Thursday, October 6, 2016

Why Modifier is Important and where to report in the claim -

Modifiers provide a means to report or indicate a service or procedure that has been performed has been altered can be altered by a specific circumstance without changing the procedure code. Modifiers are used to increase accuracy in compensation, coding consistency, editing, and to capture payment data.

Tufts Health Plan accepts all standard CPT and HCPCS modifiers submitted in accordance with the appropriate CPT or HCPCS procedure code(s). Certain modifiers, when submitted appropriately, will impact compensation.

Note: The absence or presence of the appropriate modifier may result in a claim denial. 


** Submit the appropriate modifier(s) with the corresponding CPT or HCPCS procedure codes on a CMS-1500 form for professional service in Box 24d Procedures, Services, or Supplies field

** Submit the modifier(s), when appropriate, in front of the corresponding CPT or HCPCS procedure codes on a UB-04 form for hospital services in Box 44 HCPCS/Rates field. Modifiers submitted after the procedure code may be incorrectly processed in the Tufts Health Plan system and delay payment or result in a denial.

Note: Annually and quarterly, HIPAA medical code sets3 undergo revision by CMS, AMA and CCI. Revisions typically include adding, deleting or redefining the description or nomenclature of new HCPCS, CPT procedure and ICD-CM diagnosis codes. As these revisions are made public, Tufts Health Plan will update its system to reflect these changes.

Additional Billing Information on Basic Modifiers

** Append modifier 26 to indicate the professional component that requires the use of a modifier whether in an office, inpatient or outpatient

** Append modifier TC to indicate the technical component that requires the use of a modifier, whether in an office, inpatient or outpatient setting.

** Submit global services on one line. Do not append a modifier when submitting claims for global services; providers should only bill globally when they have performed both the PC/TC components in an office setting.

** Append modifier 50 (bilateral procedure) to bilateral surgical procedure code(s) that require the use of a modifier.

** Submit bilateral surgical procedure code(s) on one claim line/service line with one unit.

** Append modifier 51 (multiple procedures) to surgical procedures that require the use of a modifier, that are billed in addition to the primary surgical procedure.

EDI Claim Submitter Information

** Submit claims in HIPAA compliant 837I format for institutional claims. Claims billed electronically with non-standard codes will reject.

** Claims submitted with non-standard modifiers will be rejected if submitted electronically.

Paper Claim Submitter Information

** Submit claims on an official claim form for professional services. Claim line(s) billed with non-standard codes will deny.

** All paper claims must be submitted on the official red claim forms. Black and white versions of these forms, including photocopied and faxed versions, will not be accepted and will be returned with a request to submit on the proper claim form.

** Submitted forms deemed incomplete will be rejected and returned to the submitter. The rejected claim and a letter stating the reason for rejection will be returned to the submitter, and a new claim with the required information must be resubmitted for processing.

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