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CPT® Codes and Code Modifiers are a very important part of the insurance billing process. It is important that correct codes and modifiers are used to ensure that submitted claims are processed and paid correctly. This article provides additional information, links and some best practices regarding CPT Codes and Code Modifiers.
NOTE: The American Medical Association owns the rights to all CPT® codes and enforces the collection of licensing fees for each Rendering Provider who submits Claims utilizing these codes.
CPT® Code Selection and Service Type Names
The Service Type name can be the CPT® Code short name or at least a client-friendly name. This is what Client will see as Service Type on any Billing documents as well as in the Client Portal.
Do not use things like "Tier 1 Rate", "Discounted Rate", or "New Rate", etc.
Additional Information can be found at: https://www.ama-assn.org/about/cpt-editorial-panel/cpt-code-process
Code Modifiers
Modifiers can be two-digit numbers, two-character modifiers, or alpha-numeric indicators. Modifiers provide additional information to payers to make sure you get paid correctly for services rendered.
If appropriate, more than one modifier may be used with a single procedure code. However, they are not applicable for every category of the CPT codes. Some modifiers can only be used with a particular category, and some are not compatible with others. Modifiers can be payer specific.
If there are questions about which modifier is appropriate, reach out to the payer directly to ensure the claim is billed correctly.
Rates
The AMA publishes the CPT® code book and CMS releases the final code value in the Medicare Physician Fee Schedule. If you follow Medicare, or assign a specific dollar amount to each CPT code this tells you how much to pay for the service rendered. Put all the codes and all their associated fees in a list, and you have a fee schedule.
If you have questions about the value of the service you are rendering you can reference the Physician Fee Schedule and/or reach out to your respective payers for guidance on how much to charge.
Additional Information can be found at:
https://www.ama-assn.org/about/cpt-editorial-panel/cpt-code-process
https://www.cms.gov/medicare/physician-fee-schedule/search/overview