All about medical billing, coding and claims modifiers

The importance of using appropriate modifiers:

The doctor performed multiple procedures

2. The procedures performed are bilateral

3. The E/M service is completed on the same day of the program.

4. Program increases or decreases

The program has both expertise and technical parts.

6. The procedure is performed by other providers [anaesthetists, surgeon physiotherapists, speech pathologists, etc.].

7. Perform surgery on either side of the body

8. E / M services are provided during the postoperative period

9. E/M service has a surgical decision

10. Unusual situation

Use the correct modifiers to maximize your reimbursement for bilateral programs.

Bilateral modifier [-50]

Depending on the insurance payer, the bilateral procedure for processing claims should be paid 150%

Medicare Part B requires a two-line program code and modifier 50. They typically process claims with 150% reimbursement. But again, you must check this in your state and in your area.

Some commercial insurance prefer two lines of the same code, one at a time 50, the second time without 50. Then the second modifier of the first line is RT or LT, the second line of modifiers RT or LT, each code has 1 Service units. Must be reimbursed 150%

Some commercial insurance prefers two lines of the same code, each with a modifier LT or RT, and each code has 1 service unit. Must be reimbursed 150%

If the program code can be billed as a bilateral J, be sure to check your physician fee schedule.

Use the LT&RT modifier to specify on which side of the procedure the surgeon completes the procedure. In my experience, the Medicare B part requires a specific modifier, LT or RT. For example, you can report process 64626 on the right C4-C7 facet joint ablation as 64626-RT.

Modifier -26. Professional components.

Example: Reporting program code 77003 - for spinal or subcutaneous subcutaneous diagnostic or therapeutic injection procedures [epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint or ankle joint] The fluoroscopic guidance and positioning of the needle or catheter tip, including neurolysis agent destruction] uses the modifier -26 to indicate that the professional component of the physician is only reimbursed rather than technical. Do not attach the -26 modifier if the provider's office has a fluoroscopy device.

Modifier -25. An important, individually identifiable assessment and management service is performed by the same physician on the same day's program or other services.

Example: Use modifier 25 to report E/M code 99213 [office or other outreach visit to evaluate and manage established patients], program code 20610 complete knee injection on the day of surgery. Modifier-25 indicates the importance and separate identifiable E/M services in addition to the procedure performed on the patient. Do not use modifier -25 to report E/M services for initial decisions on surgery.

Instead use the modifier -57 for surgical decision making

Modifier-24. Post-operative physician-independent assessment and management services

Example: If the patient comes back during the postoperative period, the modifier 24 is used to report the E/M code 99213. The doctor must identify the service as completely unrelated to the procedure recently performed on the patient. Detailed medical documentation is a good support for medical necessities.

Modifier -51 for multiple programs.

Modifiers for different program services - 59

Modifier-GP service presented according to the outpatient physiotherapy care plan
from

  Modifier-GO service proposed under the outpatient occupational therapy and care plan

Modifier-GN services are presented according to outpatient language pathology care plan

Be sure to check out the latest CPT manual. Check the CMS CCI editor. View insurance payer policies and guidelines.

What you don't know may hurt you. If you don't know, don't do it. Find it.

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