Using Modifiers Correctly

We get a lot of questions regarding the correct use of modifiers. Well, actually the questions are usually more on the lines of “One of my services was denied, what modifier can I use to get the service paid?”

The first thing I want to make clear is that it is never okay to add a modifier strictly to get a service paid. Modifiers, like cpt codes, help to describe the services that were performed. So the provider, or a coder who is reviewing the chart would have to determine if a modifier would be appropriate. A biller, just looking at the services cannot add a modifier just to ensure payment.

Having said that, it is important that billers understand modifiers and their use. Many providers do not understand modifiers, or even know that they exist. As a biller, you can educate the provider as to what the modifiers mean and what situations they should be used in. It is ultimately the provider who must determine if the services that were performed warrant adding the modifier.

A good example of this is if you receive a superbill indicating that the patient was seen for hypertension, diabetes, hypercholesterolemia and bursitis of the shoulder. The doctor indicates that he did an established office visit level 4, or a 99214 and an injection of cortisone, 20610. The provider doesn’t indicate that a modifier should be used. If both of these charges are billed out for the same date of service, most insurance carriers will bundle the office visit in with the injection.

As a biller you should question if the provider should be reimbursed for both since there were other medical conditions that the provider addressed. You can’t assume this based on the information that you have and since you were not in the room. That’s why you must check with the provider, not just add the modifier. Ask the provider what the main reason for the office visit was, if the other medical conditions were addressed, how much of the office visit was spent on the bursitis vs the other conditions, and advise him/her that the codes will most likely be bundled together.

Then you can advise him/her that there is a modifier, 25, that indicates that the office visit was a significantly separately identifiable service from the other procedure that was performed. The provider would need to advise the biller if the 25 modifier would be appropriate to use for the situation.

There are many other modifier that can be very useful as well. It is important though that billers do not get caught up in the task of getting claims paid and just use modifiers to accomplish that task. They must be used appropriately, when indicated by the provider of service. You may want to have some of the most commonly used modifiers added to the superbill so that the provider can easily indicate when the modifier is to be used.

Here is a list of some of the more common modifiers:

RT – right

LT – left

25 – significantly separately identifiable E&M service

26 – professional component

TC – technical component

50 – bilateral

59 – Distinct procedural service

79 – Unrelated procedure or service by the same physician during the postoperative period

Copyright 2010 – Michele Redmond


8 Responses to “Using Modifiers Correctly”

  1. Sheila Long Says:

    What about modifier for Texas Medicaid indicating an injection was medically necessary.

    • solutionsmedicalbilling Says:

      It sounds like you are referring to a TX Medicaid specific modifier. I’m not familiar with any such modifier.

      • Sheila Long Says:

        Everytime I bill an injection with medicaid it is denied stating I need to put medically necessary modifier – do you know what this modifier is?

      • solutionsmedicalbilling Says:

        It must be something specific to TX Medicaid. There is not a universal modifier for that. I did some research and it may be U4. You should verify that with the Medicaid office.

  2. Mark Says:

    Our hospital is looking at purchasing a private cardiology practice and would move their billing to provider based. The practice is currently using 26 modifiers on some CPT codes such as a 93306-26 or 93279-26. Assuming we purchase and move to provider based, would this be billed as a 93306 (facility setting rate + APC rate) without the modifier.



    • solutionsmedicalbilling Says:

      From what you are describing, it appears you would bill without any modifier since you are billing the global fee.

  3. Sharon Guill Says:

    Which CPT modifier would not be used on the UB-04 form?

    • solutionsmedicalbilling Says:

      I’m really not sure what you are asking. A modifier is used based on the procedure and if it is necessary to further describe the services performed. It’s not based on the form used. Any modifiers can be used on the CMS form or the UB04 form.

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