Understanding Medical Coding Modifiers: A Comprehensive Guide

Medical insurance coding is a crucial part of the reimbursement process from third party payers. A medical coder translates the physician's chart notes into codes for billing the insurance companies. Modifiers are sometimes used with Current Procedural Terminology (CPT) codes to convey additional information regarding the patient's visit or procedure. But modifiers can be difficult to understand. If the wrong modifier is used, the insurance claim can be delayed or denied, resulting in a delay in reimbursement for the medical facility. Resources are available to help translate situations in which a modifier may be needed.

Things You'll Need

• Current Procedural Terminology (CPT) code book

Show More

Instructions

• 1

  Refer to the front cover of the CPT code book. A modifier table is listed there with simple explanations of which situation the modifier may apply to.

• 2

  Refer to Appendix A of the CPT code book. This appendix gives more detailed explanations of each modifier. Anesthesia modifiers, Outpatient Surgery Center modifiers, and HCPCS modifiers (for Medicare and Medicaid).

• 3

  Read through some of the clinical examples listed in Appendix C of the CPT code book. This may help to decide if one of the examples resembles your situation.

• 4

  See Appendices E and F. These Appendices list codes that are exempt from 51 and 63 modifiers.

• 5

  Contact the patient's insurance company and ask a representative for guidelines when billing with modifiers. Insurance company billing guidelines vary. Speaking with a representative and asking questions will help to clarify your coding modifier questions.