What Are Modifier Codes?

If you’re new to insurance billing, the idea of modifier codes can be confusing. Modifier codes are a way to notify the insurance company that a healthcare service has been provided, and altered—but not altered enough that it changes the definition of the service or the insurance code associated with it. That way, you can avoid making separate procedure listings simply to describe where the service diverged from the typical standards. Knowing how to use modifiers—or using a medical billing service in St. Louis, MO that does—is critical to insurance coding. If you’re not using them properly, you may miss out on payments or be subject to audits.

Here is an overview of the most common modifier codes and when you might use them:

  • Modifier 22: This describes “increased procedural services,” which is an audit magnet, so only use it when there’s no CPT code available for the increased services. You’ll need to include documentation for why the service was needed and the reason it’s considered “increased,” such as a particularly time-consuming or severe case.
  • Modifier 24: This can also be an audit trigger if used incorrectly. Modifier 24 allows you to bill for an unrelated E/M service during a post-operation period. You’ll need to show that the service was unrelated to the surgical procedure and billing.
  • Modifier 25: This modifier code can only be added to an E/M CPT code. It allows physicians to add a “significant, separately identifiable” E/M service on the same day of another service, provided by the same physician. The chart notes must reflect that both procedures are separately identifiable. For new patients, modifier 25 can be used to bill a patient for an initial service code and minor surgical code. Established patients can be billed for separate services on the day of a surgery, so long as the diagnosis codes are different.
  • Modifier 57: If the E/M requires a major surgical procedure, you can use modifier 57 in place of modifier 25. It allows you to include procedures the day before the surgery, unless the procedure was the reason for needing the surgery in the first place.
  • Modifier 59: This modifier code is often misused, which can open you up to an audit. If no other modifier codes are appropriate, modifier 59 can be used to group services that aren’t normally coded together, but should be under the circumstances. You’ll need documentation to support that this is a different procedure or service that isn’t ordinarily performed on the same day as other services.
  • Modifier 79: This is used for unrelated services or procedures performed during a post-op period. The diagnosis code is required to be different than the operation’s diagnosis code.

If this seems overwhelming, let the experts take care of it for you. Midwest Core Billing is a medical billing service in St. Louis, MO. Our team can ensure your coding is always correct, so you get paid and meet compliance requirements. Reach out to us today to get started.