Earlier when procedure codes were not introduced, the health practitioners used to write the description of the service provided and the insurance carriers had to code the same and then pay the claim. To reduce the workload of insurance carriers, Medicare made it compulsory for the healthcare service providers to provide a medical code on medical claims in order to get reimbursement. This was when different procedure codes came into the picture i.e. ICD procedure codes, AMA CPT Procedure codes and HCPCS procedure codes and many more. These procedure codes were soon came to be known as modifiers.
Modifiers provide complete details of the service provided and the procedures used in them by the healthcare practitioners to the insurance carriers. But being a good medical coder, one should know when and when not to use the modifier. Inappropriate use can lead to claim denials. Using correct modifier appropriately will impact the reimbursement process positively.
A clear understanding of Medicare rules and regulation is very important, to assign correct and appropriate modifier codes.
Some of the circumstances where modifiers may be used are listed below:
- If service is repeated by same or different provider.
- If a service is increased or reduced.
- If billing is to be done for global surgical package.
- To designate a bilateral procedure etc.
Some of the modifiers that affect payment are provided below for better and clear understanding:
Modifier 22 – Unusual Procedural Services: 125% of the applicable fee schedule amount.
Modifier 25 – Evaluation Management Services By Same Physician: It will reimburse the applicable evaluation and management code in addition to the procedure listed on claim.
Modifier 52 – Reduced Services: 50% of the applicable fee schedule amount.
Modifier 73 – Discontinued Operative Procedure Prior To Anesthesia: 50% of the applicable fee schedule amount.
There are many more modifiers that affect reimbursement. For complete and better understanding of the modifiers 2019 join us on our live webinar on Everything You Need To Know About Using Modifiers for 2019 On MARCH 7, 2019.