Modifiers –Reimbursement or Informational?

by  Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
November 8th, 2013

Modifiers are used to help describe the encounter, and used to further explain the procedure to the payer.  Modifiers will be used if the procedure does not fit or clearly explain the entire encounter.   

There are two types of modifiers:

Claims processing requires the pricing modifier in the first position to be processed correctly.   

There are two levels of modifiers used to alter a procedure:

Modifiers are used to help describe the encounter, and used to further explain the procedure to the payer or if the procedure does not fit or explain the entire visit.  Some of the common reasons for using a Modifier may be:

Consider this example, while doing surgery for a wrist repair 25607, during the same procedure a carpal tunnel release 64721 is done, you would append modifier 51 to show the secondary procedure was performed.  Payers have what is called reimbursement edits for reporting code combinations.  If using two codes are stand-alone codes they may be subject to multiple procedure payment reduction. You would append modifier 51 to the procedure that has less value than the primary procedure. You need to be sure special rules are applied when using modifiers.

Using the appropriate modifiers can substantially impact reimbursement.  If you do not report a modifier and the procedure allows a modifier you will not be paid for the procedure.

There are industry standards related to the use of modifiers and reimbursement. While some modifiers change the payment rates some are for informational use only or impacts bundling edits. 

 

Modifier 22

Increased Procedural services

Maximum of 110% of Fee Schedule Allowance/Contracted Rate with supporting documentation

Modifier 50

Bilateral Procedure

150% of Fee Schedule Allowance/Contracted Rate

Submit one line with one unit

Modifier 51

Multiple Procedures

50% of Fee Schedule Allowances/Contracted Rate

for each additional procedure unless procedure is exempt from multiple procedure logic

Modifier 55

Follow up care only

20% of Fee Schedule Allowance/Contracted Rate 

Modifier XE

Separate encounter, distinct service

Informational /impacts bundling

Pricing Modifiers must always be in the first position for correct reimbursement and claim processing.  Use the KD modifier in the first position if there are multiple modifiers used for pricing or payment.

Below is a list of payment modifiers.

Below are links to WPS Medicare with some great information on Modifiers

Modifier

Modifier Definition

AA

Anesthesia service personally performed by anesthesiologist

(Do not file on same claim line with AD, QY, QK, QX, or QZ)

AD

Medical supervision by a physician; more than four concurrent anesthesia procedures 

(Do not file on the same claim line as AA, QY, QK, QX, or QZ)

AS*

Assistant at surgery services provided by a Physician Assistant (PA) or Nurse Practitioner (NP) 

KD**

Drug administered through a durable medical equipment (DME) infusion pump

QK

Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals 

(Do not file on the same claim line with AA, AD, QY, QX, or QZ)

QW

CLIA waived tests

QX

Certified Registered Nurse Anesthetist (CRNA) service: with medical direction by a physician 

(Do not file on the same claim line as AA, AD, QY, QK, or QZ)

QY

Medical direction of one CRNA by an anesthesiologist 

(Do not file on the same claim line with AA, AD, QK, QX, or QZ)

QZ

CRNA service: without medical direction by a physician 

TC

Technical component

26

Professional component

50*

Bilateral Procedure performed at the same session on an anatomical site 

53

Discontinued procedure (only when appended to procedure codes 45378G0105G0121

54*

The surgeon is billing the surgical care only 

55*

Indicate a physician, other than the surgeon, is billing for part of the outpatient postoperative care or used by the surgeon when providing only a portion of the post-discharge post-operative care 

62*

Two surgeons (each in a different specialty) are required to perform a specific procedure 

66*

Team surgeons 

73*

Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC) procedure prior to the administration of anesthesia 

78*

Return to an operating room for a related procedure during the postoperative period 

80*

Assistant at surgery service is provided by a medical doctor (MD) 

81*

To identify minimum surgical assistant services, and is only submitted with surgery codes

82*

Assistant at surgery service provided by a MD when there is no qualified resident available 

 Introduction to Modifiers

 Ranking Modifiers

 Informational Only Modifier Fact Sheet

 Modifier Fact Sheets

 

References:

Modifiers –Reimbursement or Informational?. (2013, November 8). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/modifiers-reimbursement-or-informational-32501.html

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