A Coder’s Guide to Smarter Billing

In medical billing and coding, accuracy is just one aspect of getting claims approved. The job also requires ensuring full and fair reimbursement while staying compliant. For users of FRG’s platform, AccuReports, mastering modifier use can make the difference between a clean claim and a costly denial.

Financial Recovery Group created a Modifier Cheat Sheet that puts essential guidance at your fingertips. Below is a breakdown of the categories from the cheat sheet, an explanation of key modifiers in practical terms, and how you can use this tool to code smarter.

E/M and Telehealth Modifiers

Modifiers clarify the nature of Evaluation and Management service, especially when they overlap with procedures, fall within post-op periods, or take place via telehealth. Correct use keeps telehealth claims compliant and ensures your E/M services are paid appropriately. Examples by modifier number include:

• 25: Indicates a separate E/M service. Use when billing for an E/M visit that goes beyond a planned procedure done the same day. Ensure that documentation is included and supports a separate E/M visit beyond the procedure.
• 24: Indicates an unrelated E/M service performed during a post-operative period. Use when billing for services provided that are unrelated to a procedure done the same day.
• 95: Indicates a telehealth service. Use when provided a telehealth service that is covered by Medicare.

Surgery and Post-Operative Modifiers

These modifiers help define when follow-up care or repeat procedures fall outside a standard global surgical package. Without them, coders risk bundling issues and delayed payments. Examples by modifier number include the following: 

• 50: Indicates a bilateral procedure. Use when billing for services that involve procedures performed on both sides of the body. Don’t use it for procedures already defined as bilateral in CPT codes.
• 51: Indicates multiple procedures. Use when billing for multiple services performed during the same session.
• 58: Indicates a staged procedure. Use when billing for multiple-stage surgical procedures planned over an extended time period. 

Payment and Unbundling Modifiers

Bundled codes can lead to underpayment if procedures are truly distinct. These modifiers protect revenue by showing when services should be paid separately.

• 59: Indicates a distinct procedural service. Use when services are distinct and should not be bundled. Ensure that this is used only if necessary, otherwise use X modifiers such as XE (separate encounter), XP (separate practitioner), XS (separate structure), and XU (unusual non-overlapping service). 
• 26: Indicates a professional component. Use when billing separately for a physician’s portion of services.
• TC: Indicates a technical component. Use when billing separately for the technical portion of a service.

Special Circumstances and Global Period Modifiers

Not all claims fit neatly into a template. These modifiers help clarify unique cases, including service under anesthesia, a mandated evaluation, or the professional portion of a split service.

• 76: Indicates a repeat procedure by the same doctor. Use when the same doctor repeats a procedure for a patient on the same day.
• 77: Indicates a repeat procedure by a different physician. Use when a different doctor repeats a procedure for a patient on the same day. 
• GA: Indicates Waiver of Liability and that an Advanced Beneficiary Notice (ABN) is on file. Use when a provider expects a denial and has a signed ABN. 

Smarter Billing Starts Here

Used properly, modifiers are essential tools for telling the full story of the services provided to a patient. Using them correctly ensures coders get credit for all the care provided and helps prevent revenue loss from avoidable denials.

To make modifier use easier, download the FRG Modifier Cheat Sheet and keep it accessible in your coding environment. It’s built for speed and clarity, whether you’re working in FRG’s proprietary software or another coding platform.

Additionally, FRG’s MRA Calculator is a great companion tool for coders because it helps evaluate how coding choices, modifiers included, affect risk adjustment and reimbursement. At its heart, coding is about telling the right story. With the right tools, you’ll tell it accurately, every time. Get started today!