Surgical Billing Services: The Role of Modifiers

Medical billing modifiers are commonly misused in different medical practices, including the providers of surgeries. Did you realize you could be required to repay money paid to you by insurance or third-party payers if you misused a modifier?

When you misuse a service billing modifier on a claim, it can be a costly mistake. That’s why it is essential to understand the basics of using modifiers to maximize reimbursement while avoiding claim denials and possible audits.

An Overview of Modifiers in Surgical Billing Services

As per AMA and the CMS, a modifier is a means of reporting or indicating that a service or process has been done and altered by some specific situation but has not changed in definition.  It may also provide additional information about services done more than once or services that have occurred unusually. When not all of the services in a bundle are done, modifiers can be used to indicate this.

Types of Modifiers

  • Level I Modifiers:

Level I modifiers, or CPT Modifiers, are two numeric digits copyrighted and updated yearly by the American Medical Association (AMA).

CPT modifiers are two-digit number codes. The CPT modifier is used to provide extra information on medical procedures, such as the need for the procedure, a change in procedure, the location of the procedure, and the total number of surgeons conducting the procedure. All of this information is formatted as a ‘CPT code modifier and sent to the insurance provider.

  • Level II Modifiers:

Level II or HCPCS modifiers can be composed of Alphabets or Alphanumeric characters. The Centre for Medicare & Medicaid Services copyrights and updates these modifiers.

An HCPCS modifier comprises two characters: a letter and a number. HCPCS modifiers are organized alphabetically by coding type. The HCPCS modifier offers detailed information on particular items for non-physician service providers. All of this information is represented as HCPCS code modifier and sent to the insurance provider.

Important to Note: Billing code modifiers 58, 59, 78, 79, and 24 are used on surgery claims.

Role of Modifiers

Modifiers come into the picture by giving detailed information that is standardized and efficient. Let’s see what purpose modifiers serve in surgical billing:

  • Modifiers, which serve as informational or billing clarification, eliminate the need for a procedure listing or separate service.
  • The use of inaccurate modifiers or the incorrect use of modifiers is deemed fraudulent and in violation of the laws.
  • This would result in additional audits and income loss in the future. As a result, familiarity with the modifications list is critical.
  • To discover correct modifiers for surgical billing services, healthcare professionals and medical billing companies can consult the modifiers guide.

How Does A Modifier Affect The Reimbursement Rate?

It should be noted that varying modifiers can affect the reimbursement rate for various diagnostics and surgeries. For example, when CPT Code Modifier 22 is used, the payer pays 110% of the usual reimbursement rate to the surgeon or diagnostician. CPT Code modifier 50, on the other hand, shows that the same procedure was performed twice and pays 150% of the initial reimbursement rate.

It is critical to take advantage of the various reimbursement rates that each payer assigns to particular CPT Code Modifiers. Different payers may have different needs and contract schedules that must be updated regularly.

Outsource Surgical Billing Services!

Insurance payers may deny or reject claims if modifiers are missing or improperly used. Also, surgeons need a strong foundation on the use of modifiers to avoid aged accounts, write-offs, and revenue leakage. This called for surgical billing outsourcing to the team of professionals and experienced billers and coders.

Our team of surgical billers and coders at 24/7 Medical Billing Services has been trained and understands the use of modifiers.  Each month, we conduct an exercise to grasp the reasons for each claim denial and mark the claims denied for coding issues for further investigation.  We strive to handle coding denials iteratively and in a structured way. This means that only a few claims are denied due to coding problems, such as incorrect or non-use of modifiers. As a result, our healthcare professionals benefit from lower denial rates, better collections, and faster cash flow.

Read more: Tips To Increase Surgery Billing And Collections

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