The Effects of Modifiers on Coding and Reimbursement

The medical insurance claim CMS-1500 or the electronic equivalent explain the story of a patient encounter to the insurance carrier. CPT and ICD-10-CM codes show what procedure(s) or service(s) were performed and the reason why those were necessary. The claim paints the picture of the patient’s encounter for that day and the reason why.

Coding and billing is not always black and white as circumstances and situations can occur that change the complexity or reason(s) why procedure(s) or service(s) are performed. Modifier allow the provider of service to explain a more complete picture of the encounter in order to receive fair and proper reimbursement.  Modifiers tell different kinds of stories and affect the reimbursement of a claim in several different ways.

They can cause an increase or decrease in reimbursement, extend a post-operative period, identify an area of the body, or identify extenuating circumstances. Some modifiers are required by insurance carriers in their policies to label situations for consideration on a particular claim, as well as bring attention to information related to the claim.  With modifiers playing so many important roles on insurance claims, it is critical that anyone involved in creating and processing medical claims understand modifiers found in CPT as well as HCPCS coding manuals.

• Identify E/M modifiers
• Discuss modifiers for services and procedures
• Learn how modifiers affect the post-operative period
• Hear about the reimbursement differences when modifiers are used
• X- modifiers.  Are they better than 59?
• Review current documentation to determine changes that need to be made
• HCPCS modifiers available

• CPT® Modifiers
• HCPCS Modifiers
• Effect of modifiers on claims reimbursement
• Review scenarios in which modifiers are necessary
• Become aware of Medicare’s information related to modifiers
• Assignment of the most appropriate modifier(s)
• Modifier sequencing

• Billers
• Coders
• Administrators
• Managers
• Supervisors
• Physician
• Non-Physician providers
• Qualified Healthcare Professionals
• Medical Assistants
• CEO
• CFO
• Claims adjusters
• Case Managers.