The Relevance of Using Perfect Modifiers in Medical Claims

The overlapping nature of certain medical procedures is such that it is impossible to report them with CPT codes alone. Although CPT coding has grown to be comprehensive enough to cover breakthrough procedures over the years, yet, physicians are not spared from submitting separate procedural forms for medical procedures requiring explanation that overshoot the CPT boundary. Recognizing a parallel system that not only obviates the necessity of submitting supplementary forms but also expedite the submission and realization of medical claims, American Medical Association (AMA) has long been known for promulgation of modifying those overlapping medical procedures through unique and efficient Modifiers, identified and approved for the very purpose of aiding physicians in successful submission and realization of medical claims for their medical services to the patient fraternity. Thus, physicians, having a unique recourse to their problems in medical billing, should be competent enough to not only know the definition of Modifiers but also the circumstances wherein they can apply them.

AMA defines Modifiers as codes that are used to “enhance or alter the description of a service or supply” under certain circumstances. From this definition, it can be inferred that modifiers provide the means by which the reporting physicians can indicate that services or procedures that have been performed have been altered by some specific circumstance but has not changed in its definition or code. Thus, modifiers can be attached along with the originally billed and coded forms, without being required to submit through separate forms. Further AMA has also identified the following circumstances that warrant the application of modifiers:

  • A service or procedure which has both a professional and technical component
  • A service or procedure which requires to be performed by more than one physician and/or in more than one location
  • A service or procedure which has been increased or reduced
  • A procedure wherein only part of a service is performed
  • A procedure wherein an adjunctive service is performed
  • A procedure wherein a bilateral procedure is performed
  • A service or procedure which is provided more than once
  • A procedure wherein rare events were witnessed

Having understood the circumstances and the extent to which modifiers can be applied during the course of preparing and submitting medical claims, physicians should also be conversant with the prevailing and acceptable modifiers that are unique to their individualistic practice specialties. Generally the following set of modifiers are frequently used and accepted by the insurance carriers:

  • Modifier-25: needs to be attached with any evaluation management service done on the same day by the same physician. Further, the procedure needs to be beyond the usual preoperative and postoperative encounter.
  • Modifier-24: can be used with any unrelated evaluation and management service by the same physician during postoperative period, and, like modifier 25, has no restriction as with the level of E/M code as long as it meets medical necessity. Also, all its components are time-based.
  • Modifier-57: allowable when an evaluation and management service results in the initial decision to perform surgery.
  • Modifier-50: allowable with bilateral procedure performed on the same day, during the same operative session, and on identical anatomical sites. Further, it can be used with add-on codes also; but cannot be used with procedures that are already described as bilateral procedures.
  • Modifier-51: handy while reporting multiple procedures performed by the same physician on the same day. But, it can be clubbed with the procedure done on the same day by another physician.
  • Modifier-59: necessitates reporting any distinct procedural service performed on the same day that is deemed apt under a medical situation. But, the physician needs to establish the need for such distinct or independent service while appending with the original procedure.
  • Modifier-26: As certain procedures are combination of both professional and technical component, this modifier is useful while reporting the service as a professional component only.

Related Tags:Connecticut Medical Billing, Delaware Medical Billing

Although the Modifier System is comprehensive enough to mitigate all challenges while coding and submitting medical claims, the voluminous knowledge accompanying it would be hard to be digested by the physicians, who have a much more challenging task of keeping their medical practice benchmarks unblemished.

Fortunately, they can look forward to proven outsourced solutions on the horizon. (, with a comprehensive outlook to their clients’ billing and coding management and with substantial hands-on experience across specialties, is uniquely poised to advise, own, and execute an efficient system of modification as part of its all-inclusive medical billing management.[subscribe2]