Unfortunately, getting the revenue you deserve will usually require using a code modifier. Modifiers are two-character designations that signal a change in how the code for the procedure or service should be applied for the claim. When modifiers are used correctly; they add accuracy and detail. When modifiers are used incorrectly; they cause denials, audits, or worse.

A modifier could be that only a portion of the normal surgery was done or that an unrelated procedure had to be done on the same day to the same patient and so on. If procedures are coded wrong or not bundled, payers will sometimes think that they already paid for that procedure or be left in the dark to error on the side of no payment.

The biggest mistake is that modifiers just are not used enough even when they are justified, resulting in lost revenue.

Some misused, underused, and misunderstood Current Procedural Terminology (CPT) modifiers…

1. Modifier 25 – Designed to obtain payment for E&M service by a physician on the same day the physician provided another procedure or service to the same patient
   • Most times the physician appends it to the procedure instead of the E&M code.
   • Example - Someone comes in to get a small laceration on her right foot repaired. While that is happening the patient tells the physician of a edema on her left leg. If the E&M service included an expanded problem-focused history and exam with medical decision making of low complexity, the physician could code the E&M services as CPT 99213. You should expect that a n E&M visit on the same day be denied. However, would get paid for both services by adding the modifier 25 to the E&M code and linking each of the services to an appropriate ICD-9-CM diagnosis code.
2. Modifier 24 – Indicates that an E&M service provided to a patient during a postoperative period by the same physician who did the procedure is unrelated to the procedure
3. Modifier 59 – Indicates a procedure that is distinct or independent from other services performed on the same patient on the same day by the physician; useful when services might normally be bundled.
4. Modifier GA – Indicates the patient has signed an advance beneficiary notice allowing the physician to bill the patient directly for a service that Medicare is expected to deny as not reasonable and medically necessary.