Types of Modifiers used to Reimburse claims; their Abuse and Misuse
Let's First get acquainted with Modifiers!
Modifiers are used as supplementary tools to provide information or adjust care descriptions to provide extra details concerning a procedure or service provided by a physician. Code modifiers help further describe a procedure code without changing its definition.
In this Article, we will go through the fundamentals of applying Modifiers properly and avoid their misuse, meanwhile we will also talk a little about some sequencing tactics below that might help you with your coding skills and bring optimal reimbursement for your practice that you are coding for.
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. The modifier provides additional information about the medical procedure, service, or supply involved without changing the meaning of the code. 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, although performance measure modifiers apply only to CPT.
Commonly used examples of CPT modifiers are as follows:
- 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 services.
- 26: Professional Component
- 59: Distinct Procedural Code
Category 2 / HCPCS 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.
Below are some examples of HCPCS Level II modifiers:
- E1: Upper left, eyelid
- TC: Technical component; under certain circumstances, a charge may be made for the technical component alone; under those circumstances, the technical component charge is identified by adding the modifier 'tc’ to the usual procedure number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only bill for technical component and should utilize modifier TC; the charge data from portable x-ray suppliers will then be used to build customary and prevailing profiles.
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. First, you can incorrectly apply it when a procedure is more accurately described with an add-on code. Also, you should not use it with an evaluation and management (E/M) service. And finally, you might incorrectly apply it to the wrong procedure, especially if you are billing claims for Medicare. Do not append modifier 51 when two or more physicians each perform distinctly, different, unrelated surgeries on the same day to the same patient.
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.
There are instances where multiple procedures are performed but modifier 51 is not appropriate. Modifier 51 is not appended to add-on codes. For example, modifier 51 would not be appended to CPT code 64462 as it is an add-on code and would be used for any additional injection sites per its definition.
Modifier 51 impacts payment. Many payers will apply a multiple procedure reduction to each additional procedure after the first reported code so be sure to list the most complex procedure first on your claims and append the modifier to any additional services reported when the situation calls for the use of modifier 51.
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. It is normally used to indicate that two or more procedures were performed during the same visit to different sites on the body.
Unfortunately, it is too often applied to prevent a service from being bundled or conjoined with another service on the same claim. It should never be used strictly to prevent a service from being bundled or to bypass the insurance carrier’s edit system.
59 should also only be used if there is no other, more appropriate modifier to describe the relationship between two procedure codes. If there is another modifier that more accurately describes the services being billed, it should be used in place of the 59 modifier.
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. Then, modifier 59 is added to the second procedure indicating a distinctly different procedure performed on separate extremities.
Level 1 Modifier 25
Level 1 modifier 25 is defined as follows:
“Modifier 25 is a Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service.”
This modifier for physicians to indicate that on the day a procedure or service (identified by a CPT code) was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided.
When not to use the Modifier 25
- Do not use a 25 modifier when billing for services performed during a postoperative period if related to the previous surgery.
- Do not add modifier 25 if there is only an E/M service performed during the office visit and no procedure.
- Do not append modifier 25 to an E/M service when a minimal procedure is performed on the same day unless the level of service can be supported as significant, separately identifiable.
Example of Appropriate Use of Modifier 25
A patient visits the cardiologist for an appointment complaining of occasional chest discomfort during exercise. The patient has a history of hypertension and high cholesterol. After the physician completes an office visit, it is determined the patient needs a cardiovascular stress test that same day. Coding example: 99214-2593015 The physician codes an E/M visit (99214) and he also codes for the cardiovascular stress test (93015). The modifier 25 is added to the E/M visit to indicate that there was a separately identifiable E/M on the same day of a procedure.
Level 1 Modifier 91
Modifier 91 should be used when repeat tests are performed on the same day, by the same provider to obtain reportable test values with separate specimens taken at different times, and only when it is necessary to obtain multiple results in the course of treatment. 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
A patient with high blood pressure who has been on a low-salt diet may receive a plasma renin activity (PRA) test (84244 Renin) in the morning in the supine position. Because physicians may use variations in PRA levels due to time of day and patient position to evaluate certain conditions such as hyperaldosteronism, they may order repeat renin in the afternoon with the patient standing upright for some time. Coding example: 8424484244-91. Report the second 84244 with modifier-91 to indicate that the lab performed two separate renin assays for the same patient on the same day.
Confusion Between Modifier 26 and TC
Modifier 26 indicates the professional component (physician’s interpretation or report) of a diagnostic, lab, or pathology service, while modifier TC represents the technical component. It’s very important to know when to bill globally and when to segregate a code into professional and technical components.
Separate payments may be made for the technical and professional components of a procedure if, for example, a facility provides the technical component of a service/procedure, while an individual physician performs the professional component.
The physician bills the procedure code for that service with modifier 26 appended, and the facility bills the same procedure code with modifier TC.
If, however, a physician provides both the professional component (supervision, interpretation, report) and the technical component (equipment, supplies, and technical support) of a service, that physician would report the global service, the procedure code without the TC or 26 modifiers. Understanding the appropriate use of modifiers 26 and TC is key to filing clean claims and avoiding 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. CPT Add-on codes are a special list of codes that let insurers know which procedures were performed in addition to the primary procedure. Healthcare providers can help simplify this complicated process by streamlining the claims submission process.
Combining CPT add-on Codes and Modifiers
If your practice uses CPT add-on codes for insurance billing, you’re probably in the habit of using modifiers to clarify information about the services you’re charging for.
For instance, healthcare providers often use modifier 59 to indicate that grouping these procedures was necessary under the circumstances. Another common modifier is modifier 51. This is frequently used to let insurers know which procedures were additional to the primary procedure.
But CPT add-on codes, by definition, indicate which procedures are secondary. These codes can’t be billed without a primary code, and the fee is already discounted as it is a secondary procedure.
This is why add-on codes are “modifier 51 exempt” and, most of the time, you won’t need to use any modifiers with CPT add-on codes. 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
A pricing modifier is a medical coding modifier that causes a pricing change for the code reported. The Multi-Carrier System (MCS) that Medicare uses for claims processing requires pricing modifiers to be in the first modifier position, before any 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 that do not have the pricing modifier in the first position may encounter processing delays.
Informational Modifiers / Statistical Modifiers
An informational modifier is a medical coding modifier not classified as a payment modifier. Another name for informational modifiers is statistical modifiers. These modifiers belong after pricing modifiers on the claim.
One payer's list of pricing and informational modifiers may not match another's list, so medical coders need to stay current on individual payer policies to avoid incorrect modifier placement that could affect claim processing.
National Correct Coding Initiative (NCCI) Modifiers
An NCCI PTP-associated modifier is a modifier that Medicare and Medicaid accept to bypass an NCCI PTP edit under appropriate clinical circumstances. 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. In the case of a global surgery, you would report the payment modifiers “before” the pricing modifiers. For example, you would code modifier 58 first and modifier 82 second in a global surgery.
The general order of sequencing modifiers is:
- Pricing
- Payment
- Location
Location modifiers, in all coding situations, are coded “last”.
If you code two pricing modifiers that include either a professional or technical component (26 or TC), always use the 26 or TC first, followed by the second pricing modifier.
Final Say on this
Payment modifiers serve as indicators to the insurance carrier of specific circumstances within a claim. Essentially, without the application of a payment modifier, the claim would face denial based on established billing and coding principles, along with global surgery guidelines. For instance, omitting modifier 25 (a significant, separately identifiable evaluation and management service on the same day as a procedure) from an E/M service paired with a minor surgical procedure like wart removal (17110) would result in the denial of the E/M service. Overall, the strategic utilization of these sequencing tactics is often overlooked, yet with proper handling, they can significantly enhance reimbursement if appropriately applied in claims.
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