Saturday, May 8, 2010


A modifier is a two-digit numeric or alpha numeric character reported with a HCPCS code, when appropriate.

Modifiers are designed to give Medicare and commercial payers additional information needed to process a claim. This includes HCPCS Level 1 (CPT) and HCPCS Level II codes.

A modifier provides the means by which a physician can report or indicate that a service or procedure that has been performed has been altered by some special circumstances(s), but has not changed in its definition or code. Modifiers also enable health care professionals to effectively
respond to payment policy requirements established by other entities. These codes should be entered in item 24D on the Form CMS-1500 or LOOP 2400 SEGMENT SV101.
Some examples of when a modifier may be appropriate include:

• A service or procedure has both a professional and technical component, but both components are not applicable.
• A service or procedure was performed by more than one physician and/or in more than one location.
• A service or procedure has been increased or decreased in complexity or performance.
• An adjunctive service was performed.
• A bilateral procedure was performed.
• Unusual events occurred during a procedure or service.

Placement of a modifier after a CPT or HCPCS code does not insure reimbursement. A special report may be necessary if the service is rarely provided, unusual, variable or new. The special report should contain pertinent information and adequate definition of the procedure or service
performed that supports the use of the assigned modifier. If the service is not documented, or the special circumstance is not indicated, it is not considered appropriate to report the modifier. A report should not be submitted unless requested.

Some modifiers are informational only (e.g., -24 and -25) and do not affect reimbursement. They can however, determine if the service will be covered or denied.

Other modifiers such as modifier -22 (unusual procedural services) will increase the reimbursement and protocol for many third-party payers if documentation supports the use of this modifier. Modifier -52 (reduced services) will usually equate to a reduction in payment.

There will be times when the coding and modifier information issued by CMS differs from the AMA’s coding advice in the CPT manual regarding the use of modifiers. A clear understanding of Medicare’s rules is necessary in order to assign the modifier correctly. It is the responsibility of each provider or practitioner submitting claims to keep abreast of the Medicare program

No comments:

Post a Comment

Most read cpt modifiers