What Are Modifiers in Medical Billing?

As defined by the American Medical Association (AMA) and the Center for Medicare and Medicaid Services (CMS), code modifiers enable medical records technicians, medical billing specialists and others with medical billing and coding training to provide a more detailed description of services and procedures performed without changing the definition of those services. For example, a modifier can be used to denote which side of the body a procedure was performed on, or to signify that not all of the services in a bundle have been performed. In medical billing, bundled services refer to a payment model in which a single payment covers multiple services or procedures that are typically performed together in a care episode, such as a hip replacement. For both healthcare providers and patients, the key benefits of bundling services include cost savings, improved care coordination and transparency in healthcare pricing.

The AMA created Current Procedural Terminology (CPT) codes as a way to standardize the documentation of medical, surgical and diagnostic services and procedures. They update CPT codes and create modifiers annually, maintaining them in CPT code books.

Expanding the coder’s ability to report unique aspects or circumstances of services or procedures, modifiers consist of 2 numbers, 2 letters, or a number and a letter that follow the 5-digit procedure code. The use of modifiers in medical billing eliminates the need for the AMA to create thousands of separate codes to account for details and circumstances associated with each procedure that is coded.

What are the advantages of using modifiers? They enable healthcare providers to:

Two types of modifiers in medical billing—CPT modifiers and HCPCS Level II modifiers—are commonly used. The AMA’s CPT modifiers, as described earlier, are alphanumeric in nature and apply to CPT codes. Examples of CPT modifiers include:

Modifiers are also separated by their purpose. Regardless of which code set they are from—CPT or HCPCS Level II—modifiers are separated into two categories: 

Insurance payers, including private insurance plans and Medicare, can deny claims if code modifiers are missing or used incorrectly. Healthcare providers and their medical billing and coding professionals, such as medical billing specialists, need to stay on top of this to avoid loss of revenue.

Some common modifiers in medical billing include:

If you have the desire to make a difference in the healthcare industry, explore careers in medical billing and coding. At DeVry, we can help you prepare to pursue career roles like medical coding specialist, medical records technician, health information clerk and many more after earning a degree or undergraduate certificate with us.

When you partner with DeVry, you study on your terms. Our 6 academic sessions per year allow you to start when you’re ready and learn at your own pace, finishing on a regular or accelerated schedule that meets your personal and professional goals. Let’s talk about getting you started in our next session.