Need for Using Proper Modifiers:
1. The physician performed multiple procedures
2. The procedure performed was bilateral
3. The E/M service ended on the same day from the procedure
4. The procedure was increased or decreased
5. The process has both professional and technical component
6. The process was performed by other provider (Anesthesiologist, Surgeon Physiotherapist, Speech Pathologists etc.)
7. Procedure on either one side from the body was performed
8. The E/M service was provided inside the postoperative period
9. The E/M service resulted to Decision of Surgery
10. Unusual Circumstance
Maximize your reimbursement for bilateral procedures by using the correct modifier.
Bilateral Modifier (-50)
Based upon the insurance payer, processing claims with bilateral procedure ought to be paid 150%
Medicare Part B requires one single line of bilateral procedure code with Modifier 50. They normally process the claim with 150% reimbursement. But again, you need to check up on this where you live as well as in your region.
Some commercial insurance would prefer Two Lines of the same code, once with 50, second without 50. Then second modifier on the 1st lines are RT or LT, modifier RT or LT on second line, with 1 unit and services information each code. Should be reimbursed at 150%
Some commercial insurance would rather two lines of the identical code with modifier LT or RT on each line with 1 unit of service each code. Must be reimbursed at 150%
Check on your Physician's Fee Schedule if the procedure code is billable as bilateral J.
Using LT & RT modifier is used to specify which argument from the body the process ended by the physician. Medicare Part B based on my experience requires specific modifier, either LT or RT. Example you may report procedure 64626 done on the Right C4-C7 Facet Joint Nerve Ablation as 64626-RT.
Modifier -26. Professional Component.
Example: Report procedure code 77003 - Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural, transforaminal epidural, subarachnoid,, paravertebral facet joint, paravertebral facet joint nerve or sacroiliac joint) including neurolytic agent destruction) with modifier -26 to point the physicians Professional Component only reimbursement and never technical component. If the provider's office owns the fluoroscopic equipment, don't append -26 modifier.
Modifier -25. Significant, Separately Identifiable Evaluation and Management Service through the Same Physician on the Same Day from the Procedure or any other Service.
Example: Report E/M code 99213 (Office or any other outpatient visit for the evaluation and management of a recognised patient) with Modifier -25 for procedure code 20610 Knee Joint Injection done on the same day of the procedure. Modifier -25 indicates significance and separate identifiable E/M service away from procedure done on the patient. Don't use modifier -25 to report E/M service that resulted for initial decision for surgery.
Instead use modifier -57 for Decision for Surgery
Modifier -24. Unrelated Evaluation and Management Service by the Same Physician During Postoperative Period
Example: Report E/M code 99213 with Modifier -24 when the patient came back throughout the postoperative period. The doctor must identify this particular service as completely unrelated with the recent procedure done around the patient. A detailed medical documentation is a great support for medical necessity.
Modifier -51 for Multiple Procedures.
Modifier -59 for Distinct Procedural Service
Modifier-GP Services Rendered under Outpatient Physical Therapy plan of care
Modifier-GO Services Rendered under Outpatient Occupational Therapy plan of care
Modifier -GN Services Rendered under Outpatient Speech Pathology plan of care
Always check your up to date CPT Book. Check the CMS CCI Edits. Look into the insurance payor's policies and guidelines.