Coding a Professional Claim


Procedure Modifier and Diagnosis Codes

A critical element in claims filing is the submission of current and accurate codes to reflect the services provided. Correct coding is essential for correct reimbursement. Inclusion of a complete and accurate list of diagnosis codes associated with the patient at the time of the encounter, including chronic conditions not necessarily treated at the time of the encounter, is part of correctly coding an encounter. It ensures that we can best match patients with appropriate care and disease management programs and members are properly classified by risk programs. We encourage you to purchase current copies of CPT, HCPCS, and ICD 10 CM code books.

Unlisted Procedure Codes

Report an unlisted code only if unable to find a procedure code that closely relates to or accurately describes the service performed. Whenever you submit an unlisted code, you must include a written description of the services with the claim. Unlisted codes require documentation and therefore should not be submitted electronically; the exception is unclassified HCPCS drug codes (refer to Unclassified Drugs).



Modifiers

A modifier provides a physician with the means to indicate that a service/procedure is altered by some specific circumstance, but not changed in its definition or code. By modifying the meaning of a service, modifiers may be used in some instances when additional information is needed for proper payment of claims. Valid modifiers and their descriptions can be found in the most current CPT and HCPCS coding books.

When multiple modifiers are necessary for a single claim line, modifiers should be submitted in the order that they affect payment.

Note: If your claim is denied due to a lack of documentation to support the use of a specific modifier, you may submit a claim payment appeal. Your appeal must be submitted in writing and accompanied by the necessary documentation.

Modifiers may be used to indicate that:

• A service or procedure has both a professional and technical component

• A service or procedure was performed by more than one physician and/or in more than one location

• A service or procedure has been increased or reduced

• Only part of a service was performed

• A bilateral procedure was performed

• A service or procedure was provided more than once

• Unusual events occurred

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