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What Are Modifiers in Medical Billing?

By DeVry University

September 25, 2023

5 min read

If you’re preparing to pursue a career in medical billing and coding, you should familiarize yourself with modifiers in medical billing. Modifiers are an essential tool used in medical billing and coding, and just one of several aspects that are important to learn.

In this article, we will answer the question, “What is a modifier in medical billing?” by defining code modifiers and examining their different types, how they’re used and the advantages they deliver to healthcare providers as they enable a greater degree of accuracy and specificity in reporting.

What is a Modifier 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:

  • Submit cleaner and more accurate claims, thereby avoiding claim denials.

  • Obtain the proper reimbursements by submitting claims that contain a higher level of specificity in coding.

  • Improve reimbursements for services that have been rendered at the same time or in an unusual manner, depending on the complexity of the case.

Types of Modifiers in Medical Billing

CPT and HCPCS modifiers

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:

  • 25: Significant, separately identifiable evaluation and management service by the same physician or other healthcare professional on the same day of the procedure or other service

  • 26: Modifier 26 is used to bill the component of a service when it has both professional and technical components. In radiology services, for example, the physician’s note on the scan is considered to be the professional component, while the machinery used is the technical component. 

  • 59: Modifier 59 is used to specify distinct procedural services. These services are different or impartial from other non-evaluation and management services that were performed on the same day. 

HCPCS Level II codes and their modifiers are maintained by the CMS and are either alphanumeric or consisting of 2 letters. Examples of HCPCS Level II modifiers include:

  • E1: Upper left, eyelid

  • TC: Technical component; under certain circumstances, a stand-alone charge may be made for the technical component of certain procedures, such as X-rays that are billed by portable X-ray suppliers.

  • XS: Separate structure, a service that is distinct because it was performed on a separate anatomical structure, such as an organ.

Pricing and informational modifiers

Modifiers are also separated by their purpose. Regardless of which code set they are from – CPT or HCPCS Level II, modifiers are separated into 2 categories: 

  • Pricing modifiers, also called payment-impacting modifiers, cause a change in pricing for the code reported. 

  • Informational modifiers, also called statistical modifiers, are any modifiers that are not pricing modifiers, and appear after pricing modifiers on claims. 

Common Modifiers in Medical Billing

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:

  • GT or 95: Used to code all of the diagnoses, evaluation or treatment of symptoms via telemedicine, this modifier is used only when the service is offered via an interactive audio and video telecommunication system.

  • 24: This modifier is appended to unrelated evaluation or management service offered during the post-operative period of a major surgery performed within 90 days by the same physician.

  • 51: Used when multiple procedures or surgeries are offered by the same provider during the same surgical session, including diagnostic imaging services offered during the surgical session.

  • 27: This modifier is used when a patient is offered multiple evaluation and management services at different outpatient facilities, such as the emergency room, a pharmacy or primary clinic on the same day, by the same physician or different physicians.

Prepare to Pursue Your Medical Billing and Coding Career with DeVry

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.

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