Monday, April 12, 2010

What is Modifiers

Part A Modifiers - Medicare

Introduction
A modifier is a two position alpha or numeric code that is added to the end of a HCPCS code to

clarify the services/procedures that are performed on the same calendar day. The dash that is
often seen preceding a modifier should never be reported.

Modifiers provide a means by which a service can be altered without changing the procedure
code. They add more information, such as anatomical site, to the HCPCS code. In addition, they
help to eliminate the appearance of duplicate billing and unbundling.

There are CPT-4 and Level II HCPCS modifiers. They are used to increase accuracy in
reimbursement, coding consistency, editing and to capture payment data.


NOT ALL HCPCS CODES WILL REQUIRE MODIFIERS.

This guidelines of when a modifier is required. A modifier should NOT be used to indicate:

• An anatomical site location on body if the narrative definition of a HCPCS code indicates
multiple occurrences

EXAMPLE: 73565 (Radiological examination, both knees, standing, anteroposterior).
It would be inappropriate to apply a modifier because the definition of this
Particular HCPCS code (73565) includes “both knees”.

• An anatomical site if the narrative definition of a HCPCS code indicates the procedure
applies to more than two sites.

EXAMPLE: 11600 (Excision, malignant lesion including margins, trunk, arms, or legs;
excised diameter 0.5 cm or less)
It would be inappropriate to apply a modifier to identify a particular anatomical site on the body when it is included (along with other anatomical sites) in the HCPCS code description.

When it is appropriate to use a modifier, the most specific modifier should be used first. Up to two (2) sets of modifiers can be used per line item. Level I modifiers should generally be used before Level II HCPCS modifiers. However, when modifiers E1 through E4, FA through F0, LC, LD, RC and TA-T9 apply, they should be used before modifiers LT, RT, or –59.

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