Basic Question on Modifiers

(system) #1

mukoya wrote on Friday, April 01, 2011:

I am yet to figure out what exactly billing modifiers are for and how they work.:

1.  What is the principle behind modifiers?
2.  How do you decide what number to enter in this box?
3.  What then does this number do to the bill for that service?
4.  How do you know the desired effect of the modifier on the bill has been achieved?


(system) #2

cverk wrote on Saturday, April 02, 2011:

Modifiers are used to justify why you may want to bill two procedure codes on the same patient on the same visit. They are things like evaluating a medical problem at the same visit you perform a procedure like removing a skin lesion. Basically you are trying to get paid for taking the time to do extra unrelated thinks for the patients benefit.

(system) #3

mukoya wrote on Saturday, April 02, 2011:

Before asking I had done basic testing to try and decipher the modifier mystery. For example I bill patient $200 for consultation and enter 30 as modifier. The billing widget still shows 200. Checkout still shows 200. How is this 30 ever reflected? Is it an absolute number or a percentage? Can it be negative? How come there is an option to “permanently” add a modifier to a service in services admin, why cant you then just change the service price altogether?



(system) #4

visolveemr wrote on Saturday, April 02, 2011:


Modifiers added in fee sheet are reflected in CMS 1500(FL 24d) and X12(Loop 2400 Service Line). Modifier are added value services to procedure codes.

ViCarePlus Team,

(system) #5

cverk wrote on Monday, April 04, 2011:

Modifiers are add-on’s to CPT codes. They are used to extend the meaning of a CPT code. The most common in primary care is 25 which is added to an evaluation and management code when you are also going to charge a surgical procedure code on the same day.  Without that modifier you cannot get paid for both CPT codes. You would be suprised how often new problems come up once the exam room door is closed.  The patient schedules with the office to have a wart removed, and once they have your attention they would like evaluation for something unrelated that they did not wish to discuss with office staff such as an STD exposure. So you have treated their wart for which you bill a surgical CPT code and assign an ICD9 code for warts.  You also bill an evaluation CPT code, with a 25 modifier-substantial unrelated evaluation and management service, and assign a ICD9 diagnosis code for STD exposure. CPT code books have lists of modifiers which all have individual meanings and are unfortunately proprietary and owned by the AMA unlike ICD9 codes. Fee schedules are mostly decided on by the Federal government and medicare under a schedule called RBRVS which are updated at least annually and published on the medicare CMS internet site, and recently changed at the various whims of congress.  Commercial plans usually contract and pay based on a given percentage such as 120% of medicare RBRVS. So billing is composed of demographic and insurance information, a CPT code sometimes with a modifier if indicated, one to four diagnosis codes to justify the CPT code which are indicated by a diagnosis code pointer, and a fee for that service. These form the basic components of a clean claim which on paper is a CMS1500 form. If any of the components are missing, the claim is rejected electronically usually by the clearing house and you have to correct it before it goes through to the carriers. For the most part this is the focus of practice management software, and EMR software is designed to document the components of your patient visit to justify the CPT code that was selected for billing.

(system) #6

mukoya wrote on Monday, April 04, 2011:

Hey All, Thanks for your Useful Inputs.

Cverk, I guess your explanation that the codes are standard and have individual meaning is what I had not gotten all along.

I thought they were arbitrary estimated figures modifying CPT codes by an absolute amount of money or a percentage of the cost of the CPT.


(system) #7

aethelwulffe wrote on Monday, April 04, 2011:


The link above contains the text for CPT modifier 91.  Basically, that modifier indicates that the proceedure it is attached to (diagnostic testing of some sort) was performed a number of times on the same day (like multiple blood tests, EKG’s etc…) to provide monitoring, where normally that CPT is only billable one time per visit.  There are lots of modifiers:  “did it in an ambulance”  “did it in the patient’s home”, etc…

You might wanna look at some of the free ICD-9/ICD-10 and CPT code references.  Wikipedia has a pretty good layout itself. 
  There are (huge) printed references as well.  It might be good if you can check out a copy and get used to some of the inns and outs of that sort of thing.
  There are lots of magical mysteries in billing, such as what code/diagnosis/modifier combinations are actually billable among other subtleties that allow insurance companies to deny…err…I mean process claims.  You don’t need to know the inns and outs, but perhaps a few hours perusing such a set of tomes, as well as perhaps talking to some billers or practice managers that deal with the peculiarities of their particular specialty might give you some real insight.  Copies of paper billing sheets from institutions that have their “shit together” and use refined lists of diagnosis and proceedure combinations that work well together would be good references.  There are also a few practice manager magazines out there that have good data about billing practices on a regular basis as well….such as one called “Practice Manager”.  If you are in a position to develop for or advise folks on the tech side of billing (I have no idea what you actually do), a wee bit of info in this regaurd might really go a long way.


(system) #8

mukoya wrote on Monday, April 04, 2011:

Thanks Aethelwulffe. Will Check out your references.

What I do? Well, I am one of those doctors who was dragged to medical school when thier heart was in IT. Where I stay/Work (Kenya in East Africa) you train for what has higher odds of giving you daily bread, not what you love. My friends and relatives believed medicine stood a higher chance of feeding me!.

Worked in rural Kenya in a state run facility for 4 years as general practitioner. There were no EMRs, Patients would carry small booklets for every visit, doctor writes his progress notes in them and patient carries booklet home till next visit. No facility based records for outpatients.

A year and a half ago, came back to the city (Nairobi) for postgraduate studies. Looking around, Radiology was the closest medicine came to I.T, so I enrolled for my 4 years in University of Nairobi for Diagnostic Imaging and Radiation Medicine. In my second year now.

While in Radiology, I was shocked at how doctors, especially in radiology, were not taking up technology. Decided to start Organizing myself for installation and support for radiology solutions including Picture Archiving and Communication System (PACS), Radiology Information System (RIS) -this is like an EMR for radiology practices - and support for other advanced radiology solutions like Image processing e.g Osirix Workstation e.t.c. The main radiology software I am using is ClearCanvas. Been Open source. Have now gone Dual licensing from a day or so ago.

While at it, I received requests for solutions to cover clinics etc, which are much more prevalent than radiology centres anyway. I started searching for a software i could resell or Opensource that I could Support. That is how I landed on OEMR.

So, I am looking to establish a support company for medical IT solutions here, including OEMR.

O.k. Now you know what I am about and, yes, I need to know about billing if i am to support OEMR. I am aware I still have considerable ground to cover regarding billing and I will follow your advice on this.


(system) #9

mukoya wrote on Monday, April 04, 2011:

Just to add, I got a  significant insight into power of technology in medicine that would later influence my doing radiology and engaging is such issues as OEMR during my elective term as an undergraduate at Penn-state University and Lehigh Valley Hospital in Pennsylvania back in 2002.

(system) #10

jcahn2 wrote on Monday, April 04, 2011:

Off topic.
Ahoy Mukoya.
I am Penn State class of 1968.  Hershey Medical Ctr 1972.  Go Lions!

(Paul Esthappan) #11

Modifiers indicate that a service or procedure performed has been altered by some specific circumstance, but not changed in its definition or code. They are used to add information or change the description of service in order to improve accuracy or specificity. Modifiers can be alphabetic, numeric or a combination of both, but will always be two digits.