Tuesday, September 14, 2010

CPT modifiers - full overview

What is CPT Modifiers 

CPT Modifiers provide additional information to payers to make sure your provider gets paid correctly for services rendered.

CPT modifiers are used to provide additional information to insurance payers for procedures or services that have been altered or "modified" in some way. It is a prefix modifier to the CPT 5 digit procedure code. These modifiers were developed by the AMA and HCFA and copyrighted by the AMA. The use of modifiers is very important to insure provider services are properly reimbursed. Adding the modifier is the last step in the coding process.

Numeric, Alpha Characters, or Alpha-Numeric

CPT modifiers can be 2 digit numbers ranging from 21 to 99, two character modifiers, or alpha-numeric. The numbering order of modifiers does not necessarily mean modifiers are related to one another just because the numbers are adjacent. New modifiers were assigned based on the availability of numbers with no clear link to the established modifiers. More than one modifier may be used with a procedure code.

CPT modifiers are not applicable to every category of the CPT codes. Some modifiers are only used with a particular category. For example -21, 24, 25, & 27 are only used with Evaluation and Management (E&M) procedures.

Some modifiers are not compatible with others. For example the -50 Bilateral Procedure is not compatible with the -LT (Left Side) and -RT (Right Side) modifiers.

Typically Use Only Two

The UB-04 form allows four modifiers. However the Centers for Medicare and Medicaid Services (CMS) or other payers may not not recognize the third and forth modifiers. It is therefore important to place the modifiers first which will affect reimbursement.Some modifiers are informational only and do not affect reimbursement. Theycan however, determine if the service will be covered or denied.
Other modifiers such as modifier -22 (unusual procedural services) will increase thereimbursement and protocol for many third-party payers if documentation supports the use ofthis modifier. Modifier -52 (reduced services) will usually equate to a reduction in payment.

Modifiers -LT and -RT identify the left and right sides of the body. These are often confused with the -50 Bilateral Procedure modifier. -LT and -RT are only used when the procedure is performed on one side of the body and is and organ that is paired like kidneys, lungs, legs, ears, etc.

Functional Modifiers

When more than one modifier is used, the functional (or pricing) modifier is placed in the first modifier field. The informational modifier is then placed in the second modifier field. A good example is if a provider bused a CPT code with the -22 and the -LT modifier, the -22 is placed first and the -LT in the second modifier field.

If the informational modifier is listed first, the insurance payers system will suspend the claim for manual review and slows claim processing.

2 comments:

  1. what modifier do i use for treating 2 body parts on the same day

    ReplyDelete
  2. what modifier should I use for VA Medicaid for billing OT AND PT for an outpatient on the same day or PT and ST.

    ReplyDelete

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