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Rules for Modifiers

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 but not change the code or its definition. Modifiers may be appended to CPT codes for visits, tests or procedures. They create various reimbursement consequences for the service(s) provided. The proper use of modifiers improves the handling of claims at the payer’s office.

Modifiers may be used to describe:

  • A location (i.e., right or left eye, upper or lower lid)
  • A bilateral service
  • The professional or technical component of a service
  • 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

Certain modifiers are considered “informational” and have no effect on reimbursement (e.g., RT for 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., modifier 50 increases reimbursement for certain tests to 200% of the allowed amount, but only 150% for surgery).

If necessary, multiple modifiers may be used to describe a service. Most computer systems can accept at least two modifiers per line. The current version of the paper CMS-1500 form and Medicare administrative contractors (MACs) are able to accept up to four modifiers per line, When multiple modifiers are reported on a single line, modifiers with reimbursement implications should be placed before informational modifiers (i.e., 68761-79E2). If both modifiers impact reimbursement, they are usually placed in ascending order (e.g., 68761-5158).

Physicians in a group practice function as an extension of one another. Medicare considers them to be the “same physician” if they are in the same specialty. Therefore, if a modifier would apply to a service provided by a surgeon, for instance, the same modifier(s) should be utilized for services of another group member as if rendered by the surgeon. For example, modifier 24 applies when a glaucoma specialist sees a patient for pre-existing
chronic open angle glaucoma in the post-operative period of cataract surgery performed by his partner.

Modifier errors are common. If omitted or used incorrectly, they may cause claims to be denied or improperly reimbursed. Some modifiers, when used in excess, may “red flag” a provider for a payer review.

 

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