- Repeat service by the same or different provider (76, 77)
- Increased procedural services (22)
- Reduced service or discontinued procedure (52, 53)
- Identification of professional or technical only component (26, TC)
- Service provided by a resident under physician’s supervision (GC, GE)
These modifiers are separated into two categories:
Payment modifiers: These directly affect the pricing or payment of a service. When reporting more than one modifier, the payment modifier should be placed in the first modifier Payment modifiers 22, 24, 25, 26, 50, 52, 53, 54, 55, 57, 58, 59, 62, 78, AA, AD, TC, QK, QW, and QY affect reimbursement and must always be supported by documentation in the medical record. Overutilization of these modifiers may raise a red flag and prompt payer audits or reviews.
Nationally, overutilization of modifiers 22, 25, and 59 has prompted both the Centers for Medicare & Medicaid Services (CMS) and the Office of Inspector General (OIG) to conduct medical claims reviews. The OIG is expected to publish a report in 2022 on E/M services billed with modifier 25 in conjunction with same-day minor surgical procedures performed by a dermatologist.
- Informational/statistical modifiers: These are placed in the second modifier position. Generally, HCPCS Level II modifiers are reported in the second position when reported with CPT modifiers. The same applies to lateral- ity modifiers.
For example, if a surgical CPT code is reported that requires a laterality modifier (RT, LT) and the surgical procedure is also a difficult or unusual procedure,modifier 22 should be placed in the first modifier position and modifier RT or LT in the second modifier position.
Coding tips for Successful Modifier Use
Here are a few strategies you can implement for proper use of Modifiers:
- Educate coders, billers, and providers on proper modifier
- Utilize an encoder, such as AAPC’s Codify, to validate CMS NCCI CPT/HCPCS Level II modifier combinations upon claim
- Build payer-specific CPT/HCPCS Level II modifier combinations into your practice management system. Claim edits are less expensive to work than claim
- Work claim edits and claim denials daily; fewer days in accounts receivable equals higher
Perform a billing and coding documentation audit at least annually, either internally or by enlisting the help of an outside organization.
[…] Read also: How to sequence Payment and Informational Modifiers with CPT codes […]
[…] modifier is an informational modifier only. An informational modifier is a medical coding modifier not classified as a payment modifier. Another name for informational […]