminal cancer visits a dermatologist for an unrelated skin condition . The visit would be billed with a modifier

14. Mostly used for DPT CB When therapy services exceed the annual therapy cap set by Medicare, providers can request an exception based on medical necessity. If the exception is granted, the CB modifier is used on the claim to indicate that the services qualify for payment beyond the cap. GN Modifier GN is specifically used for Medicare outpatient physical therapy services to denote services under an outpatient care plan . GP Services are delivered under an outpatient physical therapy plan of care for different payer. 25 Significant, separately identifiable evaluation and management (E/M) service by the same physician* on the day of a procedure. 59 Distinct Procedural Service identifies procedures/services not normally reported together , but appropriately billable under the circumstances

15. Anesthesia Documentation Modifiers AA   Anesthesia services performed personally by an anesthesiologist. QK Medical direction by a physician of two, three, or four concurrent anesthesia procedures  involving qualified individuals. AD Medical Supervision by a physician, more than four concurrent anesthesia procedures . QY   Medical direction of one CRNA/AA (Anesthesiologist's Assistant) by an anesthesiologist . QX   CRNA/AA (Anesthesiologist's Assistant) service with medical direction by a physician . QZ   CRNA service without medical direction by a physician.