What is a Modifer?

A modifier is a two-digit numeric or alpha numeric character reported with a CPT/HCPCS code,

when appropriate. Modifiers are designed to give Medicare and commercial payers additional
information needed to process a claim.
A modifier provides the means by which a physician can report or indicate that a service or
procedure that has been performed has been altered by some special circumstances(s), but has
not changed in its definition or code. Modifiers also enable health care professionals to effectively
respond to payment policy requirements established by other entities. These codes should be
entered in item 24D on the Form CMS-1500 or electronic equivalent.

Some examples of when a modifier may be appropriate include:
A service or procedure has both a professional and technical component, but both
components are not applicable

A service or procedure was performed by more than one physician and/or in more than

one location

A service or procedure has been increased or decreased in complexity or performance

 

An adjunctive service was performed

 

A bilateral procedure was performed

Unusual events occurred during a procedure or service

Placement of a modifier after a CPT or HCPCS code does not insure reimbursement. A special

report may be necessary if the service is rarely provided, unusual, variable or new. The special
report should contain pertinent information and adequate definition of the procedure or service
performed that supports the use of the assigned modifier. If the service is not documented, or the
special circumstance is not indicated, it is not considered appropriate to report the modifier. A
report should not be submitted unless requested.

Some modifiers are informational only (e.g., -24 and -25) and do not affect reimbursement. They

can however, determine if the service will be covered or denied.
Other modifiers such as modifier -22 (increased procedural services) will increase the
reimbursement and protocol for many third-party payers if documentation supports the use of
this modifier. Modifier -52 (reduced services) will usually equate to a reduction in payment.

There will be times when the coding and modifier information issued by CMS differs from the
AMA’s coding advice in the CPT manual regarding the use of modifiers. A clear understanding
of Medicare’s rules is necessary in order to assign the modifier correctly. It is the responsibility of
each provider or practitioner submitting claims to keep abreast of the Medicare program
requirements.

The use of modifiers is an important part of coding and billing for health care services. Modifier

use has increased as various commercial payers, who in the past did not incorporate modifiers
into their reimbursement protocol, recognize and accept CPT/ HCPCS codes appended with
these specialized billing flags.

Correct modifier use is also an important part of avoiding fraud and abuse or noncompliance

issues, especially in coding and billing processes involving the federal and state governments.
Several of the top billing errors involve the incorrect use of modifiers.

This article courtesy of: http://www.medicarenhic.com/providers/pubs/ModifierBillingGuide0611.pdf