Billing with Modifiers
Understanding insurance billing is confusing in and of itself. This article will explore the use of modifiers when submitting insurance claims. If you need a refresher on the basics of insurance claims see my article on CPT Billing codes. Let’s get started.
What is a modifier?
A modifier is a two digit code that changes (i.e., modifies) the procedure or CPT code in some way. For instance, if you want to let the insurance company know that the service provided was done using a telehealth platform, you would use a modifier. Modifiers are listed in section 24D of the CMS 1500 Claim Form. The good news is that most modifiers do not apply to the work we do, however, there are a few that you may want to familiarize yourself with.
Modifier 59: Distinct Procedural Service
Modifier 59 is used to indicate that a distinct procedure or service was provided on the same day. To justify use of this modifier, your documentation should support that a separate service was rendered on the same date of service by the same provider. Given the frequent misuse of modifier 59, CMS established four new modifiers as subsets of modifier 59 ( XE, XS, XP, XU) effective January 1, 2015. These modifiers were developed to provide greater specificity in situations when modifier 59 may have been used. These new modifiers should be used in lieu of modifier 59 whenever possible and Modifier 59 should only be used if there isn’t another more specific modifier to use.
The new modifiers are defined as follows:
XE – “Separate encounter, A service that is distinct because it occurred during a separate encounter” This modifier should only be used to describe separate encounters on the same date of service.
XS – “Separate Structure, A service that is distinct because it was performed on a separate organ/structure”
XP – “Separate Practitioner, A service that is distinct because it was performed by a different practitioner”
XU – “Unusual Non-Overlapping Service, The use of a service that is distinct because it does not overlap usual components of the main service”
Example 1: Client is seen for an individual session by you. Later that day, they are seen a part of a family session performed by you (modifier XE). Your claim form would be coded:
Example 2: Client is seen for an individual session by you. Later that day, they are seen a part of a family session performed by a colleague (modifier XP). Your claim form would be coded:
In both of these examples, you would only use a modifier if the same client is the “identified patient” and it is that client’s insurance that you are billing. A modifier would not be necessary if the family session was billed under the family member’s health plan.
Modifier 76: Repeat Procedure by the Same Physician
Modifier 76 should be used in situations where the same procedure is repeated on the same day, by the same provider. Unlike Modifier 59 or the new “X” Modifiers referenced above, Modifier 76 cannot be used when two different CPT codes are billed together. Therefore, this modifier should only be used when the same CPT code is used twice on the same date of service.
Example: Your client is seen for a family session with their mother. Later that day they are seen for a family session with their father.
Add modifier “GT “Interactive audio and video telecommunications systems or “GQ” Asynchronous telecommunications system to the procedure codes when billing to indicate the use of telecommunications services.
If you are treating someone who is currently in hospice care, it is likely that your claim will be denied unless you use a modifier. To avoid a claim rejection use the following modifier:
- GW – Service not related to the hospice patient’s terminal condition
These modifiers do not need to be billed with every claim, however, if you need to indicate the type of provider performing the service use the following modifiers:
AH – A Clinical Psychologist (CP) rendered a diagnostic or therapeutic service
AJ – A Clinical Social Worker (CSW) rendered a diagnostic or therapeutic service
GC – Service has been performed in part by a Resident under the direction of a teaching physician
Please note that this is my best understanding related to the use of modifiers. This information is provided as a guide and should not be solely relied on without review of the specific billing requirements for your particular situation. For instance, some modifiers cannot be used if billed with Evaluation and Management codes. Also, the improper use of modifiers can trigger an audit by an insurance company, especially if used routinely. Because of this, the use of modifiers must be done carefully upon review of the specific billing requirements pertaining to a particular set of circumstances. Please refer to the Medicare Claims Processing Manual for more information.
If you have had success in using modifiers please leave a comment below. I will do my best to answer any questions you might have.
- Completing CMS-1500 Claim Form
- Purchase CMS 1500 Claim Forms
- Modifier 59 Article
- Modifier 76 Fact Sheet