If you aren’t in the medical field you may want to know what to expect from Medical CPT Modifiers. With all the different coding and billing issues with insurance and medical services these are things you will want to know. That way you are well aware where your money is going and what your medical expenses may be.
What to Expect From Medical CPT Modifiers?
A medical code set, Current Procedural Terminology (CPT) is used to report medical, surgical, and diagnostic dealings and services to various entities. Health insurance firms, physicians, and authorized organizations are some who have taken to this procedure. These CPT codes are used in numerical diagnostic coding, at times of electronic medical billing process. CPT is a registered trademark of the American Medical Association (AMA).
At times, the CPT code isn’t quite enough. In such cases, we turn to Medical billing modifiers. They are an important addition to CPT codes, which give more information about how, why, and where a procedure was performed. They provide a mechanism to link distinct and detailed circumstances related to the performance of a service or a medical procedure.
The increased need for additional information
Since most of the medical procedures and services are quite complex, patients, and surgeons might need additional information, like CPT coding. This is where the CPT modifiers come into play. CPT Modifiers, just like modifiers in the English language, provide added data about the surgical procedures. A CPT modifier describes the multiple procedures performed; the event that led to the performance of that procedure, which part of the body was subjected to the surgery, how many surgeons worked on the patient, and other information necessary to claim medical insurance.
CPT Modifiers consists of two characters – numeric, alphanumeric, or a combination of both. Most CPT modifiers are numeric, but there are a few alphanumeric anesthesia modifiers described by AMA. CPT modifiers are added at the end of the CPT codes with a hyphen. In some cases, more than one modifier may be required. You need to code the “functional” modifier first, and the “informational” modifier next. The difference between the two is simple – you need to list the functional modifiers first, that most directly affects the repayment process.
There’s an upfront reason to this. While CMS-1500 and UB-04, the two most commonly claimed forms, have four CPT modifiers, clients don’t always notice the modifiers after the first two places. Due to this, you want the most important modifiers to be visible first. You can’t just use a modifier in your medical bill; there are rules leading to that.
How can CPT modifiers be used?
If a surgeon performs a surgery to remove the bone cyst from the lower arm of a patient, a graft must be obtained from some other part of his body. The surgeon is unable to fully exercise the surgery, owing to minor complications. The CPT code used for this procedure is 24115. However, since the surgery wasn’t fully executed, a modifier for reduced service, 52, can be added at the end of this CPT code. The entry in the medical billing modifier will be 24115-52. Similarly, for various other complications in the surgery, there are predefined modifiers that can be added at the end of the CPT code.
CPT modifiers used for anesthesia
Just like all other procedures, there’s a special set of modifiers used for anesthesia procedures. They are simple alphanumeric characters associated with the condition of the patient to whom the anesthesia is being administered. The modifiers associated with anesthesia are:
- P1 – the patient is normal and healthy
- P2 – the patient has a mild systemic disease
- P3 – the patient suffers from severe systemic disease
- P4 – the patient has a threat to life
- P5 – the patient can’t survive without surgery
- P6 – a patient declared brain-dead
Every patient is administered anesthesia before undergoing a surgery. Depending on the condition of the patient after administration of anesthesia, the modifiers are assigned.
Supplement reports for insurance
While you claim for medical insurance, the insurance company might request a quote for further information, to understand why a particular surgery or operation was performed. The insurance company will file a supplementary report stating their need for additional information. In such cases, the modifiers are used to provide the additional information required, without which your insurance claim might be rejected.