Importance of Using Proper Modifiers:
The physician performed multiple procedures
The procedure performed was bilateral
The E/M service was done on the same day of the procedure
The procedure was increased or decreased
The procedure has both professional and technical component
The procedure was performed by other provider (Anesthesiologist,
Surgeon Physical Therapist,
Speech Pathologists etc.)
Procedure on either one side of the body was performed
The E/M service was provided within the postoperative period
The E/M service resulted to Decision of Surgery
Unusual Circumstance
Maximize your reimbursement for bilateral procedures by using the
correct modifier.
Bilateral Modifier (-50)
Depending upon the insurance payer, processing claims with
bilateral procedure should be paid 150%
Medicare Part B requires one single line of bilateral procedure code
with Modifier 50. They normally
process the claim with 150% reimbursement. But again, you have to
check on this in your state and in
your region.
Some commercial insurance would prefer Two Lines of the same
code, once with 50, second without
50. Then second modifier on the 1st line is RT or LT, modifier RT or
LT on second line, with 1 unit of
service each code. Must be reimbursed at 150%
Some commercial insurance would prefer two lines of the same code
with modifier LT or RT on each
line with 1 unit of service each code. Must be reimbursed at 150%
Always check on your Physician’s Fee Schedule if the procedure
code is billable as bilateral
Using LT & RT modifier is used to specify which side of the body the
procedure was done by the
physician. Medicare Part B based on my experience requires specific
modifier, either LT or RT.
Example you may report procedure 64626 done on the Right C4-C7
Facet Joint Nerve Ablation as
64626-RT.
Modifier -26. Professional Component.
Example: Report procedure code 76005 - Fluoroscopic
guidance and localization of needle or
catheter tip for spine or paraspinous diagnostic or therapeutic
injection procedures (epidural,
transforaminal epidural, subarachnoid,, paravertebral facet joint,
paravertebral facet joint nerve or
sacroiliac joint) including neurolytic agent destruction) with modifier
-26 to indicate the physicians
Professional Component only reimbursement and not technical
component. If the provider’s office owns
the fluoroscopic equipment, do not append -26 modifier.
Modifier -25. Significant, Separately Identifiable Evaluation and
Management Service by the Same
Physician on the Same Day of the Procedure or Other Service.
Example: Report E/M code 99213 (Office or other outpatient
visit for the evaluation and
management of an established patient) with Modifier -25 for
procedure code 20610 Knee Joint
Injection done on the same day of the procedure. Modifier -25
indicates significance and separate
identifiable E/M service outside the procedure done on the patient.
DO NOT use modifier -25 to report
E/M service that resulted for initial decision for surgery.
Instead use modifier -57 for Decision for Surgery
Modifier -24. Unrelated Evaluation and Management Service by the
Same Physician During
Postoperative Period
Example: Report E/M code 99213 with Modifier -24 if the patient
came back during the
postoperative period. The physician must identify this service as
completely unrelated with the recent
procedure done on the patient. A detailed medical documentation is
a good support for medical
necessity.
Modifier -51 for Multiple Procedures.
Modifier -59 for Distinct Procedural Service
Modifier –KX Specific Required Documentation on File
Medicare requires Outpatient Physical Therapy & Speech Therapy
provider affected by the Therapy
cap to append a second Modifier –KX if the beneficiary is on
exception and his diagnosis is considered
under the list of automatic exemptions for automatic process or
manual process.
Modifier-GP Services Rendered under Outpatient Physical
Therapy plan of care
Modifier-GO Services Rendered under Outpatient
Occupational Therapy plan of care
Modifier -GN Services Rendered under Outpatient Speech
Pathology plan of care
The physician performed multiple procedures
The procedure performed was bilateral
The E/M service was done on the same day of the procedure
The procedure was increased or decreased
The procedure has both professional and technical component
The procedure was performed by other provider (Anesthesiologist,
Surgeon Physical Therapist,
Speech Pathologists etc.)
Procedure on either one side of the body was performed
The E/M service was provided within the postoperative period
The E/M service resulted to Decision of Surgery
Unusual Circumstance
Maximize your reimbursement for bilateral procedures by using the
correct modifier.
Bilateral Modifier (-50)
Depending upon the insurance payer, processing claims with
bilateral procedure should be paid 150%
Medicare Part B requires one single line of bilateral procedure code
with Modifier 50. They normally
process the claim with 150% reimbursement. But again, you have to
check on this in your state and in
your region.
Some commercial insurance would prefer Two Lines of the same
code, once with 50, second without
50. Then second modifier on the 1st line is RT or LT, modifier RT or
LT on second line, with 1 unit of
service each code. Must be reimbursed at 150%
Some commercial insurance would prefer two lines of the same code
with modifier LT or RT on each
line with 1 unit of service each code. Must be reimbursed at 150%
Always check on your Physician’s Fee Schedule if the procedure
code is billable as bilateral
Using LT & RT modifier is used to specify which side of the body the
procedure was done by the
physician. Medicare Part B based on my experience requires specific
modifier, either LT or RT.
Example you may report procedure 64626 done on the Right C4-C7
Facet Joint Nerve Ablation as
64626-RT.
Modifier -26. Professional Component.
Example: Report procedure code 76005 - Fluoroscopic
guidance and localization of needle or
catheter tip for spine or paraspinous diagnostic or therapeutic
injection procedures (epidural,
transforaminal epidural, subarachnoid,, paravertebral facet joint,
paravertebral facet joint nerve or
sacroiliac joint) including neurolytic agent destruction) with modifier
-26 to indicate the physicians
Professional Component only reimbursement and not technical
component. If the provider’s office owns
the fluoroscopic equipment, do not append -26 modifier.
Modifier -25. Significant, Separately Identifiable Evaluation and
Management Service by the Same
Physician on the Same Day of the Procedure or Other Service.
Example: Report E/M code 99213 (Office or other outpatient
visit for the evaluation and
management of an established patient) with Modifier -25 for
procedure code 20610 Knee Joint
Injection done on the same day of the procedure. Modifier -25
indicates significance and separate
identifiable E/M service outside the procedure done on the patient.
DO NOT use modifier -25 to report
E/M service that resulted for initial decision for surgery.
Instead use modifier -57 for Decision for Surgery
Modifier -24. Unrelated Evaluation and Management Service by the
Same Physician During
Postoperative Period
Example: Report E/M code 99213 with Modifier -24 if the patient
came back during the
postoperative period. The physician must identify this service as
completely unrelated with the recent
procedure done on the patient. A detailed medical documentation is
a good support for medical
necessity.
Modifier -51 for Multiple Procedures.
Modifier -59 for Distinct Procedural Service
Modifier –KX Specific Required Documentation on File
Medicare requires Outpatient Physical Therapy & Speech Therapy
provider affected by the Therapy
cap to append a second Modifier –KX if the beneficiary is on
exception and his diagnosis is considered
under the list of automatic exemptions for automatic process or
manual process.
Modifier-GP Services Rendered under Outpatient Physical
Therapy plan of care
Modifier-GO Services Rendered under Outpatient
Occupational Therapy plan of care
Modifier -GN Services Rendered under Outpatient Speech
Pathology plan of care
All about Medical Billing & Claims Modifiers:
As Summarized by: Ms. Pinky Mcbanon
Senior Medical Billing Specialist (Dansalan Group, Inc.)
As Summarized by: Ms. Pinky Mcbanon
Senior Medical Billing Specialist (Dansalan Group, Inc.)
| If you think you were underpaid or were not properly reimbursed with the services you rendered, one possible reason is because proper modifiers were not used or no modifiers were used. Contact us and we will show you how efficient and knowledgeable we are with proper use of modifiers on medical claims. |
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