Have you ever faced a situation in which a perfectly documented and well-prepared claim gets denied? This may be because of a missing or incorrect 2-digit code.
After the procedural codes, modifiers are probably the most important part of a claim. That’s because they tell the insurance payers the exact story of the provided service. Without them, payers will remain oblivious to the actual circumstances in which a service or procedure was performed, and most likely deny your claims.
Since they are so important, we decided to create a detailed guide on modifiers in medical billing and how to use them properly in your claims.
So, let’s start.
Modifiers in Medical Billing – A Brief Description
At its core, a modifier in medical billing is a two-character code, either numeric or alphanumeric. It is appended to a Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) code. The basic function of a modifier is to provide additional information about the medical service or procedure performed, without changing the definition of the code itself.
The modifiers are specific and standardized. They are maintained by two authoritative bodies. The American Medical Association (AMA) maintains Level I (CPT) modifiers, while the Centers for Medicare & Medicaid Services (CMS) maintains Level II (HCPCS) modifiers.
This all sounds very complex. So, let’s try to understand modifiers in medical billing with an example.
An Example of Modifiers in Medical Billing
Suppose that a patient comes to your clinic to get an X-ray of his left arm. You perform the X-ray and bill it with the correct CPT code. But how will you specify that the X-ray was performed on the left arm? Without modifiers, there is no way of doing this.
In this case, you can use the modifier ‘LT’ to indicate that the left arm was imaged. If, later, the patient returns to have his right arm imaged, you can simply use the same CPT code with the modifier ‘RT’.
Why Do We Use Modifiers in Medical Billing?
The use of modifiers is fundamentally about communication and compliance. When a claim is submitted without the necessary context, automated payer systems often default to the most conservative interpretation of the service, which frequently results in denial or reduced payment.
We use modifiers in medical billing to achieve several critical outcomes:
- Submit Cleaner, More Accurate Claims: Modifiers clarify the “who, what, where, and why” of a procedure.
- Avoid Claim Denials and Bundling Issues: Payers use automated edits (like NCCI edits) to bundle services together. Modifiers can help you bypass these edits when appropriate.
- Obtain Proper Reimbursements: Sometimes modifiers can allow you to get more money for a service than what is permissible by the CPT code. For example, in the case of bilateral surgeries or when an assistant helps you with the procedure, you can use the appropriate modifiers to get up to 150% reimbursement.
- Ensure Compliance: Using modifiers correctly demonstrates adherence to payer policies and AMA guidelines.
Types of Modifiers in Medical Billing
Now that we have discussed what modifiers in medical billing are and why they are important, let’s take a look at the different types of modifiers:
Level I (CPT Modifiers)
These are two-digit numeric codes (e.g., 25, 59, 50). They are maintained and copyrighted by the AMA. These modifiers are primarily used with CPT codes to identify variations in medical procedures and services performed by physicians. They cover a wide range of scenarios, from surgical alterations to evaluation and management (E/M) circumstances.
Level II (HCPCS Modifiers)
These are alphanumeric codes consisting of two letters or one letter and one number (e.g., LT, RT, TC, P1-P6). The CMS maintains them. While they can be used with CPT codes, they are essential for adding specificity that Level I modifiers might miss, particularly regarding anatomical location (Left/Right/Eyelids/Digits) and the technical vs. professional components of diagnostic tests.
Please note that this is a high-level classification of modifiers in medical billing. The modifiers can also be sub-classified into two categories:
- Pricing/Payment modifiers: As evident from the name, the pricing modifiers directly impact the reimbursement amount of your claims. For example, “modifier 26 (professional component)” is a pricing modifier. When you append this to your claim, you are telling the payer that you are only billing for the professional component of the service. So, the payer will deduct the cost of the technical component from the total reimbursement.
- Informational/Statistical modifiers: Informational modifiers, on the other hand, provide more details about the service or circumstance, without changing the base payment. Examples of information modifiers can be RT or LT. These modifiers indicate that a service was performed on the left or right side of the body.
List of Common Modifiers in Medical Billing
There are tens or even hundreds of different modifiers in medical billing. Remembering each of them can be difficult. That’s why we have listed the most frequently used modifiers in the table below:
| Type | Modifiers |
|---|---|
| Therapy Modifiers | GN, GO, GP, KX, CO, CQ |
| Anatomical Modifiers | E1, E2, E3, E4, FA, F1, F2, F4, F5, F6, F7, F8, F9, LC, LD, LM, LT, RC, RI, RT, TA, T1, T2, T3, T4, T5, T6, T7, T8, T9 |
| Podiatry Modifiers | Q7, Q8, Q9 |
| End-Stage Renal Disease (ESRD) and erythropoiesis-Stimulating Agent (ESA) Modifiers | AX, EA, EB, EC, AY, ED, EE, EJ, EM, G1, G2, G3, G4, G5, G6, GS, JA, JB, JE, V5, V6, V7, V8, V9 |
| Advance Beneficiary Notice of Noncoverage (ABN) Modifiers | GA, GX, GY, GZ |
| Telehealth Services Modifiers | 93, 95, FQ, GQ, GT, G0 |
| Laboratory Modifiers | 90, 91, 92, LR, QW |
| Surgical Modifiers | 22, 50, 51, 52, 53, 62, 66, 73, 74, PA, PB, PC |
| Anesthesia Modifiers | AA, AD, G8, G9, P1, P2, P3, P4, P5, P6, QK, QS, QY, QX, QZ, 23, 33 |
| Assistant at Surgery Modifiers | AS, 80, 81, 82 |
| Global Surgery Modifiers | 24, 25, 54, 55, 57, 58, 78, 79, FT |
| Hospice Modifiers | GV, GW |
| Other CPT Modifiers | 26, 27, 33, 59, 76, 77, 96, 97 |
| Ambulance Modifiers | D, E, G, H, I, J, N, P, R, S, X, GM, QL, QM, QN |
| Quality Reporting Incentive Programs Modifiers | 1P, 2P, 3P, 8P, AQ, AR, MA, MB, MC, MD, ME, MF, MG, MH, X1, X2, X3, X4, X5 |
| Additional HCPCS Modifiers | AB, AE, AF, AG, AI, AK, AM, AO, AT, AZ, BL, CA, CB, CG, CR, CS, CT, DA, ER, ET, FB, FC, FS, FX, FY, G7, GC, GE, GG, GJ, GU, J1, J2, J3, JC, JA, JB, JC, JD, JG, JW, JZ, KX, L1, LU, M2, PD, PI, PO, PN, PS, PT, Q0, Q1, Q3, Q4, Q5, Q6, QJ, QQ, RD, RE, SC, SF, SS, SW, TB, TC, TS, UJ, UN, UP, UQ, UR, US, X1, X2, X3, X4, X5, XE, XP, XS, XU |
| Advanced Diagnostic Imaging Appropriate Use Modifiers | MA, MB, MC, MD, ME, MF, MG, MH, QQ |
Note: While filing claims, payment modifiers must always be given priority over informational modifiers. These should be listed before informational/statistical modifiers.
Final Thoughts
In this guide, we tried to simplify modifiers for you. We hope that this blog will serve as your go-to resource every time you have confusion regarding modifiers. Learning how to use modifiers in medical billing is essential if you want your claims to be reimbursed. Otherwise, be prepared to lose a big chunk of your revenue.
If you are having difficulty filing error-free claims, it is better to get professional medical billing and coding services from reliable partners like NeuraBill.
