Modifiers: Scenarios

According to the American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS), a modifier provides the means to report or indicate that a service or procedure that has been performed has been altered by some specific circumstance but has not changed in its definition or code.

Box Definition

Box 24d is used to identify the medical services and procedures provided to the patient. Enter the CPT code(s) and applicable modifier(s). This field accommodates the entry of up to four two-digit modifiers.  Please note: this article addresses modifiers only, even though the HCPCS/CPT code is included in Box 24D.

Modifiers appear in Box 24D - Procedures, Services, or Supplies

Some common behavioral health modifiers used are:

TT	Individualized service provided to more than one patient in the same setting.
HF	Substance abuse program.
59	To identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances.
25	To report an Evaluation and Management (E/M) service on a day when another service was provided to the patient by the same physician or other qualified healthcare professional.
GT	To indicate a service was rendered via synchronous telecommunication.
95	Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system.
GQ	To report services delivered via asynchronous telecommunications system.

Adding Modifiers to Services

The Claim Line Item rule is the main source of modifier automation when not directly tied to a standalone service billing profile. For more information, see the article on Claim Line Item Rule - Adding Modifiers.

Below are example scenarios by form and service type to help guide you toward the appropriate method.

CMS-1500: Professional Claims

Modifiers can be added to service lines in two ways, depending on the claim form type and any unique billing conditions. 

Scenario A: This service always needs a modifier, no matter the payer.

Solution: Add a dedicated modifier to the Professional Service Line in the Service Billing Profile.

Scenario B: This service needs a modifier only when billing a specific payer.

Solution: Create a Claim Line Item rule using the specific Services Billing Profile and Payer name.

Scenario C: This service needs a modifier only when it is billed with another service on the same claim form.

Solution: Create a Claim Line Item rule using the specific Services Billing Profile and the Claim Line Number condition.

Requirement: The service will always be ordered lower on the claim's service lines. *See Sequence Priority*

UB-04: Institutional Claims

Scenario A: This service always needs a modifier, no matter the payer.

Solution: Add a dedicated modifier to the Service Billing Profile.

Best Practice for Modifier Claim Rules

1. Create a naming format for all claim rules within AveaOffice. Examples include:
   • Payer Name, HCPCS/CPT Code, Modifier #
   • Payer Name, Type of claim (UB-04 or CMS-1500), Revenue Code for UB-04 claims, Modifier #
   • Description of Service, HCPCS/CPT Code, Modifier #
   • Billing Profile Name, Modifier #
   • Whatever format is chosen, be consistent.
2. Identify similar claim rules and determine if they can be consolidated and/or used for future claim rule requirements.
   • Maintaining all-organization claim rules makes for a cleaner process, less time for AveaOffice to parse through the claim rules, and is more efficient when researching the list of claim rules to determine how a claim ended up with 1, 2,3 and should have been A, B, C on the claim.
   • For example: If Payer A requires modifier 59 for all services and Payer B also requires modifier 59 for all services, use one claim rule. Do not make two claim rules for two different Payers when the condition and behavior match.
3. Review the Active state of claim rules. Assign or schedule tasks to review claim rules regularly.  When a claim rule is no longer required, set the claim rule's Active toggle button to No.
   • By scheduling this task, the claim rule analysis is much cleaner, less system processing time, and the team's research is more efficient. 

EDI File

CPT Code

Loop 2400, Segment SV101-2 (CPT Code) and SV101-(3-6) (Modifiers)

Related Articles

Adding Modifiers to Services