Claim Modifiers: More Code-Speak on Your Medical Bills

April 26, 2013 in health care costs, Health Insurance, Hospital Bills, Insurance Bills

If you have ever been hospitalized or had a major test/procedure performed, you may have received a frustratingly hard to decipher medical bill from your provider. And, if you are insured, you will also have received a similarly cryptic Explanation of Benefits (EOB) describing your insurance company’s payment decision. (The EOBs can sometimes be a bit clearer and more detailed than the average provider bill.) To the average lay person, medical bill jargon does not sync with customer psychology in the way that other bills, like retail, residential services, etc. do. Most other industries present their bills in a careful way, focusing on clear billing, to make sure that customers know why they have financial responsibility.

CPT and Claim Modifier Codes

With that in mind, let’s look more closely at some of the usual suspects that show up on an unreadable medical bill. One type of common code is called a Current Procedural Terminology or CPT code. This code, in plain English, represents a service that a doctor (or other medical professional) provides.

CPTs often do not “read” well. Patients not involved in the medical industry themselves may have no idea what one of these codes represents on a bill. Looking at the charge associated with it can be frustrating when there’s no common-vocabulary explanation to make the patient remember just what was done in the provider office. This means that patients who are proactively concerned about their care, and costs, will often call providers or insurers just to ask “what does this CPT code mean?”

About Claim Modifiers

Claim modifiers are additional digits attached to a CPT to explain to an insurer or other party how a procedure may have differed from “the norm.” Some modifiers are also used to differentiate a core service from an advanced service level based on the doctor’s documentation. Two main reasons why a provider might add a modifier to a CPT, according to a consumer advocacy newsletter from FAIR Health, Inc, are when multiple (identical or similar) services are performed, or when a procedure “takes more time than is typical” – so, these extra numbers often come along with higher billed amounts.

So, again, patients who get even more information about how the industry works will call and ask about CPTs, and they’ll ask about modifiers, with a few main goals, including two important ones:

  • to understand which charges match which services
  • to check for errors

The second goal is important because of how many times a “billing error” results in another big heap of medical debt pushed onto a patient. Take responsibility for your medical finances by checking your bills and questioning line items that are unclear.

Leave a reply

You must be logged in to post a comment.