What Is a Modifier in Medical Billing & how Does It Work?

Medical billing is a vast field and there are a lot of people interconnected to do the job perfectly. This is the mere reason why medical billing services have modifiers to cover all the different aspects of medical billing services.

Now, you might wonder what is a modifier in medical billing services? To sum it up, modifiers have the most important role to play when it comes to medical billing.

Modifiers are known to modify the medical codes and update any kind of changes in the codes of the medical services provided to the patients.

Let’s have a detailed look at the role of modifiers in the medical billing field.

What is a modifier in medical billing?

What is a modifier in medical billing

As mentioned above, modifiers have a very important role to play regarding the medical codes and their upgradation related to different situations. Modifiers are used by medical practitioners in order to decide what procedure to be performed while slightly modifying it in any given medical situation.

The physician is supposed to provide a complete record of the medical procedures that he performed to get reimbursements against the services and this is where the modifiers step in because they are the ones having the medical codes for different supplies or procedures.

Therefore, the medical practitioners add a modifier to the already mentioned medical code in the bill so that the change in the procedure can be reflected in the final bill.

The dictionary definition of modifier is “the means to report or indicate that a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code.”

Types of modifiers

There are two main types of modifiers namely CPT modifiers and HCPCS modifiers. Let’s have a look at them.

CPT modifiers

A CPT modifier is the name given to a numeric code that comprises two digits. The CPT modifiers are basically used to add additional information about the medical procedures that describe the need for the medical procedures, any kind of change or modification that occurs in the medical procedures, the exact site of the medical procedure, and the exact number of surgeons involved in conducting the said procedure.

Types of modifiers

All of this above-mentioned information is represented in the form of a “CPT code-modifier” and later on forwarded to the insurance company in the form of the medical bill.

For instance, 24115-52 is a code for reduced services by the medical practitioners especially for excision or curettage of a bone cyst or benign tumor, humerus, with autograft (including the whole process used to get the graft)” because of certain complications.

Some common examples of CPT modifiers are:

  • 22- Procedural services – increased
  • 24- Unrelated evaluation of the service by a physician or any other qualified healthcare provider in a specific postoperative time frame
  • 23- Unusual anesthesia
  • 52- Reduced services
  • 25- Significant identification of managerial services provided by the physician on the same day
  • 56- Preoperative management
  • 55- Postoperative management
  • 53- A discontinued procedure
  • 59- Distinct medical services
  • 57- Decisive surgery
  • 99- Different modifiers

HCPCS modifiers

An HCPCS modifier is one that mainly comprises two characters- that is a digit and a letter.

The HCPCS modifiers have coding categories starting from A and going all the way to Z. These modifiers are used to provide additional information regarding specific terms which are used by medical practitioners to provide non-physician kinds of services.

All the information is written in the format “HCPCS code-modifier” and then further sent to the insurance company.

For instance, A0428-QN is a code that represents “basic life support ambulance service, non-emergency transport, furnished by the provider of services.”

Have a look at some examples of HCPCS modifiers:

  • AA- Anesthetic services provided by anesthesiologists
  • AD- Medical supervision by a healthcare practitioner for over four concurring anesthetic procedures
  • AJ- Clinical social worker (CSW). This is a term that describes a group that is employed by a CSW to maintain the bills and records of services provided by a CSW.
  • GW- Services provided to a patient related to his terminal condition if he is living in a hospice.
  • GY- The services or items which are excluded from Medicare benefits but are still termed as medical services.
  • GZ- All the services or items which are denied are considered to be unreasonable or unnecessary.
  • QN- Ambulance service which was provided by the host himself

Final thoughts

Modifiers are termed as a vital part of medical billing and all those physicians who provide services that are a little modified than already prescribed medical services; consider modifiers as life savers as without them they cannot earn reimbursements for their provided medical services.