How to Use Medical Billing Modifiers for Government Payers

In medical billing, modifiers may be necessary when you encounter claims with Medicare and other government payers. Knowing what to do in each instance can be a huge time saver.

How to use modifiers for Medicare

Medicare claims always require the use of appropriate modifiers such as the following:

  • Modifiers that indicate laterality.

  • Modifiers that indicate services were provided by resident medical students. It may also require a specific modifier to indicate that the reason another physician assisted was because a resident physician was unavailable. (Resident physicians are no longer medical students but are still in the learning phase of their careers. They have MD behind their names but continue to work with supervision before taking board examinations.)

  • Modifiers to indicate that a non-physician practitioner, such as a nurse practitioner or a physician assistant, provided a service. Another modifier indicates that a non-physician who assisted a physician is seeking a separate reimbursement (applicable only if the procedural code is one that has been determined to require the additional assistance).

For additional information about Medicare modifier requirements, go to the CMS website.

In addition to Medicare, other government payers also require modifiers.

Tricare

Tricare, funded by the Department of Defense, insures active military members and their eligible dependents, as well as retired military members who have chosen to exercise the option to remain covered and their dependents. The options available to patients depend on their military status and where they live.

Tricare’s processing software accepts all current modifiers, so when you bill this carrier, you want to make sure that you use all applicable modifiers. For example, a patient may have surgery for a hernia, which has a 90 day global package. That same patient may later see the same physician for a different ailment that requires a separate and appropriate modifier in order to be paid.

Tricare benefits are administered through three Tricare area administrators: Tricare North, Tricare South, and Tricare West. Each of these administrators maintains a website that allows providers to verify fee schedules, check on required modifiers, and view other payer specific information.

Workers’ Comp (The Department of Labor)

The Department of Labor recognizes current modifiers as determined by Medicare, but they still determine payment based on the approved procedure and diagnosis codes regardless of the modifiers.

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