Types of Modifiers used to Reimburse claims; their Abuse and Misuse
Let's First get acquainted with Modifiers!
Modifiers provide extra details about procedures or services. Code modifiers help further describe a procedure code without changing its definition.
This article covers applying Modifiers properly and coding tactics for optimal reimbursement.
Proper Application of Modifiers
A little more preview about applications of Modifiers
A medical coding modifier is two characters (letters or numbers) appended to a CPT or HCPCS Level II code. Modifiers provide extra info without changing code meaning. Medical coders use modifiers to tell the story of a particular encounter.
There are two categories of modifiers used which are as follows:
- Category 1: CPT modifiers
- Category 2: HCPCS modifiers
Category 1 / CPT Modifiers
The American Medical Association (AMA) holds copyright in CPT. CPT modifiers are generally two digits, with exceptions for performance measure modifiers.
Commonly used examples of CPT modifiers are as follows:
- 25: Distinct E/M service by same provider on same day as procedure.
- 26: Professional Component
- 59: Distinct Procedural Code
Category 2 / HCPCS Modifiers
CMS maintains HCPCS Level II codes and modifiers. HCPCS Level II modifiers are alphanumeric or have two letters.
Below are some examples of HCPCS Level II modifiers:
- E1: Upper left, eyelid
- TC: TC modifier indicates technical component charge, used by portable x-ray suppliers.
Let’s take a look at 3 commonly misused modifiers, and how they’ve been applied to different care situations.They are named as follows:
- Level 1 Modifier 51
- Level 1 Modifier 59
- Level 1 Modifier 25
- Level 1 Modifier 91
Level 1 Modifier 51
Modifier 51 is defined as multiple surgeries/procedures. Multiple surgeries were performed on the same day, during the same surgical session. This modifier can be misused in several different ways. Incorrectly applying a modifier when an add-on code is more appropriate. Also, you should not use it with an evaluation and management (E/M) service. Incorrectly applying a modifier to the wrong procedure, common in Medicare billing. Do not use modifier 51 for surgeries by different physicians on the same day.
Modifier 51 comes into play only when two or more procedures are performed. It is not to be used when a procedure is performed along with an Evaluation and Management (E/M) service.
Modifier 51 not always appropriate for multiple procedures. Modifier 51 is not appended to add-on codes. Do not use modifier 51 with CPT code 64462, an add-on code for additional injection sites.
Modifier 51 impacts payment. List most complex procedure first and use modifier 51 to avoid payer reductions.
Level 1 Modifier 59
CPT Manual Defines Modifiers 59 as a “Distinct Procedural Service”:
The 59 modifier is considered the most misused modifier by coders. Used to show multiple procedures done at different body sites during one visit.
Often used to prevent services from being bundled on the same claim. Avoid using it solely to prevent bundling or bypass insurance edits.
Use modifier 59 when no other modifier fits the procedure relationship. Use a more specific modifier instead of 59 if available for accurate billing.
Example of Appropriate Use of Modifier 59
A dermatologist does a Photo Dynamic Therapy session with a BLU-U machine on the face/scalp of a patient. Following the face/scalp session, the BLU-U was repositioned to treat the other extremities. Coding examples: 96567 and 96567-59. The first code is the face/scalp performed on the patient. Modifier 59 added to second procedure for distinct procedure on separate extremities.
Level 1 Modifier 25
Level 1 modifier 25 is defined as follows:
Modifier 25 signals a separate E/M service by the same provider on the same day as another procedure.
Modifier 25 indicates a separate E/M service beyond the procedure/service on the same day.
When not to use the Modifier 25
- Do not use modifier 25 for postoperative services related to a prior surgery.
- Do not add modifier 25 if there is only an E/M service performed during the office visit and no procedure.
- Do not use modifier 25 for an E/M service with a minimal procedure unless the E/M is distinctly significant.
Example of Appropriate Use of Modifier 25
Patient sees cardiologist for chest discomfort during exercise. The patient has a history of hypertension and high cholesterol. After visit, patient needs stress test same day. Coding example: Code E/M visit 99214 and stress test 93015. Modifier 25 signals a separate E/M on the same day as a procedure.
Level 1 Modifier 91
Use 91 for medically necessary repeat tests on same day to get multiple results. When billing for a repeat test, use modifier 91 with the appropriate procedure code.
When not to use the Modifier 91
- Used for a rerun of a laboratory test to confirm results
- Due to testing problems for the specimen
- Due to testing problems with the equipment
- When another procedure code describes a series of test
- When the procedure code describes a series of test
- For any reason when a normal one-time result is required
Example of Appropriate Use of Modifier 91
Patient with high BP on low-salt diet gets morning supine PRA test. Repeat afternoon standing PRA test ordered to evaluate conditions like hyperaldosteronism. Coding example: 8424484244-91. Use modifier 91 on the second 84244 to show two separate renin assays done for the same patient on the same day.
Confusion Between Modifier 26 and TC
26: professional component, TC: technical component. Proper billing of global vs professional/technical is critical.
Separate payments for technical and professional components when facility & physician handle different parts.
Physician bills with 26, facility bills with TC.
Physician bills global service code without modifiers if providing both professional & technical components. Proper use of 26 and TC is crucial to avoid claim denials for duplicate billing.
Appropriate Use of Modifiers with CPT Add-On Code
Healthcare providers often perform several procedures on a patient in one session. Add-on codes indicate additional procedures done with a primary procedure. Streamlining claims submission simplifies the complicated billing process.
Combining CPT add-on Codes and Modifiers
Using modifiers with CPT add-on codes clarifies billed services for insurance purposes.
Modifier 59 is commonly used to show necessary grouping of procedures. Another common modifier is modifier 51. This is often used to indicate additional procedures beyond the primary to insurers.
But CPT add-on codes, by definition, indicate which procedures are secondary. Add-on codes need a primary code and are discounted.
Add-on codes are "51 exempt" and usually don't need modifiers. However, you can always check the CPT manual for any exceptions if you're unsure
Sequencing of Modifiers
There are three types of modifiers used depending on nature.
- Pricing modifiers / Payment Impacting Modifiers / Reimbursement Modifiers
- Informational Modifiers / Statistical Modifiers
- National Correct Coding Initiative (NCCI) Modifiers
Pricing Modifiers
Pricing modifier alters the reported code's price. Medicare's MCS mandates pricing modifiers in the first position before informational modifiers. On the CMS 1500 claim form, the appropriate field is 24D. You enter the pricing modifier directly to the right of the procedure code on the claim. Claims without the pricing modifier in the first position may face processing delays.
Informational Modifiers / Statistical Modifiers
Informational modifiers don't affect payment. Another name for informational modifiers is statistical modifiers. These modifiers belong after pricing modifiers on the claim.
Stay current on payer policies for accurate modifier placement & to prevent claim issues.
National Correct Coding Initiative (NCCI) Modifiers
NCCI PTP-associated modifiers bypass edits when clinically appropriate for Medicare/Medicaid. Bypassing or overriding an edit is also called unbundling.
What Proper Sequencing Tactics for Applying Modifiers?
Pricing modifiers are always sequenced “before” payment modifiers and/or location modifiers. The only exception to this rule is when a global surgery package is involved. For global surgery, report payment modifiers before pricing modifiers.
The general order of sequencing modifiers is:
- Pricing
- Payment
- Location
Location modifiers, in all coding situations, are coded “last”.
For two pricing modifiers involving 26 or TC, use 26 or TC first, then the second modifier.
Final Say on this
Payment modifiers indicate specific claim circumstances to the insurance carrier. Payment modifiers prevent claim denials per billing and global guidelines. Omitting modifier 25 for a significant E/M with a minor surgery on the same day leads to E/M denial. Proper modifier sequencing enhances reimbursement if appropriately applied in claims.
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