Ranking Modifiers

by Steve Adams

Modifiers enable a provider to report that a service or procedure has been altered by some specific circumstance, when that circumstance is not defined by a different code.  The use of modifiers eliminates the need for separate procedure listings that may describe the modifying circumstances.

Modifiers may be used to indicate that:

  • A service or procedure has a professional or technical component.
  • A service or procedure was performed by more than one physician and/or in more than one location.
  • A service or procedure has been increased or reduced.
  • Only part of a service was performed.
  • An add-on or additional service was performed.
  • A bilateral procedure was performed.
  • A service or procedure was provided more than once.
  • Unusual events occurred.
  • A service or procedure was performed on a specific site.

Some modifiers are used for informational/statistical purposes only, and do not affect reimbursement, while other modifiers, when used, will always affect reimbursement.

Understanding which modifiers affect reimbursement and which ones don’t will allow you to better understand how to properly submit a claim when more than one modifier is needed to describe a service. 

To help you use multiple modifiers on a single CPT code, you will need to know how to “Rank a Modifier.”  To properly rank a modifier you’ll need to know two things:

  1. The three categories of modifiers; and
  2. The rules for ranking when multiple modifier categories are used. 

The Three Modifier Categories

There are three categories of modifiers:

  1. Pricing Modifiers
  2. Statistical Modifiers that Affect Pricing
  3. Statistical / Informational Modifiers

Again, when more than one modifier is submitted, the modifiers must be ranked.  The following categories serve as a reference point when ranking modifiers.

  1. 1.      Pricing Modifiers are considered part of the seven-digit procedure code by the CMS and are used to determine the reasonable charge or fee for a service.

    *TC       *26

* Denotes modifiers which are valid for the first modifier field only.

  1. 2.      Statistical Modifiers that Affect Pricing are appended to a procedure code and always cause the reasonable charge or fee for the code billed to be modified in the same way every time.
*AA *AD AH AJ AS GM
QB *QK QU *QX *QY QZ
SG *UN *UP *UQ *UR *US
22 50 51 52 53  
54 55 56 62 66 73
74 78 80 82 99  

* Denotes modifiers which are valid for the first modifier field only.

  1. 3.      Statistical / Informational Modifiers are used for documentation purposes and can affect the processing or payment of the code billed:

 

AT
F1
G1
GC
GW
Q3
QM
*SF
VP
*90
AM
F2
G2
GE
GY
Q4
QN
T1
23
91
CC
F3
G3
GG
GZ
Q5
QP
T2
24
E1
F4
G4
GH
KO
Q6
QQ
T3
25
E2
F5
G5
GJ
KP
Q7
QS
T4
47
E3
F6
G6
GN
KQ
Q8
*QT
T5
57
E4
F7
G7
GO
LC
Q9
QV
T6
58
EJ
F8
G8
GP
LD
QA
*QW
T7
59
EM
F9
G9
GQ
LR
QC
RC
T8
76
EP
FA
GA
GT
LS
QD
RP
T9
77
ET
FP
GB
GV
LT
QL
RT
TA
79

* Denotes modifiers which are valid for the first modifier field only.

Putting It All Together

Whenever you use only one modifier you are only using one category and ranking doesn’t apply:

As an example, when billing for the professional component (26) or the technical component (TC) enter the 26 or the TC modifier in the first modifier field.

Or, you are billing for a separately identifiable EM service (25) on the same day as a minor surgery enter the 25 modifier in the first modifier field.

When using a pricing modifier and a statistical modifier that affects pricing; enter the pricing modifier in the first modifier field and the statistical modifier that affects pricing in the second modifier field.

As an example, when billing for the professional component (modifier 26) in a Health Professional Shortage Area (HPSA) (modifier QB) enter 26 in the first modifier field and QB in the second

When using a pricing modifier and a statistical/informational modifier; enter the pricing modifier in the first modifier field and the statistical/informational modifier in the second modifier field.

When billing for the professional component (modifier 26) and repeated procedure by the same physician (modifier 76) enter 26 in the first modifier field and the 76 in the second modifier field.

When entering a statistical modifier that affects pricing with a statistical/informational modifier, enter the statistical modifier that affects pricing in the first modifier field.

When entering more than one statistical/informational modifier with no modifiers that affect pricing, it does not matter which modifier is entered first. The exception is for the SF, QT, QW and 90 modifiers. These three modifiers are valid in the first modifier field only.

When more than four modifiers apply, enter modifier 99 in the first modifier field.  In the narrative field (item 19 on the claim form) list all modifiers in the correct ranking order being sure to identify which detail line or procedure code to which the modifiers apply.

Hope this helps you better understand how to rank modifiers on a single CPT code.

 

 



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