Healthcare Coding: Modifiers in Urology


As you know, CPT modifiers are two digit numeric or alpha-numeric numbered modifiers that are appended to CPT codes to report a particular service or procedures that maybe altered by specific circumstances and these circumstances do not affect the change in the specific description of the CPT code used. Go through this expert urology medical coding and billing article for more.

Now, this is quote is taken directly from the current procedural terminology CPT Appendix A. A modifier supplies a means to report or indicate that a service or procedure has been altered by some specific circumstance but not changed really in the definition of that code. Modifiers also enable health care professionals to effectively respond to payment policy requirements established by other entities.

Remember that the 51 modifier will not be – you will not need to append that to Medicare claims. Medicare will append the 51 modifier for you as per the recent Medicare guidelines. But it is suggested that you continue to append the 51 modifiers for private carrier, non-Medicare carriers.

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Now, not all insurance carriers will honor all CPT modifiers. So, the only way you can really find out which modifiers a particular carrier will observe and will follow is to check the insurance manual that they give you. To check - actually call the carrier and speak with them.

Speak with the carrier reps, and many times they are able to help you as to which modifiers are acceptable. And actually look at the EOBs, the Explanation Of Benefits that come with your payments from the carriers and see which modifiers have been accepted to ensure correct use of modifiers.

Now, the most commonly accepted modifiers are 22, 25, 26, 50, 51 and 80. And remember that a modifier should be used when there is a risk of denial of payment for a service if it happens to be billed without a modifier. But also remember, that you should not use modifiers routinely to just to try to be paid for service or to increase a fee for that service, if the service is not really unusual.

We have medical and surgical modifiers. The medical modifiers, in other words use most often in the office, but also modifiers that can be used in the hospital whether it's inpatient or outpatient are 24, 25, 26 and 57. And then, you can see the many surgical modifiers that are available for our use.

Who should append modifiers?

Well, in the best of circumstances, a urologist or the physician should understand the use of modifiers. And he should be really placing the modifiers on the specific codes.

Unfortunately, physicians and urologist are not always up to date with respect to knowledge of

modifier use. And it comes down to both the urologist and the coder working together in placing the right modifier when necessary. On occasion and in some practices, the professional coder is really the only who is placing modifiers.

Sequencing of modifiers for payment

Now, the modifier that should go in the first position after the CPT code, these are called pricing, functional modifiers, to get paid modifiers. And this would include modifier 24, 25, 57, 58, modifier 59, 76, 77, 78 and 79.

To understand sequencing of modifiers, these modifiers always go first. So, you should memorize this group of modifiers because if you memorize these then you will know that all the others go after these modifier.

We have informational or compliancy modifiers, in other words, how to get paid. And these modifiers usually go in the second position after the above modifiers placed in the first position.

Now, we also have HCPCS modifiers which are basically informational modifiers. And then, if you look those over, you'll see that they are alphameric and some alphanumeric. These always go last. The HCPCS modifiers, the alphameric or the alphanumeric that you have always go the last. And then if you do know and memorize the first punch, the first level, you will always know that the HCPCS go last and then any other modifier goes in the second position.

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