Adding a modifier to a CPT code
Since medical procedures and services are often complex, we sometimes need to supply additional information when we’re coding. CPT Modifiers, like modifiers in the English language, provide additional information about the procedure. In English, a modifier may describe the who, what, how, why, or where of a situation. Similarly, a CPT modifier may describe whether multiple procedures were performed, why that procedure was necessary, where the procedure was performed on the body, how many surgeons worked on the patient, and lots of other information that may be critical to a claim’s status with the insurance payer.
CPT Modifiers are always two characters, and may be numeric or alphanumeric.
CPT modifiers are added to the end of a CPT code with a hyphen. In the case of more than one modifier, you code the “functional” modifier first, and the “informational” modifier second. The distinction between the two is simple: you always want to list the modifiers that most directly affect the reimbursement process first.
There’s a straightforward reason to this, too. While CMS-1500 and UB-04 forms, the two most common claim forms, have space for four modifiers, payers don’t always look at modifiers after the first two. Because of this, you always want the most important modifiers to be visible. We’ll return to this point in a few examples after we examine the CPT modifiers.
In our system we allow for 3 modifiers. the instructions below will explain how to add the modifier to the CPT Code
First, navigate to the payment source that needs the modifier on the CPT code.
List Maintenance > Payment Sources
Find the insurance you would like to edit the CPT Codes for, and click on the name to edit.
If the insurance company is waterfalling CPT codes from a different payer, you will need to load up that Insurance Company.
Under the insurance company, select the Rates tab
In the procedure grid, edit the procedure that contains the CPT Code
You should now see the CPT Code under the Insurance Rate grid
Click on the Edit in the row of the CPT Code that you want to add a modifier to
Change the CPT Code value to include the modifier.
You can add up to 3 modifiers in in this CPT code
[CPTCode]-[Mod1]-[Mod2]-[Mod3]
For example: 97110-UB-TL
97110 THERAPEUTIC EXERCISES, EACH 15 MINUTES, ONE OR MORE AREAS
U2 - MEDICAID LEVEL OF CARE 2, AS DEFINED BY EACH STATE
TL - EARLY INTERVENTION/INDIVIDUALIZED FAMILY SERVICE PLAN (IFSP)
Save the CPT Code by clicking the Update button
The Bill Setup for the Insurance Company will need to have the modifier defined. If it does, generating a new EDI file or CMS1500 will contain the modifier that was entered above.