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Medical Coders Using Modifiers

Steve Verno, Certified Biller shares some insight into what modifiers are:

What is a modifier? Simply put, it is a two digit code that is used to inform the insurance company that a service was performed but something else happened during the visit. Modifiers are listed in Appendix A of the CPT manual.  Each CPT section has a set of guidelines.  These guidelines give us clues on some modifiers we can use. For example:  In the Evaluation and Management Section, you have the following:  The physician's interpretation of the results of diagnostic tests/studies (ie, professional component) with preparation of a separate distinctly identifiable signed written report may also be reported separately, using the appropriate CPT code with modifier 26 appended.

The Modifier

A modifier doesn't change the service being reported.  For example:  A patient comes in with back pain and during the visit the patient says: "Oh by the way, I have a splinter in my big toe!".  So the doctor looks and lo-and-behold there is a wooden splinter the size of a sequoia tree. The doctor removes the splinter, provides care for the back ache and the patient leaves in much better condition than before. 

In this example, the doctor treated both the back problem and the splinter problem.  The doctor can bill for the back care and the splinter removal.  However, a modifier would be needed to separate the two services.  The office visit didn't change, it was provided in full.  What was different was doing the splinter removal during the visit.  The main reason for the visit was the back problem. The splinter removal was an added service. 

As always, Steve reminds us: " Work smart when using modifiers.  Read all available information, especially the CPT manual and carrier policy manuals. Never second guess when using a modifier."

Read the full training post here!
=> Steve Verno on Modifiers

Using specific modifiers should be supported by the medical record documentation.  Overuse and misuse of modifiers is a surefire way to open your provider to denied claims and possible audits.  The key is reading the chart AND the CPT Manual.  Billers must enter modifiers onto the CMS 1500 form.  The National Uniform Claim Committee developed an instruction manual for the CMS 1500 form.

Medical Coders and billers may also need to know the insurance company Modifier policy.  For example, Blue Cross and Blue Shield of Michigan's Modifier 25 policy can be found here:
http://www.msms.org/AM/TextTemplate.cfm?TEMPLATE=/CM/ContentDisplay.cfm&CONTENTID=1414&SECTION=Home

BCBS of Missouri's Modifier 59 policy can be found here:
http://www.bcbsms.com/index.php?q=provider-coding-policy-search.html&action=viewPolicy&path=/policy/ecode/Modifier_59.html&source=ecode

About the Author: Steve is a Certified Master Medical Coder and Certified Master Medical Biller and Medical Coding/Billing Instructor. He also is the co-owner of Lucrum Consulting, LLC, which provides training in medical coding and billing issues, and helps physician's practices in areas such as A/R recovery, appeals, and staff training.