April 2010

Verify validity of modifiers


Please remember to verify the validity of the modifiers you bill in combination with Current Procedural Terminology (CPT®) and Healthcare Common Procedure Coding System (HCPCS) codes. We examine each modifier billed to ensure it complies with the requirements in the Medicare Claims Processing Manual (PDF).

Modifiers generally fall into one of two categories:

  • Informational modifiers provide additional information about the service rendered
  • Functional modifiers provide information that impacts the amount of reimbursement either directly or through the use of National Correct Coding Initiative (NCCI) or Correct Code Editor (CCE) edits


Submitting a functional modifier that is not compatible with the base CPT or HCPCS code will delay processing of your claim.

The Centers for Medicare & Medicaid Services (CMS) assigns Procedure Indicators to each base code, indicating:

  • Whether the code is eligible for a modifier
  • What modifiers are valid to bill with the code


Asuris Reimbursement Policies utilize these indicators to determine how the use of modifiers will impact reimbursement.

We are receiving an increasing number of claims being billed with modifiers that are not valid for the procedure with which it is being billed. We encourage you to become familiar with our Modifier reimbursement policies and the CMS Procedure Indicators for the current year.

Here is an example:
To determine if CPT 21011 Excision, tumor, soft tissue of face or scalp, subcutaneous; less than 2 cm is eligible for an assistant surgeon, review our Modifiers -80, -81, -82, -AS; Assistant at Surgery (Modifiers #109) reimbursement policy. The policy indicates that "Asuris will reimburse for assistant at surgery when the procedure code has been assigned a CMS Assistant at Surgery Indicator 2."

To determine whether the code has a valid indicator assigned, refer to the CMS Physician Fee Schedule Relative Value File:

  1. Select the current year from the Calendar Year list.
  2. Click on the document link in the Downloads section of the Details page.
  3. Read and accept the End User Point and Click Agreement.
  4. Open the file titled PPRRVU with the most current date. The file is available in an Excel or text file.
    • A list of various indicators and calculators is populated across the top of the page
    • A list of CPT and HCPCS codes is populated down the left margin.
  5. Scroll across the top of the page until you find the title of the modifier you want to use, then scroll down to where that column intersects with the base procedure code.

According to this table, CPT 21011 has an indicator of 2 for assistant at surgery; meaning that Regence will reimburse for an assistant surgeon.

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