Appropriate Modifiers can Reduce Denials

Posted by Ecareindia on February 28th, 2015

Everyone in the healthcare billing space knows very well that a wrong modifier can have a huge impact on the reimbursement. It is to avoid such errors that healthcare entities have employed dedicated teams to pay more attention in coding and applying modifiers. However, with the ICD-10 transition, the coding strategies are expected to change widely. Medical coding specialists can carry out medical claims processing, only if they are well-versed in ICD-10 medical coding techniques. Modifiers vary based on other factors too, so using the appropriate ones is very important for proper claim payment and to minimize denial management efforts and a pile up of accounts receivable management. Let us take a look at the importance of Modifiers and how widely they vary:

What are Modifiers?

Each medical service rendered by Providers is assigned with a specific CPT code. Sometimes, to shed more light on a particular service, two digit alpha, numeric or alpha-numeric codes are used along with the original CPT code and these codes are called Modifiers. They help a great deal in explaining to the Payers whether the service involved one or more physicians, had professional or technical component, provided in one location or multiple locations, why 2 similar services were done the same day etc.

Modifiers vary based on the following factors:

  • Modifiers vary from in-network to out-of-network Providers. Payers completely pay the contracted amount, if the medical services are provided by in-network Providers. It is applicable once the deductible and coinsurance are exhausted. In case the same services are provided by out-of-network Providers, then the insurance coverage and reimbursement patterns vary. They are differentiated with the help of modifiers. Using the appropriate modifier is essential to avoid later denial management.
  • In addition to in-network and out-of-network Providers, there are FQHC (Federally Qualified Health Center) Practitioners. Their main goal is to provide exceptional primary care services to underserved rural and semi-urban communities. Here again, the modifiers vary widely. 0524, 0519, 0527, and 0521 are a few examples of FQHC revenue codes. Using appropriate modifiers along with these codes is essential for error-free medical claims processing.
  • With the impending ICD-10 medical coding implementation, over 200,000 new codes and modifiers are expected to be included in the existing code set. Carrying out medical claims processing based on the new code set and modifiers can be truly challenging. In addition, healthcare entities will have the necessity to train their staff on the new coding strategies, which requires a huge investment. To avoid such things, they can take help from reputed offshore medical claims processing companies who can perform medical coding precisely based on the new techniques.

About e-care India:

E-care India has 15 years of medical billing and coding experience in the industry. E-care’s 3 offshore medical billing delivery centers have been providing end-to-end medical claims processing, denial management services seamlessly to its clients. To know more about e-care and its services, log on to

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