Skillful use of modifiers can generate tens of thousands of dollars in reimbursements a year. On a claim, attaching the two-digit modifier to a CPT code tells the payer that the service or procedure was altered by some circumstance. “When you bill, you don’t generally send other notes or documentation with a claim, so modifiers explain and eliminate questions,” Sheffield says.
One of the most common errors made with modifiers is assigning one to the wrong code group. CPT codes fall into two groups: procedure and evaluation and management (E/M). Some modifiers have a similar meaning but can only be used in one group. For instance, modifier 25 only works with an E/M code. “It means that particular service was done for a separate reason from the office visit, so you deserve additional reimbursement,” Sheffield says. The modifier with a similar meaning in the procedure group is 59.
“If you mess those up, you don’t get paid for a service,” Sheffield says. For instance, if a facility billed for both indirect and direct rehab in the same visit without a modifier, they miss out on a reimbursement for one of those services every time the error occurs.
Maximizing the earning potential of modifiers requires knowing more than the definitions of each modifier. Each commercial payer also follows different rules for their use. “You can charge for a venipuncture to send out blood for analysis with a 90 modifier,” Sheffield says. “But only some payers cover using the 90 modifier – others do not want a modifier.” The reimbursement averages $3. “Which doesn’t sound like much, but if you do 30 a week it adds up,” she says. In 5 years, it would total over $23,000.
Modifiers can also validate reimbursements during the global period of a procedure or service when anything more done with that patient pertaining to that original condition is not billable. For E/M codes, use, 24; for procedures, 79.
Global periods can also extend prior to the condition designated by the code, such as with surgery. Usually anything done the day prior to the procedure is included in the global period, including office visits. “But if you decide to do surgery on the same day that someone comes to see you, then append the 57 modifier to get reimbursement for that office visit outside the global package,” Sheffield says. The modifier tells the payer the patient came in for an office visit and a sudden decision for surgery was made during that visit.
Modifiers can also justify what appears to be two disparate codes. For instance, a physician can get reimbursements for both a well visit and a sick visit in the same visit. A patient may come in for an annual exam (a well visit) but then complain of an earache (a sick visit). “You can bill for both on the same visit if your documentation backs it up,” Sheffield says. “That’s another use for your 25 modifier.”
Physicians may also be required to perform certain tasks that may seem superfluous or questionable to a payer. A 32 modifier signals that the service was mandated. “Like if you’ve got someone requiring a second opinion before a surgical procedure, you can use modifier 32 to indicate that you’re essentially being made to do this,” Sheffield says. “This one doesn’t really get you a higher reimbursement, but it might get you the normal reimbursement rather than nothing.”
One of the more complex examples of the use of modifiers comes into play with chronic conditions. If a patient has sinusitis and also has chronic problems, like high blood pressure and diabetes, additional reimbursements can be earned with the right modifier.
For instance, if the physician gives an antibiotic injection for sinusitis, the injection reimbursement would normally be bundled into the sinusitis-focused office visit. “But you can bill for both the office visit and for administering the shot — in addition to the antibiotic itself, that’s a different code — with a 25 modifier,” Sheffield says.
When you append a 25 modifier to the office visit, “you show that the office visit had to do with something beyond the sinusitis, because other conditions had to be taken into consideration,” Sheffield says. “Those conditions make for a more complicated visit, so you can code with modifiers to earn the maximum reimbursement from that.”
The change to ICD-10 coding will not be affecting E/M codes, procedure codes, or modifiers for outpatient billing at this point. “You’ll be using the same modifiers that you’ve been using the last 10 years or so,” Sheffield says. But she recommends that practices learn all they can about modifiers. “They make you more money and help you avoid having to refile claims,” she says. “How is that not a worthwhile investment?”