Have an example of CPT/HCPCS which is almost always billed with a specific Modifier?

fhalamuda

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Hi All,

I'm looking for any examples of CPT or HCPCS codes which are almost always (like >80% of the time) billed with one, very specific, very predictable modifier.

I'll gladly accept any examples anyone can share regardless of medical specialty, modality, etc. I'll also accept answers like "I can't think of any examples" because it helps me to reinforce that I'm not struggling needlessly to come up with an example on my own.

Let me share an example answer that would not fit my request. CPT 73140 will reasonably bill with a finger modifier of FA - F9. Even though it's common to include a finger modifier, the 73140 doesn't work as an answer to my question because the exact modifier used is a variable.

Thank you to everyone who takes a moment to read or to comment on my question.

Ferdinand, CPB
 

CodingKing

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I'm going through the opposite problem right now. I have to come up with every single modifier combo that could possibly be billed with each section of the CPT book.

I have one example for you for Medicare. There's specific DME items that need to have a modifier like A7007 needs to be billed with NU modifier

Not sure if this example works but the following codes require a AU, AV, AW. I forgot which one but there is a specific code medicare wont pay with AW, I think it the gradient pressure


  • A4217 – Sterile water/saline, 500 ml
  • A4450 – Tape, non-waterproof, per 18 square inches
  • A4452 – Tape, waterproof, per 18 square inches
  • A5120 – Skin barrier, wipes or swabs, each
  • A6531 – Gradient compression stocking, below knee, 30-40 MMHG, each
  • A6532 – Gradient compression stocking, below knee, 40-50 MMHG, each
  • A6545 – Gradient compression stocking, wrap, non-elastic, below knee, 30-50 MM HG, each
 
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mhstrauss

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Hi All,

I'm looking for any examples of CPT or HCPCS codes which are almost always (like >80% of the time) billed with one, very specific, very predictable modifier.

I'll gladly accept any examples anyone can share regardless of medical specialty, modality, etc. I'll also accept answers like "I can't think of any examples" because it helps me to reinforce that I'm not struggling needlessly to come up with an example on my own.

Let me share an example answer that would not fit my request. CPT 73140 will reasonably bill with a finger modifier of FA - F9. Even though it's common to include a finger modifier, the 73140 doesn't work as an answer to my question because the exact modifier used is a variable.

Thank you to everyone who takes a moment to read or to comment on my question.

Ferdinand, CPB


The only example I can think of is situational for my clinic, because of equipment ownership:

I work for a multispecialty clinic, which has several radiologists employed. Our attached hospital, which is separate for billing purposes, but is physician-owned, has CT equipment. Any CT-related service (ie., 70450, 72125) will always have a mod 26, since we are billing for the interp only. But, like I said, that is specific to our situation.

I cannot think of any other examples, other than the one you mentioned--with the possible mod being variable.

And really, there probably shouldn't be many. The purpose of a modifier is to alter the definition of a CPT code slightly, and if that were to happen more than 80% of the time, like you're looking for, then chances are the AMA would update the CPT code description to correlate with the way it's most often billed.
Does that make sense?

Hope that helps some!!
 

fhalamuda

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Thank you both Coding King and Meagan for your examples.

Of the two, the DME codes are the closer to my question. However, it seems that all of those "A" codes and the three suggested modifiers can be used in different combinations with each HCPCS code being vaiable with two of the three modifiers. That means that I still don't yet have an example yet of a CPT/HCPCS which nearly always have just one specific modifier.

Good luck with the huge modifier task you too have shared Coding King.
 

Jozses

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For services reportable as an L3923 orthosis that has a rigid plastic or metal component, you must add the CG modifier. If you bill a claim for L3923 without a CG modifier, it will be denied. Similarly, if a spinal garment for example L0450, L0454, L0621, L0625, or L0628 is made primarily of a nonelastic material, such as canvas, cotton, or nylon, or has a rigid posterior panel, you must add the CG modifier or the service will be rejected or denied for incorrect coding.
 
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