Accurate coding is crucial for the reimbursement of any medical claim. However, while reimbursement is important for a healthcare practice’s revenue cycle, what really sets a profitable practice apart from the ones making ends meet is how fast the claims are processed and reimbursed. And what determines swift claim approval? Coding specificity!
So, while you can ensure coding accuracy through the relevant service and procedural (CPT/HCPCS) codes, you must also pay attention to coding specificity for faster claim acceptance. You can do that through two-digit codes, called modifiers, like modifier 99.
However, there are several technical guidelines, dos and don’ts, and other important factors to consider when appending the 99 modifier to codes. Let’s discuss these in this guide.
Modifier 99: Understanding the Basics
There may be instances, such as complex medical procedures, where more than one modifier is required to report supplemental information about the service or procedure, or to fully capture the circumstances in which the service or procedure was performed. Simply speaking, in such cases, a single modifier may not explain the medical procedure entirely.
But what if it takes more than four modifiers to accurately describe a service?
This is where modifier 99 comes into play. 99 can only be used if a single line item needs more than four modifiers to explain the service.
Why is This the Case?
Using modifier 99 is conditional because of the Health Insurance Claim form. For instance, on the standard CMS-1500 form (or its digital version), field 24D is used to report the applicable modifiers. However, only four blank spaces are available on each claim line to report the relevant modifiers.
So, if the situation requires more than four modifiers to explain a service, then only modifier 99 should be used in the first blank space/box. The rest of the modifiers for the particular scenario should be added to field 19 of the form, which is reserved for ‘Additional Claim Information’.
Therefore, it is safe to say that the 99 modifier is a highly effective tool for medical billing professionals for two reasons.
Number 1, it clarifies that more than four modifiers are applicable to the procedural code. Number 2, it contributes to coding accuracy and specificity in medical billing, reducing the chances of a claim denial.
Note: Some payer systems, including Medicare’s automatic claim processor, may handle multiple modifiers differently. Also, note that while some payers want you to report modifier 99 only if more than four modifiers are applicable, others may want you to report the first three, and then 99 in the fourth box.
Accurate Usage Guidelines for Modifier 99
The following are the guidelines that medical billing teams should keep in mind when using this modifier.
Use the Modifier for the Correct Instance
Modifier 99 can only be used where four or more modifiers apply to a single code to explain the procedure or service, which is rare in real-world clinical scenarios.
Justify Its Use with Documents
The medical billing team should justify every modifier’s usage with appropriate documentation, proving its necessity.
Ensure Correct Sequence of Modifiers
Since modifier 99 represents more than four modifiers, you must ensure that these modifiers are reported in the right sequence in field 19. Typically, pricing modifiers are reported first, followed by payment, location, and then informational modifiers.
When Not to Use Modifier 99
- Cases where 4 or fewer modifiers are reported in total.
- If the payer’s system can handle multiple modifiers without the 99 modifier.
- When split-billable or shared rules apply. Because using modifier FS (indicating a split/shared visit) and 99 together confuses the claim scrubbing software.
Additional Tips for Modifier 99
We recommend:
Learning How to Report the Modifier
Reporting the modifier has its designated sequence. Start by entering the modifier in the 24D slot. Next, enter the detail line specific extras in the 19th field. Lastly, always check the payer guidelines, since Medicare may skip it for electronic systems.
Checking Payer-Specific Guidelines
Modifier 99 may not apply to electronic submissions because Medicare allows multiple modifiers directly. Similarly, commercial payers may require the modifier for all other modifiers used in the reporting.
Lastly, Medicaid policies may be different in each state. Therefore, it is crucial to review payer manuals.
Final Thoughts on Modifier 99
Modifier 99, although used rarely today, used to come in quite handy during paper-based claim submissions. It is used to inform the payer that multiple modifiers are applicable to the service or procedural code. This translates to higher coding accuracy, specificity, and rightful reimbursements without delays or denials.
However, for professionals who still find the modifier’s description and usage challenging, our medical billing and coding services are here to help. Our certified coders are experts at detecting missing and misused modifiers, protecting your claims from denials.
