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Sometimes, the most important charges are lost because of incorrect modifiers. Make sure your billing team is well-versed on code addendums to correctly explain services to payers to get correct reimbursements.

Misstep 5: Choosing Incorrect (or Forgetting!) Code Modifiers

Code modifiers are an addendum to a selected CPT code, which help accurately describe to the insurance payer the type of services provided to the patient. Often, services don’t fit nicely into one CPT code—so modifiers can make the difference with explaining what exactly was provided to the patient. For example, if a patient had two distinct procedures performed during the same encounter on the same day, a modifier would be needed.
Code modifiers can easily be missed, used incorrectly, or abused. It’s also important to understand each payer’s requirements. Individual payers have varying levels of acceptance of certain modifiers, and the misuse of modifiers will cause claim denials.
Understanding HCPC levels is key to accurate reimbursement. HCPC Level 1 codes refer to CPT code charges. HCPC Level II codes are included for injectable drugs, medical equipment, or supplies provided in addition to treatment—such as splints or crutches. If you supply medical equipment, ensure you use correct code modifiers to prevent denials.

What are HCPC and CPT modifiers? HCPC modifiers begin with a letter and can be combined with numbers. Common samples of HCPC modifiers in urgent care include NU, RT, TC, and LT—along with Q5 and Q6. Medicaid has state-specific requirements for the use of modifiers beginning with U. CPT modifiers are always numeric, and modifiers 25, 26, and 59 are frequent in urgent care. As of 2015, the Centers for Medicare and Medicaid Services have subset requirements to clarify the 59 modifier for a more accurate service description.

Advice: Ensure coders understand the proper use of modifiers. Run a report on your most used CPT codes and corresponding modifiers and include these for easier selection on your superbill or in your EHR. Use code scrubbing software to automate repetitive modifier and code selections. Audit periodically to ensure modifiers are correctly correlated to provided services.

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Looking for a better EMR/PM and billing services for your urgent care? Take a look at DocuTAP’s cloud-based, tablet-run EMR and revenue cycle management services designed specifically for urgent care clinics.

This resource was first published prior to the 2019 merger between DocuTAP and Practice Velocity. The content reflects our legacy brands.

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