What is the Correct Way to Use Medical Service Modifiers for Flawless Medical Billing?
When you code for multiple medical services or procedures done on the same day, you need to add a modifier to the HCPCS or CPT codes to get paid. The CMS (Centers for Medicare & Medicaid Services) provides a list of modifiers to use for getting those claims reimbursed.
However, the OIG (Office of Inspector General) often reports that even the most commonly used modifiers are misused in various healthcare practices, sometimes knowingly, sometimes not.
Inaccurate use of modifiers can lead to:
- Unjustified upcoding
- Documentation errors
- Improper payments or overpayments
- Denials
- Raising fraud alerts
- Extensive audits
- Payment reversals
In this short article, we discuss some common modifiers and how to use them correctly.
Modifier 25
Definition: "Significant, separately identifiable evaluation and management (E/M) service by the same physician or other qualified health care professional on the same day of the procedure or other service."
Do not use Modifier 25 if:
- It's used with non-E/M codes
- No other service was performed
- It's for post-op services unrelated to surgery
- It's for a provider who didn't perform the service
- The procedure is not documented
Modifier 59 Definition: “Distinct Procedural Service.”
Modifier 59 identifies procedures/services that are not usually reported together.
Use Modifier 59 if:
- No other appropriate modifier applies.
- An unrelated service is performed by the same provider on the same day.
- The same or similar procedures are not usually done in the same session.
Tip: If documentation supports use modifier 59 or –XS (Separate Structure) for different anatomical sites.
- Modifier 59 or XE can also be appended to distinguish two different unit of intervals of the same service.
- Use modifiers 59 or –XU properly for a diagnostic procedure which is performed before a therapeutic procedure only when the diagnostic procedure is the basis for performing the therapeutic procedure
- Use modifiers 59 or –XU properly for a diagnostic procedure which occurs after a completed therapeutic procedure only when the diagnostic procedure isn’t a common, expected, or necessary follow-up to the therapeutic procedure.
Do not use Modifier 59 if:
- It's attached to an E/M service.
- It's used to unfairly unbundle procedures.
- The code descriptions are different.
Though the National Correct Coding Initiative (NCCI) edits allow the use of modifier 59, determining if it is appropriate to use can be tricky. To read more about bundling and unbundling of multiple procedure payment, visit here:
Modifier 26 Definition: “Professional Component of the services”
Modifier TC Definition: “Technical Component of the services”
These modifiers are common when billing diagnostic radiology services like X-rays, MRIs, CT scans, and ultrasounds.
Use Modifier 26 if:
- The provider reviews and interprets the reports.
- The provider does not own the equipment.
Use Modifier TC if:
- The provider owns the equipment.
- It indicates only the technical part of the procedure.
After visiting the CMS website, you can search for allowed amounts and Facility and Non-Facility Payments. While you may do that you can also confirm if any particular radiology CPT code might need TC or 26 Modifier. We just have to put the CPT code in given search bar and also add the other relevant information and rest is easy:
Searching the CPT code will come with the result like shown in the figure. Here we can see that Modifier TC and 26 are indeed applicable with 75710 CPT code here. You may also observe difference the Pricing of the Modifiers here. Which is important to note because they directly impact the payment of the services billed.
Importance of Sequencing Modifiers
Sequencing modifiers correctly is crucial. It is similar to sequencing the primary diagnosis code when adding ICD-10 codes in the claims.
General Order of Sequencing:
1. Pricing
2. Payment
3. Location (always coded last)
Example:
If you code two pricing modifiers that include either a professional or technical component (26 or TC), use the 26 or TC first, followed by the second pricing modifier.
AltuMED PracticeFit enables Medical Billers with an inbuilt scrubber feature, reducing the chances of coding errors to 92%. Schedule a PracticeFit demo to know more:
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