Monograph - Rules for Modifiers - M18 |
| |
This publication provides a detailed discussion about modifiers used in billing ophthalmic services. An overview of the monograph is discussed below.
Modifiers on claims provide additional information about the service or procedure performed. They are used as an extension to alter or "modify" a CPT code, and have various reimbursement consequences for the associated service or procedure.
Modifiers may be used to describe:
- A location (i.e., right, left, upper lid)
- A bilateral service
- A service has both a professional and technical component
- A repeat or additional service
- An increased or reduced service
- Only a portion of a service
- Unusual circumstances
- That more than one physician provided services
- The physical location where services were provided
Certain modifiers are considered "informational" and have no effect on reimbursement (e.g., -RT, right eye). Other modifiers, known as "payment" modifiers, cause an increase or a decrease in reimbursement, depending on the specifics. Some modifiers may have more than one meaning that varies with circumstances, depending on the service or procedure they describe (e.g., -50 which increases reimbursement for tests to 200% of the allowed amount, but only 150% for surgery).
More than one modifier may be used to describe a service. Most computer systems can accept two modifiers added to a CPT code, and CPT contains alternative mechanisms (099xx) for listing multiple modifiers (-99). Payment modifiers with reimbursement implications should be placed before informational modifiers (i.e., 68761-51E2). If both modifiers impact reimbursement, they should be placed in ascending order (i.e., 68761-5158).
Physicians in a group practice function as an extension of one another. Medicare considers them to be the "same physician", especially if they are in the same specialty. Therefore, modifiers should be utilized to describe the services of another group member as if rendered by the performing doctor in the group. For example, when a glaucoma specialist sees a patient in the postop period of cataract surgery, performed by his partner, for pre-existing chronic open angle glaucoma, then -24 applies.
Modifier errors are common. They may cause claims to be denied or improperly reimbursed. The following discussion provides a definition of the various modifiers used in ophthalmic practices. |
| |
|
Purchase This Resource
|
|
|
| |
|
|
| |
|
Or Purchase Entire Library
|
| Save! You can purchase the entire Monograph library for the initial cost of $500 (based on single physician practice). |
| |
|
|