About Medical Billing, Coding and Claims Modifiers
1. The physician performed multiple procedures
2. The process performed was bilateral
3. The E/M service ended on the same day of the procedure
4. The procedure was increased or decreased
5. The process has both professional and technical component
6. The process was done by other provider (Anesthesiologist, Surgeon Physical Therapist, Speech Pathologists etc.)
7. Procedure on either one side from the body was performed
8. The E/M service was provided inside the postoperative period
9. The E/M service resulted to Decision of Surgery
10. Unusual Circumstance
Maximize your reimbursement for bilateral procedures by using the correct modifier.
Bilateral Modifier (-50)
Based upon the insurance coverage payer, processing claims with bilateral procedure should be paid 150%
Medicare Part B requires one single line of bilateral procedure code with Modifier 50. They normally process the claim with 150% reimbursement. However, you need to check up on this where you live as well as in your region.
Some commercial insurance would rather Two Lines of the identical code, once with 50, second without 50. Then second modifier around the 1st line is RT or LT, modifier RT or LT on second line, with 1 unit and services information each code. Should be reimbursed at 150%
Some commercial insurance would rather two lines of the identical code with modifier LT or RT on each line with 1 unit and services information each code. Should be reimbursed at 150%
Always check in your Physician's Fee Schedule if the procedure code is billable as bilateral J.
Using LT & RT modifier is used to specify which argument from the body the procedure ended through the physician. Medicare Part B according to my experience requires specific modifier, either LT or RT. Example you may report procedure 64626 done around the Right C4-C7 Facet Joint Nerve Ablation as 64626-RT.
Modifier -26. Professional Component.
Example: Report procedure code 77003 - Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural, transforaminal epidural, subarachnoid,, paravertebral facet joint, paravertebral facet joint nerve or sacroiliac joint) including neurolytic agent destruction) with modifier -26 to point the physicians Professional Component only reimbursement and never technical component. When the provider's office owns the fluoroscopic equipment, do not append -26 modifier.
Modifier -25. Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service.
Example: Report E/M code 99213 (Office or other outpatient visit for the evaluation and control over an established patient) with Modifier -25 for procedure code 20610 Knee Joint Injection done on the day that from the procedure. Modifier -25 indicates significance and separate identifiable E/M service away from procedure done on the patient. Don't use modifier -25 to report E/M service that resulted for initial decision for surgery.
Instead use modifier -57 for Decision for Surgery
Modifier -24. Unrelated Evaluation and Management Service by the Same Physician During Postoperative Period
Example: Report E/M code 99213 with Modifier -24 if the patient came back during the postoperative period. The physician must identify this particular service as completely unrelated using the recent procedure done around the patient. A detailed medical documentation is a good support for medical necessity.
Modifier -51 for Multiple Procedures.
Modifier -59 for Distinct Procedural Service
Modifier-GP Services Rendered under Outpatient Physical rehabilitation plan of care
Modifier-GO Services Rendered under Outpatient Occupational Therapy plan of care
Modifier -GN Services Rendered under Outpatient Speech Pathology plan of care
Check your current CPT Book. Check the CMS CCI Edits. Check the insurance payor's policies and guidelines.
