Do you know that you can get into serious trouble if you use incorrect modifiers in medical billing? Even worse, if you have used the wrong modifier and the insurance company or payor had paid you for the service attached with a modifier, you have to return their money. In short, it can be a costly mistake when claims are made on the wrong modifiers. As a provider, you must know what is a modifier in medical billing, when to use and when not to use modifiers to modify the reimbursements or maximize the payments in order to avoid claim denials.
Here are some common modifiers, and red flags that you should constantly watch for in the medical billing process.
What is a modifier in medical billing?
Modifiers are used to give a concise view of the medical billing demonstrating the type of services and procedures provided by the physician or healthcare organization. These codes are added to Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) for a similar purpose.
It becomes more complex to understand the right use of modifiers when insurance companies or third-paying parties make their own rules of how these modifiers are used while doing HCPCS or CPT billing. It is also important to understand that it is not specifically correct to use all modifiers along with CPT or HCPCS codes while medical billing.
The federal government and Healthcare organizations keep changing the rules for medical coding and billing. Therefore, it is also necessary to keep yourself updated with the Local Coverage Determination (LCD), Medicare Administrative Contractors (MAC), and National Coverage Determinations (NCD) to claim and code your bills correctly.
Misuse of modifiers
Many times, providers remain unaware of the new updates in the coding and billing systems and here they make mistakes and add wrong modifiers. Hence, it is necessary to avoid using wrong modifiers because they can bring serious consequences for the modifiers and might lead to a critical audit.
Unfortunately, the audit performed due to the wrong modifier use can lead to hefty legal ramifications along with heavy fines. The audit is not necessarily finished after a conviction but can last for years. If the misuse of modifiers were found in Medicare billing, fines can go up to $10,000 for every wrong entry. This means whenever you use a wrong modifier in your claim, you’ll have the legal obligation to pay $10,000 for every occurrence. And believe us, that adds up rapidly.
What are HCPCS and CPT codes in medical billing?
HCPCS are alpha-numeric five-character code sets that are used to bill Medicaid and Medicare patients. These codes are used for the patients who receive the services of a physician, procedures, and the equipment for their health conditions that are covered by the CPT codes.
CPT codes, however, are five-character codes of four types designed and issued by the American Medical Association. For these codes, two-character modifiers are used to elaborate any type of procedure the patient has received from the assigned doctor. These CPT codes are both numeric and alphanumeric.
Advantages of adding modifiers
Unless modifiers are used correctly, they cannot help you gain anything but may cost everything. The correct use of modifiers aid in;
- Minimizing the claim denial rate and making your claims clean and accurate
- Claims are submitted more precisely with a significantly higher level of coding. So, the high and quick reimbursements can be expected
- Claims are approved in a timely manner without creating a revenue gap due to denials, resubmitting, and follow-ups. Physicians are compensated for the services they rendered no matter the nature of the case. These codes specify the exact equipment, service, or procedure the patient has taken.
Common Types of Modifiers
Level I Modifiers: CPT modifiers are also called Level I modifiers and are managed and updated by the American Medical Association (AMA) annually.
Level II Modifiers: HCPCS of Level II Modifiers are a combination of numbers and alphabets. These modifiers are regulated by the Center for Medicare and Medicaid Services (CMS).
Common Modifiers in the Medical Billing codes
- GQ – GQ modifier is used for the services rendered over an asynchronous telecommunication system. It is the system where a physician gathers the medical history of a patient, pathology reports, and images and sends them over to a senior medical practitioner to review and have their opinion on the treatment and diagnosis.
- 95 or GT – Modifier 95 or GT can be used when all the evaluation treatments and diagnoses are meant to be coded via telemedicine. This modifier can only be applied when the treatment and medicines were given only over a telecommunication system either via phone or video commutation. When there’s an insurance payer, code 95 would be written as GT.
- GO– GO modifier is used to code the acute stroke telehealth services offered.
- Modifier 24 – The code is used to append the unmatched management and evaluation services offered after the procedures of major surgeries. These codes must be applied if the post-procedure services are rendered over 90 days of period by the same surgeon. However, the modifier cannot be used to bill for these services.
- Modifier 25 – It is commonly used by pediatrics. It is used to connect all the evaluations and management performed by the same surgeon on the same day.
- Modifier 26– Modifier 26 is used to bill the services performed by both physicians and technicians. It is to understand that this modifier can also be used for technical services such as radiology. Note that the scan performed by the physician or technician will be considered the professional service offered and the machinery would be considered the technical component used in the service.
- Modifier 27 – This modifier can be used for a variety of reasons. This includes when the patient is offered multiple evaluation and management services from the same or different surgeons, used clinical service, pharmacy, and primary care on the same day.
- Modifier 51– Modifier 51 is used to bill for multiple services and procedures offered to the patient by the same provider but in a single procedural setting or surgical session.
If the modifiers are not written correctly or not routed correctly for payers, it is a high chance of getting them denied. For this, it is essential for billers and coders to avoid related issues and minimize the claim denials by using the correct modifiers.