Medical Billing Tips: How (and How Not) to Use Common Modifiers

Billing modifiers help with the accuracy of recording and managing medical billing procedures. These modifiers provide information about CPT or HCPCS codes. They help identify complicated medical procedures performed in a session. 

Before, a saying in medical billing states: "If the procedure is not documented, it is not done." Given the nature of how complex a medical procedure can be, the need to record the exact process arose. Codes determine the evidence of a specific procedure performed. 

Billing modifiers increased the accuracy of the entire medical billing process. Reimbursements and claims are now easier to process. 

The CPT Code

Current Procedural Terminology or CPT. The American Medical Association (AMA) published CPT for outpatient and office settings. You can identify the CPT code as the five-digit number code.

The CPT Code Modifier

The CPT code modifier is the two-digit code appended to the five-digit CPT code. They describe the E/M - Evaluation, and Management performed in a regular office visit.

The HCPCS Code Modifier

The Healthcare Common Procedure Coding System or HCPCS. Medicare and commercial payers use these codes, depending on a given circumstance. You can identify these codes as two alpha digits, two alphanumeric digits, or a single alpha digit.

How to Use the CPT and HCPCS Codes

Private and government payers have their own set of guidelines. The CPT codes are acceptable to both. But, it's still essential to follow their guide, in which code to use.

It is expected that one procedure requires a CPT code for one payer and an HCPCS code for another. You must contact the payers to verify their accepted codes. It is best to confirm the medical equipment, vaccines, or medicines codes.

Tip: Use billing codes and modifiers according to the payer's guidelines at all times. They determine which code to use in a procedure. 

Common CPT Modifiers

CPT Modifier 22

• This CPT modifier identifies increased procedural service or workload.
• Tip: Use procedures with increased technical difficulties. 
• Example: Excessive bleeding during surgery. 

CPT Modifier 25 

• This CPT modifier describes a significant, identifiable service performed in a procedure. 
• Tip: Use with an E/M code. 
• Example: Two distinct diagnoses by one doctor in a single visit.

CPT Modifier 26

• This CPT modifier identifies the professional CPT service with a global definition. ( Technical and Professional).
• Tip: Use when the provider reads a diagnosis report from a different provider group. 
• Example: A doctor receives an ultrasound result done from a different clinic.

CPT Modifier 50

• This modifier identifies a procedure on both sides of the patient's body. 
• Tip: Before using this code, check the CPT definition. Determine if bilaterally is omitted.
• Example: Surgery on both sides of the body like arms, shoulders, or legs.

CPT Modifier 59

• This modifier identifies specific procedural services not reported together. 
• Tip: Always include complete documentation when using this modifier.
• Example: Two separate visits in one day involving different body parts. 

CPT Modifier 52

• This modifier identifies reduced services. 
• Tip: Use this code when a doctor opts out or discontinues a procedure or service.
• Example: When a patient refuses to cooperate with the doctor. 

CPT Modifier 51

• This modifier identifies multiple procedures.
• Tip: Use this code when a doctor performs multiple procedures in one session.
• Example: If the doctor requires two x-rays for evaluation. 

Common HCPCS Medicare Modifiers

Medicare modifiers describe the location of the procedure performed in the body. The modifiers RT - Right side and LT are the most common. 

Eyelid Modifiers

The level II HCPCS Medicare claims need eyelid modifiers. Here's the list:

• Epilation: 67820 – 67805.
• Punctal plug procedures: 68760 – 68761.
• Chalazion excision: 67800 – 67805.

• E1 – Procedures or services performed on the upper-left eyelid.
• E2 – Procedures or services performed on the lower-left eyelid.
• E3 - Procedures or services performed on the upper-right eyelid.
• E4 - Procedures or services performed on the lower-right eyelid

The four HCPCS modifiers to describe modifier 59 are:

• XE -  HCPCS modifier describing a separate encounter
• XS -  HCPCS modifier describing a separate structure
• XP -  HCPCS modifier describing a separate practitioner 
• XU -  HCPCS modifier describing a separate  unusual service 

Paying close attention to the medical coding modifiers can keep you out of deep water. Avoid denials and increase your billing services every time. Keep in mind that accuracy is the key to a smooth billing process.

CPT and HCPCS modifiers should always be correct and appropriate. Payment modifiers are confusing if not recorded in the right way. We hope that this article enlightened your mind about medical billing modifiers. Always remember to pay attention to these small details at all times.

Partner with DrCatalyst

If you're interested in how to optimize your medical coding services, call us today.

At DrCatalyst, we make sure that billing modifiers are accurate and correct. Claim rejections play no part in our service. Rest assured that our team checks the valid format and data requirements. We specialize in correcting coding errors to get you paid faster.

We can also help submit an appeal on your behalf for claim denials. It is unfortunate that resubmitting a denied claim is not possible. Our goal is to help you avoid those kinds of situations. 

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