What are Modifiers?

What are Modifiers?

Modifiers provide service providers an ability to reflect that a service or procedure has been performed and  has been altered  by some specific circumstance but does not changed its definition or code.

What is the purpose of using a Modifier?

1. Modifiers used on claims provide additional information on the codes billed and will affect how the code will be paid by the funder.
2. Modifiers add or subtract to a tariff code.
3. Modifiers answers questions such as “How many units?”,”Assistant fees”,”When/How long”

Note: Different specialists have their own modifier codes only applicable to their claims and always ensure “Network Pricing and Contracts” are reviewed before these claims are submitted.

Which Specialties make use of Modifiers?

1. Anesthetists
2. General Practitioners and 
3. General Surgeon (042), 
4. Gynaecologists (016), 
5. Paediatricians (032, 033), 
6. Dermatologists (012), 
7. Specialist physicians (018). This specialty has many sub-disciplines specialising in cardiology (018003), clinical haematology (018001), critical care (018006), endocrinology (018004), gastroenterology (018010), nephrology (018002), pulmonology (018005), Rheumatology (0180121) and others. 
8. Physiotherapist 

How to capture a Modifier on a Claim

1. Select your preferred method of capturing an invoice.
2. Complete all the required claim header information.
3. Capture the required procedure codes followed by the associated modifier code.

Note: Modifiers will always relate to an item that it is claimed for and therefore can not be captured as an individual item i.e a Modifier must always follow a procedure code.

 What are the most commonly used Modifiers?

1. 0009 - Assistant fee(GP) - 20% of the fee for the main procedures
2. 0008 - Specialist  assistant fee - 33.33% of the main procedures
3. 0011 - Emergency procedures. A medical emergency is any condition where death or irreparable harm to the patient will result if there are undue delays in receiving appropriate medical treatment.This modifier is not applicable in planned procedures 
4. 0018 - Body mass index (BMI > 35), calculates 50% of all procedures done
5. 0023/0036 - Anaesthetic time 
6. 0008 - Only 50% of the fee for the additional procedure may be charged (Physiotherapists only)
7. 0019 - used by paedetricitians on neonates. Surgery on neonates up to and including 28 days after birth or low birth weight infants (less than 2500g) under general anaesthesia. 0019 adds 50% to the ICU tariff, i.e. 1205, 1206, 1207, 1208 and 1210.

Note: There are certain codes that can not be Modified in the Phsyiotherapy sector examples are code ending in the following 407, 501, 502, 503, 507, 509, 701, 702, 703, 704, 705, 706, 707,708, 801, 803, 901 and 903