CPT modifiers are short alphanumeric additions attached to the end of billing codes to provide more accurate information about medical procedures and services.
Modifiers play a huge role in the billing process. They may describe things like:
In short, the information provided by a CPT modifier can make or break the status of a claim. Choosing a medical billing company that understands how to use CPT modifiers helps physicians guarantee that they receive the maximum return on their claims.
At Mediclaim, we pride ourselves on our knowledge and understanding of CPT modifiers and their intricacies.
Our staff knows CPT modifiers inside and out, which ensures an effective and efficient billing process for our customers.
Not everyone uses modifiers properly. Providers and billers often use them incorrectly or disingenuously, which ultimately leads to denied claims and billing headaches.
Insurers are on the lookout for funny business when it comes to CPT modifiers. When they suspect that billers have used modifiers inappropriately, they will request the relevant medical record.
In the best-case scenario, these reviews delay reimbursement. Worse, however, they may lead to claim denials and further difficulties with insurers including an audit.
A few CPT modifiers have earned a special reputation for causing billing confusion. Here, we’ll review the notorious 25, 59, and 78/79 modifiers, plus some tips for their correct usage.
Physicians who bill for evaluation and management (E/M) will often run into the 25 modifiers.
According to CPT guidelines, the 25 represents a “significant, separately identifiable evaluation and management (E/M) service by the same physician on the same day of the procedure or other service.”
To qualify for a 25, an E/M procedure needs to be ‘significantly’ separate from the other services renders. For example, a dermatologist who conducts a biopsy on a suspicious irregularity found during a regular exam might use modifier 25 for billing purposes.
As with other modifiers, the key to using 25 properly is maintaining proper documentation. If you’re a provider, make sure to demonstrate your thought process in your notes or other documents—insurers may very well ask you to prove your case down the line.
Modifier 59 indicates a ‘distinct procedural service.’ It is used to indicate that a provider performed two or more procedures at the same visit, but on different parts of the body.
Sometimes, though, billers use modifier 59 to keep insurers from bundling a procedure with another service in the same claim.
However, billers should only use the 59 to indicate a distinct and separate service. Furthermore, billers should only use the 59 modifiers when no other, more appropriate, and the specific modifier is available.
Modifiers 78 and 79 indicate post-operative procedures. Namely, 78 represents an unplanned, related procedure following the initial service, while 79 indicates an unrelated post-operative procedure.
78 only applies to a related, unplanned procedure in the post-operative period.
A physician can only bill 78 if they did not know that the second procedure would be necessary until after the first procedure concluded. Separate, related, planned procedures do not qualify for modifier 78.
In contrast, 79 indicates an unrelated procedure performed by the same physician in the post-operative period.
As the above modifiers make clear, grasping the fine distinctions between CPT modifiers isn’t always easy.
Luckily, Mediclaim understands CPT modifiers, so you don’t have to. It pays to choose a billing company that understands every part of CPT coding, including proper modifier usage.
When you choose Mediclaim, you can trust that we’ll keep your 25s, 59s, and 78s picture-perfect to minimize claim disputations and maximize payouts.
For more information about our services and medical billing solutions in PA, contact us today!