Modifier Rule Education

As anyone in the coding world knows, modifiers are a critical component for accurate billing and maximum reimbursement. The notorious complexity of modifier rules creates considerable lag when it comes to the forms review and editing process. The questions below highlight key factors that must be taken into account when applying modifiers to procedures. 

What does your practice management system allow or require?

The first challenge for posting claims correctly to the practice management (PM) system is to make sure modifiers are entered correctly. Each PM system specifies the format and number of modifiers that may be posted on a claim. For example, some PM systems do not allow more than one or two modifiers to be posted per procedure line item. Other PM systems may allow only numeric modifiers, requiring any all alphabetic (GA) or alpha-numeric (E1) modifiers to have a numeric equivalent posted on the claim. Less frequently, PM systems may request that you post modifiers in box 19 on the CMS-1500 claim form.

Note: If you plan to change PM systems in the future, it is important that you ask how the new PM system handles modifiers.

What situational details require a modifier to report the procedure fully?

The following factors require one or more modifiers:

  • Multiple procedures performed on the same day
  • Procedure repeated on the same day
  • Split or shared work of a surgical procedure between multiple providers
  • Procedures increased, reduced or discontinued
  • Patients classified in a global period from a previous surgery
  • Same procedure completed by multiple assistant surgeons
  • Procedural service rendered in a particular location (e.g., a rural area, an HPSA area,  a teaching facility)
  • Procedure performed in a hospital setting (technical and professional components of a procedure must be billed separately)
  • Procedures considered a non-covered service
  • Provider participated in government sponsored incentive programs (e.g., the Physician Quality Reporting Initiative (or PQRI), Electronic Prescribing)

Which payor rules apply when using modifiers?

Insurance carriers or payers frequently stipulate their own modifier rules, especially for modifiers 22, 25, 50, 51, 59, 76 and 78. Most payers publish their modifier guidelines so that their customers know in advance of what is permissible. However, if modifier guidelines are not available, providers should contact the medical director of the payer in writing to request this information.

How should modifiers be sequenced on procedure lines?

Even though there is no official guideline by the Centers for Medicare & Medicaid Services (CMS), conventional practice dictates any modifiers that can affect reimbursement should be listed before modifiers that are information only (e.g., modifiers 22, 26, 50, 52, 53, 58, or 80 should be listed before modifiers RT, LT, FA-F9).   

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