The Use of Modifiers in Medical Billing

The use of modifiers in medical billing and coding

In medical billing and coding, CPT codes were designed to describe medical procedures and services in detail. However, a CPT code on its own does not always provide a complete picture. Modifiers were introduced to better explain what services took place and also how those services should be reimbursed. That said, applying modifiers correctly can be challenging without a comprehensive understanding of not only the services being rendered but what particular insurance companies will recognize.

General Uses for Modifiers

Modifiers are always two characters and can be a combination of letters and numbers. These are affixed to the end of a CPT code. Some modifiers are purely descriptive, such as RT (right) and LT (left) to indicate the site of the procedure. Others are intended to direct how a procedure is reimbursed by the insurance carrier. Multiple modifiers can be added to a single CPT code, however, this must be done in a certain order. Generally speaking, a modifier that affects payment should be listed first, followed by any modifier that is descriptive in nature.

Multiple Procedures

A commonly needed but often misused modifier in billing is 59. According to and the CPT handbook, modifier 59 is meant to indicate a “distinct procedural difference”.  In other words, this code should only be used when two markedly different procedure methods are implemented during the same session. Modifier 59 should not be used for the sole purpose of preventing procedures from being bundled.   

Reduced Services

Sometimes it is necessary for a provider to indicate that a procedure was aborted or incomplete. According to CPT Appendix A, several modifiers exist for this, dependant on a handful of factors. For instance, when a professional provider chooses to perform a reduced form of the intended procedure, and no other procedure code accurately describes this, modifier 52 should be used. However, if the provider finds that the patient is at risk and the procedure needs to be terminated, modifier 53 is more appropriate.

Modifiers and Insurance Companies

When billing out to an insurance company, it is crucial to know their modifier rules. Improper implementation of a modifier can result in a denial and ultimately bring reimbursement to a halt. Additionally, there are certain modifiers that are required by some insurance carriers in order to be paid. Some, such as PT and 33, have similar meanings but must be selected based upon the payer. Keeping a comprehensive reference guide or list of these modifiers will ensure that claims are paid quickly and correctly.

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