Code Modifiers: How They Affect You
Doctors and insurers use standard codes for each medical service or supply. That helps them communicate about treatments and payments clearly. Current Procedural Terminology, or “CPT®” codes, stand for specific services, like a 10-minute primary care visit. For supplies and equipment like bandages and crutches, there are other codes called HCPCS. (It stands for Healthcare Common Procedure Coding System.) CPT codes start with a number, while HCPCS codes start with letters. You may see both CPT and HCPCS codes on your bill or Explanation of Benefits (EOB).
CPT codes are five digits long; HCPCS codes are one letter plus four digits. Both types of codes may be followed by a two-digit number called a modifier. That gives the insurer more information to adjust their payment. For instance, if you had more than one x-ray in the same visit, the modifier will show that. If the code you see is seven characters long, a modifier has been added.
Why do modifiers matter? If you go out of network, your plan may have limits on what it will pay. Modifiers can be used to help identify those limits. For instance, suppose you get two surgeries during the same operation. Some plans may agree to pay 100 percent of their allowed amount for the first procedure. But, they may pay only part of the allowed amount for the second one. Your plan will know what to pay because your doctor will include modifier 51 to show you had more than one procedure.
Does your bill or EOB seem high, or do you think you see an error? If so, ask your insurer about the codes on your bill or EOB, and make sure they show the services you received.
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Breaking the Code: How CPT® Codes and Modifiers Affect Your Costs
Medical care is complicated, and sometimes it can be hard to describe exactly what services you received. So, providers and insurers use a standardized set of codes to help them communicate clearly. These Current Procedural Terminology, or “CPT,” codes are developed and updated by the American Medical Association (AMA), and used by most providers around the country.
|Wrist fracture repair||Carpal tunnel release|
|Your surgeon’s charge||$2,000||$1,000|
|Your plan’s allowed amount||$1,000||$600|
|Your plan pays||80% of $1,000 = $800||50% of $600 = $300|
|You pay||$2,000 - $800 = $1,200||$1,000 - $300 = $700|