All About Medical Billing, Coding & Claims Modifiers

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Importance of Using Proper Modifiers:

1. The physician performed multiple procedures

2. The procedure performed was bilateral

3. The E/M service was done on the same day of the procedure

4. The procedure was increased or decreased

5. The procedure has both professional and technical component

6. The procedure was performed by other provider (Anesthesiologist, Surgeon Physical Therapist, Speech Pathologists etc.)

7. Procedure on either one side of the body was performed

8. The E/M service was provided within the postoperative period

9. The E/M service resulted to Decision of Surgery

10. Unusual Circumstance

Maximize your reimbursement for bilateral procedures by using the correct modifier.

Bilateral Modifier (-50)

Depending upon the insurance payer, processing claims with bilateral procedure should be paid 150%

Medicare Part B requires one single line of bilateral procedure code with Modifier 50. They normally process the claim with 150% reimbursement. But again, you have to check on this in your state and in your region.

Some commercial insurance would prefer Two Lines of the same code, once with 50, second without 50. Then second modifier on the 1st line is RT or LT, modifier RT or LT on second line, with 1 unit of service each code. Must be reimbursed at 150%

Some commercial insurance would prefer two lines of the same code with modifier LT or RT on each line with 1 unit of service each code. Must be reimbursed at 150%

Always check on your Physician’s Fee Schedule if the procedure code is billable as bilateral J.

Using LT & RT modifier is used to specify which side of the body the procedure was done by the physician. Medicare Part B based on my experience requires specific modifier, either LT or RT. Example you may report procedure 64626 done on the Right C4-C7 Facet Joint Nerve Ablation as 64626-RT.

Modifier -26. Professional Component.

Example: Report procedure code 77003 – Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural, transforaminal epidural, subarachnoid,, paravertebral facet joint, paravertebral facet joint nerve or sacroiliac joint) including neurolytic agent destruction) with modifier -26 to indicate the physicians Professional Component only reimbursement and not technical component. If the provider’s office owns the fluoroscopic equipment, do not append -26 modifier.

Modifier -25. Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service.

Example: Report E/M code 99213 (Office or other outpatient visit for the evaluation and management of an established patient) with Modifier -25 for procedure code 20610 Knee Joint Injection done on the same day of the procedure. Modifier -25 indicates significance and separate identifiable E/M service outside the procedure done on the patient. DO NOT use modifier -25 to report E/M service that resulted for initial decision for surgery.

Instead use modifier -57 for Decision for Surgery

Modifier -24. Unrelated Evaluation and Management Service by the Same Physician During Postoperative Period

Example: Report E/M code 99213 with Modifier -24 if the patient came back during the postoperative period. The physician must identify this service as completely unrelated with the recent procedure done on the patient. A detailed medical documentation is a good support for medical necessity.

Modifier -51 for Multiple Procedures.

Modifier -59 for Distinct Procedural Service

Modifier-GP Services Rendered under Outpatient Physical Therapy plan of care

Modifier-GO Services Rendered under Outpatient Occupational Therapy plan of care

Modifier -GN Services Rendered under Outpatient Speech Pathology plan of care

Always check your up to date CPT Book. Check the CMS CCI Edits. Check the insurance payor’s policies and guidelines.

WHAT YOU DON’T KNOW MIGHT HURT YOU. IF YOU DON’T KNOW IT, DON’T MAKE IT UP. FIND IT.

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