Misunderstood Modifiers

Many attended my presentation on Modifiers last month in Dallas at AAPC®️Healthcon where I discussed many modifiers that effect the Global Billing process and Surgery Claims. As many will attest that we only scratched the surface when it comes to modifiers. There are so many modifiers to use in so many areas of reimbursement and there are so many that are misunderstood. Today I’m going to pick on modifier 95 and GT. First let’s answer a question though.

Why are Modifiers Misunderstood ?

First let’s answer the question of why modifiers are so misunderstood. Well as we know they are numerous and not only created by CPT®️ and CMS®️but are also used by insurance payers who often create their own modifiers not found in our code books. Over the years I have found myself overwhelmed by all the options. Just when we think we understand how to use a particular modifier, a different payer decides they don’t want us to use it and they say “No use this instead” It’s a headache right?

Telehealth Modifiers

As we have seen in the last year, misunderstood modifiers become the most evident when we are billing for Telehealth services. I have to admit I was definitely not a fan of these modifiers as I just could not grasp when you use which one so it was a struggle but I persevered.

Let’s start with Modifier 95-(synchronous telemedicine service rendered via a real-time audio and video telecommunications system) as this is the most common modifier we see today for most payers, but it wasn’t used as widely as it is now.

Back in 2017 it was new and Per the AMA, modifier 95 means: “synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system.” Plus before the PHE Telehealth coverage was significantly different for each insurer. Back then it was only used for services that were listed in Appendix P of the CPT manual.

Now we have the PHE and so in 2020 payers that only allowed it in certain circumstances now said ok we have to maybe rethink how we use this modifier. So how is it interpreted now?

Well when providers had to start seeing patients via telehealth that were located now at home , we know that normally would have been in POS 11 Office. The CMS Contractor needed a way to determine that the service is telehealth. So since they were at home instead of physically POS 11, they needed to know if it was a truetelehealth visit or if the telehealth visit was due to the PHE and intended for POS 11 (Office).

So in comes CMS saying “Ok let’s use modifier 95 to the POS 11 code so the office, or other POS( place of service) can be reimbursed , and we will know it was telehealth during the PHE.

Remember though that back when it was introduced there was some overlap between when we could use modifier 95 and our next modifier GT.

Then we come to Modifier GT which tells the insurance company that the service was done via an interactive audio and video telecommunications system. So they sound similar right? So now during the PHE when more insurance companies are changing their interpretations of these modifiers for this unique era of the Public health crisis, we find our heads spinning and wondering when to use each one.

My advice is continue to check payor policies for non CMS payers as to how they want the POS and modifiers appended for each type of service. The concept of checking payer policies will never change but if you make a habit of organizing them and just updating them as needed, then you will simplify things for your practice and be the one everyone can count on for up to date accurate information.

Another thing Ive learned that makes things pretty simple is:

“Never argue how to bill something with an insurance company if they have a specific policy on how it’s supposed to be billed, especially with modifiers!”

They are not created equally and they will interpret them differently which is why there is so much confusion with 95 and GT. So until we are out of the PHE and beyond it’s best to always get in their policy and find out which modifier they want and POS to indicate telehealth service during the PHE. When it comes to getting paid, we let them tell us how to report services on a claim form, plain and simple.

Stay Alert with CMS

It’s so important to watch CMS changes because as we have seen the updates are ever changing and new updates to covered codes for the PHE get updated. As with everything in this industry we cannot say “Well that’s the way I’ve always done it” This will get you numerous denials when you have stayed the same but the insurance carrier blows right past you.

Stay Vigilant and alert and learn to enjoy research. It’s your best friend and teacher. It will make you a better coder and a better biller.

Let me just say to all you readers who are new to coding and reimbursement that regardless of if you work in billing or coding or both that yes it can be challenging but no matter what role we are on the most important quality you can have is a positive attitude. When you struggle with learning new modifiers just take it slow and try to learn a few at a time until you understand. Don’t have a negative attitude thinking you will never grasp it. Instead take a pro active approach and get organized. Look up a few on payer websites and see how they define and interpret them. My biggest lightbulb 💡 moments were when a payer described a modifier in a more clear and concise way than another payer and it was such a cool moment when it clicked.

You can have those moments too! Stay positive and determined.




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