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BUSINESS OF SAN ANTONIO
MEDICINE MEDICINE

The Theft & The Gift
Two Characters Can Impact Your Reimbursement:

THE IMPORTANCE OF USING MODIFIERS By Rajam Ramamurthy, MD

By Deion Whorton, Sr.
It is a dreary wet day, December 24, 2020. Little difference does that make; nowhere to go anyway. The year will end soon;
the year stolen from me. Why does it have to happen to me? It was not my creative moment; my head fell on the desk and
It is important for physicians and their during the postoperative period that is not the pen rolled out of my hand on to the note pad.
staffs to know when it is applicable to ap- related to a surgery. This modifier should be
pend a modifier to a CPT or HCPSS used if a patient sees a medical provider after The Theft
code. Using the correct modifier is crucial in contracting nasopharyngitis within a few
It was the year before Christmas when all through the world
order to be reimbursed at the correct weeks after an appendectomy.
Nothing was moving not even the planes I am told.
rate. Failure to append a modifier to a code Modifier 25- Significant, Separately Iden-
Children spent hours in front of the screen
can also delay payment. tifiable Evaluation and Management by the
What ever happened, why does mom not scream.
Modifiers are used to supply additional in- same physician or other healthcare profes-
Some weary troubled eyes peaked over the masks,
formation or to report an adjustment to a sional on the same day of a procedure or an-
Whiles others spue the poison and go about their tasks.
procedure or service provided by a medical other service. This modifier is only appended
Humanity receded into their homes and bolted the doors
professional. Depending on the situation, to an E/M code when another service is pro-
What of the millions with no roof nor doors or floors?
modifiers can increase or decrease the reim- vided during a visit. This modifier is likely to
While patients crowd the over filled hospital,
bursement rate for services rendered. trigger an audit with the insurance carriers if
Argument abound that this is a hoax, in the capital.
There are two types of modifiers associ- used in excess. Insurance carriers are known
News from far and near of kith and kin dying,
ated with medical billing. The first type of to pend these claims and request medical
The mind numbs with zoom gatherings unable to silence the crying.
modifier used in medical billing is CPT records. This modifier should be used if the
By summer, no, Thanksgiving, for sure Christmas, I concede bereft,
modifiers. These modifiers, in numeric for- original purpose of the encounter was for
A year when no memories were made, just lament the grand theft.
mat, were adopted by the American Med- evaluation and management. If an

ical Association. The second type that is OB/GYN requests an ultrasound during the
I woke up with a stiff, sore neck; the outside was ablaze with the winter sun. I felt that someone had come into the room.
used in medical billing is HCPCS modi- office visit, the provider can bill for the office
I picked up the pen and it danced on the page as though it had a mind of its own.
fiers. Unlike CPT modifiers, there are hun- visit and the ultrasound. Modifier 25 must applicable modifier should be used based on
dreds of HCPCS modifiers and they are in be appended to the evaluation and manage- the documentation. Some insurance payers The Gift
alpha or alpha numeric format. These mod- ment code. If the purpose of the visit is may require you to append the code twice
It was days after Christmas when all through the world
ifiers are often used when reporting a sur- strictly for an ultrasound, you should not bill and append RT and LT modifiers.
Weariness descended and the sprit curled.
gical procedure. an office visit. Modifier 57- Decision for Surgery- This
When in the news papers arose such a chatter
It is important to report a HCPCS mod- Modifier 33- Preventative Service- This modifier is appended to an E/M code when
It spread like a storm in Facebook and Twitter.
ifier when the procedure is not performed modifier is appended to services that are a physician decides the patient needs sur-
There was a little man brilliant and bossy
bilaterally (this will be discussed later in this considered preventative care. The payer will gery. The surgery is generally done within 24
At once I knew it had to be the straight talking Fauci
article). There are HCPCS codes that are pay 100% of the allowable when used appro- hours after evaluation. This modifier is typi-
Now Pfizer, now Novavax, now Glaxo and Moderna,
used to indicate a provider’s credentials and priately. Internal and family medicine cally appended to emergency room and ini-
On Johnson, on Sanofi, on Astra and Zeneca.
the location where services are providers will append this modifier to well tial hospital care evaluation and
To the bench, to the lab, brilliant minds reach tall
rendered. Government insurance carriers visits and any immunizations that are recom- management codes. If a patient presents to
Sweat and slog to answer the clarion call.
typically require providers to append these mended. A gastroenterologist provider may the emergency room and it is determined
Chimneys were cooled to an unbelievable freeze
modifiers, if applicable. Every insurance car- use this modifier if they perform a that he or she has appendicitis, the patient
Down came St. Nicolas and let out a big sneeze.
rier is different regarding the use of HCPCS colonoscopy due to family history or age. will need emergency surgery. The patient
With a twinkle in his eyes and nod of his head
modifiers. It is imperative that the billing Modifier 50- Bilateral Procedure- This will more than likely be admitted based on
He opened the freezer and the laid the little vial on the box of gingerbread.
and coding team knows when it is appropri- modifier is appended to a procedure code this finding. The reported codes on the
He flew up the chimney, and jumped onto a strange looking sleigh
ate to append the appropriate modifier. when the procedure is performed on match- claims will be the appropriate E/M code
It had UPS painted on it and it took off with a sway.
ing organs. Examples of a matching organs with the appended modifier and the appli-
Below are examples of the commonly are ears. If a pediatric patient has recurrent cable CPT code for the appendectomy. Hear now! Hear now! Neighbors and friends
used CPT & HCPCS modifiers, episodes of otitis media in both ears, the pa- Have you checked your freezer; it is all good what the New Year portends?
along with examples of when it is tient may require tympanostomy tubes to Deion Whorton Sr. is the CEO
appropriate to use these modifiers: prevent fluid from accumulating around the of PCS Revenue Cycle Manage- I woke up with a jolt and ran to the window, the glass of milk was empty, and the cookies were gone.
I looked up and saw two red dots rapidly fading in the distant sky. I turned around and made my way to the freezer.
Modifier 24- Unrelated Evaluation and ear drums. The modifier should be appended ment. He is passionate about help-

Management Service by the same physician to the appropriate code describing the inser- ing physicians and healthcare
Rajam Ramamurthy, MD was the 2004 President of the Bexar
or other qualified healthcare professional tion of the tympanostomy tubes. There may professionals increase profitability within their
County Medical Society and is Professor Emeritus, Department
during a postoperative period- This modifier be additional codes reported if there is fluid organization. PCS Revenue Management is a
of Pediatrics/Neonatology at UTH San Antonio.
should be used for a visit that has occurred prior to the tubes being inserted. If so, the member of the BCMS Circle of Friends.

32 SAN ANTONIO MEDICINE • February 2021 Visit us at www.bcms.org 33