Modifiers
Modifiers are two-position alpha or numeric codes (e.g., 25, GH, Q6, etc.) which can be appended to a Current Procedural Terminology (CPT®) or Healthcare Common Procedure Coding System (HCPCS) code.
- Professional claims (CMS-1500) and facility claims
(UB-04) can include up to four modifiers per CPT/HCPCS
code depending upon the service provided.
- When more than one modifier is used, placement of the modifiers is critical for correct reimbursement. Functional modifiers should always be placed in the first modifier field followed by informational modifiers.
Our Modifier reimbursement policies include reimbursement
details and examples of how to use the modifiers. View
our Modifier
reimbursement policies.
Functional modifiers
These provide additional information
that impacts the amount of reimbursement either directly
or through the use of Centers for Medicare & Medicaid
Services (CMS) National
Correct Coding Initiative (NCCI) or Regence Correct
Code Editor (CCE) edits.
- View
our Regence
Functional Modifier List.
- Any functional modifier that affects pricing should
be placed in the primary position.
- Documentation should be included in the
patient’s
medical record supporting the use of any functional
modifier used.
- Coding functional modifiers first may allow the
claim to be auto-adjudicated, ensuring your claim
is processed quickly.
- Submitting a functional modifier that is not compatible
with the base CPT or HCPCS code will cause your claim
to be either delayed or denied.
- Only submit modifiers when appropriate.
Modifier use should relate to separate patient encounters,
separate anatomic sites or separate specimens.
Informational modifiers
These provide additional information about the service
rendered. The following modifiers are considered informational
by Regence, and therefore, not required. These include:
- Modifier -LS FDA-monitored IOL
Implant
- Modifier -90 Reference (Outside)
Laboratory
- Modifier -QM Ambulance arranged
by provider
We recognize all Health Insurance Portability and
Accountability Act (HIPAA)-compliant modifiers. A full
listing of modifiers can be found in CPT or HCPCS manuals.
- We follow the CMS modifier indicator rules for
determining whether a special circumstance could
be indicated by a modifier.
- CMS NCCI and Regence CCE code pairs define when
two codes may not be reported together except under
special circumstances. When these special circumstances
are met, the proper modifier should be appended to
the appropriate code to describe the circumstance.
Preventive services modifiers
Routine colonoscopy or sigmoidoscopy screenings that become diagnostic should be billed with Modifier - 33 Preventive Service or Modifier -PT CRC screening test, converted to diagnostic test or other procedure. Learn more.
Resources
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