Understanding how to use modifiers is essential to proper reimbursement. This video will review several of the most commonly used modifiers and how to use them appropriately. What is a modifier? A modifier is two digits appended to a CPT code that provides additional information that can be used for payment or tracking purposes. Modifiers also enable health care professionals to effectively respond to payment policy requirements. Here is a list of commonly used modifiers. We will discuss each in further detail. Modifier 25 is used when an office visit or other evaluation and management service is done on the same day as a test or minor procedure. The work required for the E&M service must exceed the normal pre- and post-op care included in the procedure's reimbursement. Modifier 25 should only be used with 10-day global procedures. If the decision for a procedure with a 90-day global is made on the same day of the surgery, use modifier 57. Novitas Solution presents the following questions to ask to determine the appropriateness of using modifier 25. If the answer to one or more of these questions is yes, then the modifier 25 could be warranted. Are there signed symptoms and conditions a physician or other qualified health care professional must address before deciding to perform the procedure or service? Were the physician's evaluation and management of the problem significant and beyond the normal pre-operative and post-operative work? Is there one or more diagnosis present that is being addressed and or affecting the treatment and the outcome? Important guidance to note from CMS. If the procedure was scheduled in advance, it is not appropriate to bill an E&M on the same day and the modifier 25 would not qualify. Modifier 59 is used when there is an NCCI edit in place that states the two codes being billed cannot be billed together due to an unbundling relationship. Modifier 59 is used to indicate that in this particular circumstance, both services should be paid because no unbundling is taking place. In 2015, CMS introduced X modifiers to provide more clarity as to what circumstances are occurring. CMS is currently accepting both modifier 59 and the X modifiers. The X modifiers identify specific situations where the services should not be bundled. These include when the procedures are performed on different anatomical sites, XS, performed during separate encounters, XE, performed by different practitioners, XP, or when a diagnostic service leads to a therapeutic service on the same day, XU. Here is an example from CMS where modifier 59 or XE may be appropriate. Here is an example from CMS where modifier 59 or XU may be appropriate. Modifier 22 is used when unusual circumstances result in services above and beyond that which is normally included in the CPT code. The report must be submitted for review and must clearly indicate why the procedure exceeded the usual service. The documentation should include a statement of the circumstances which should also be clearly documented in the report. The statement should be as specific as possible to the case. Templated statements rarely receive additional reimbursement. Modifier 24 is used when an office visit or other evaluation and management service is performed in the global period of a procedure and the office visit is unrelated to the procedure. Modifier 78 is used for a return to the cath lab or operating room or a procedure that is related to a previously performed procedure and is still within its global period. This modifier applies to procedures with both 10- and 90-day globals. Modifier 79 is used for a return to the cath lab or operating room for a procedure that is unrelated to a previously performed procedure and is still within its global period. This modifier applies to procedures with both 10- and 90-day globals. There are three modifiers used when providing services via telehealth. Modifiers 95 and GT are both for synchronous services. The payer will determine which modifier they prefer. Modifier GQ is used for asynchronous services. Payers have very specific policies when it comes to telehealth. It is important to review all payer requirements to ensure compliance. Most payers also require a specific place of service along with the telehealth modifier. Some require place of service 02 while others require place of service 11 or 12. For accurate reimbursement, be sure you understand how to use payment modifiers. Always review payer policy to be sure of what the payer requires.

modifiers

medical coding

CPT codes

payment

tracking purposes