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What Is Modifier In Medical Billing And Coding

Making A Good Choice Of Medical Billing Company for Good Practice

Best Medical billing company have been known to provide solutions to doctors that allow them to concentrate on providing health care to their patients. It can be quite difficult for a doctor running a private practice to take care of patients, bill them and follow-up on their payments. This is where these companies come in. They do all the billing and accounting for the doctors.

When you sign up with these Best Medical billing services for small practices, you will be able to provide better and personalized care to your patients. This helps to improve your reputation as a good doctor. Word of mouth will soon bring you more patients thereby increasing the size of your practice. It is therefore important that you carefully select the billing company to work with.

You should find out what kind of fee structure they will offer. Will they bill you per patient or will they bills you one flat-rate per month. Carefully weigh the pros and cons of both methods before you make your decision. If your practice is small, then you should look for one that will charge you a small percentage of every bill that they handle. If your practice is big then you should look for one that charges you a flat rate per month.

You should also look for medical billing companies that are well versed in the latest methods of coding and are using updated billing software. This will show that they are professionals who strive to keep up with the latest regulations concerning medical billing methods. You should also look for those who have been in the field for a long time. The testimonials pasted on most web sites may be entirely false and you need to look for independent reviews and first-hand testimonials from other companies.

What is a Medical Billing Modifier?

For processing a claim, Modifiers are added to provide additional information necessary to the Current Procedural Terminology (CPT®) or Healthcare Common Procedure Coding System (HCPCS) codes. The information includes identifying the reasons a qualified healthcare professional or doctor provided a specific service and procedure.

The usage rules of modifiers by insurance or third-party payers vary with specific CPT® or HCPCS billing codes, making it more complicated. HCPCS or CPT® codes do not allow the usage of all modifiers.

Besides that, keeping up with the following is also critical to make sure the coding of the claims is correct:

  • Local Coverage Determinations (LCD)
  • National Coverage Determinations (NCD),
  • Medicare Administrative Contractors (MAC)

Modifiers Misusing In Billing Can Trigger Audits

It can lead to hefty fines if you misuse medical billing and coding modifiers. Unfortunately, it can trigger an audit, and they can go many years back. The $10,000 Medicare audit fines for each occurrence may get implemented. You might be charged $10,000 for each occurrence every time you bill a modifier on a claim incorrectly, and these fines add up quickly.

What Are CPT and HCPCS Codes?

American Medical Association® publishes CPT® codes that consist of four types or categories. These codes describe any changes to the procedure and are five-digit codes and two-character modifiers. These codes are numeric or alphanumeric.

HCPCS codes are five-character, alpha-numeric standardized code sets. These are used for billing and coding Medicare and Medicaid patients. These codes correspond to services, treatments, procedures, and equipment not covered by CPT® codes. HCPCS billing codes are monitored by the Centers for Medicare and Medicaid Services (CMS).

Advantages of Using Modifiers


There are a lot of advantages and benefits to using modifiers for medical billing and coding. And the usage of modifiers in medical billing and coding helps in:

Submitting clean and accurate claims to avoid claim denials

Obtaining the right reimbursements by submitting a higher level of coding specificity claims

Receiving improved reimbursements for medical services. It implies services rendered alongside or in an uncommon manner depending on the unambiguous nature of the case.

Few Facts To Remember:

If you have added modifiers in medical billing and coding, here are a few facts to keep in mind:

  • It is is not always appropriate to call in to review and add a modifier just because a service or treatment was denied.
  • Review can be requested when you add the 24, 25, 26, 58, 59, 76, 78, or 79
  • modifiers to a denied service: .
  • it isn’t a good practice to try another
  • modifier
  • if one modifier does not result in a paid claim.

Importance of Modifiers

Medical Billing and Coding modifiers play a vital role in medical claims processing, and they are of utmost importance. Therefore, there must be extra care shown while using these modifiers in healthcare facilities and providers’ medical billing and coding processes. There could be serious damage to reimbursements if they fail. Why are modifiers important in the medical billing and coding process? Let’s dig deep:


Simply, modifiers are two-digit codes comprising alpha, numeric or alpha-numeric codes. They describe and explain the Codes for a specific treatment or procedure, or medical service provided by a Provider.

These modifiers help third-party payers immensely, especially when processing medical billing and claims. They subsidize the proper reimbursement for services a provider gives.


Modifiers provide clarification to insurance payers as follows:

  • They explain the technical or professional components of the provider services or a combination of both
  • They stipulate the number of physicians involved in interpreting a particular service, treatment, or procedure
  • It clearly indicates if a service, treatment, or procedure is performed in more than one location.
  • If a service or treatment performed completely or partially, the modifiers also clarify it.
  • If any mishap occurred during the treatment course or during service, the details are coded.


Frequent misuse of medical billing and coding modifiers is not unusual for private practices. If you have used a modifier incorrectly, you might have to return money that you get paid by insurance or third-party payers.

This can be a costly and heavy on pocket mistake if you incorrectly use a medical billing and coding modifier on a claim. Here are some details and information you need to know about Medical billing and coding modifiers.

GreenSense Billing provides medical billing and coding services with the correct use of modifiers so that you submit error-free claims to get prompt reimbursements. We provide exceptional services that streamline your revenue cycle and maximize practice collections to make sure you focus on patients like never before.

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