The completed CMS 1500 claim form is designed to tell a story about the patient’s visit. The form can tell you who the patient is, what was wrong with them, what services were performed, when they were seen, and who treated them.

The goal of billing is to provide everything about that encounter so that the claim processor will have everything they need to accurately process the claim; at first pass. This means the usual information, including date of service, type and provider of service as well as any special circumstances, complex treatments or surgical support that was needed.

Since the CMS 1500 claim form is concise with very strict entry requirements and limited areas for documentation, a modifier is often used to further describe the events of the visit.

A modifier is a two-digit code that is added to field 24D of the CMS 1500 form in order to alter, clarify or add to what has been reported on other areas of the claim.

Maybe the procedure that was being performed was so complex that it required more than one physician (modifier 62). Maybe the procedure was performed on a newborn weighing 2 pounds (modifier 63). Maybe the same procedure was performed on both sides (modifier 50 or LT and RT). Or maybe multiple procedures were performed during the same session (modifier 51).

Modifiers are a critical part of the billing process. Not only do they serve to provide clarity and detail but they also ensure that a claim will be paid correctly. If a modifier is incorrect or absent it could result in a claim paying less than expected.

For example

A patient is in need of physical therapy due to pain in her wrist. She obtains a referral from the primary care physician and preapproval from the health carrier. Therapy is rendered and the claim is billed to the health carrier. The claim is later denied because it lacked the information needed to complete processing. After a call to the health carrier, the biller discovers that the plan requires a modifier to indicate whether it was the left wrist (LT) or the right wrist (RT).  The claim is corrected, rebilled and subsequently paid by the plan.  

The CPT-4 manual provides the full list of modifiers, all designed to fit a wide range of different needs and situations. This should be your first stop when referencing modifiers and how they should be used.

Keep in mind that every situation is different and the rules for every health carrier may be different. One carrier may have mandatory requirements for certain modifiers while another carrier may consider that same modifier to be optional. Call the carrier or check their website online if you have questions about how a modifier should be used or if a modifier is appropriate for the claim that you are billing.

It bears repeating, using modifiers to distort the true complexity of the visit as a means to increase reimbursement may subject the provider’s billing practice, and the biller, to unwanted scrutiny and incorrect reimbursement.

Refer to the 2016 CPT Manual for the full list (with descriptions) and the proper usage of all modifiers.

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