Health Information Management

Tip: Know payer policies for modifier use

APCs Insider, October 15, 2010

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Knowing when to append a modifier can challenge even the most experienced coder. Coders need to know more than just the modifier’s definition to determine whether a modifier is needed, and if so, which one.

Always check your payers’ policies for every modifier. Although payers cannot change the definition of a modifier, they can create policies for modifier usage.

If you receive a significant number of denials for inclusive services, you may not be following the payer’s policies. Contractors will specify what each procedure includes, so you need to be familiar with what each payer requires. Otherwise, you won’t be able to appropriately report codes and modifiers.

CMS and CPT also specify what is included in certain procedures, but payer policies may include more than CMS and CPT guidelines.

This tip was adapted from “Right modifier, wrong modifier? How can you tell?” in the October issue of Briefings on APCs.



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