HIPAA Compliant Modifiers

HIPAA Compliant Modifiers And Multiple Visits for San Francisco Health Plan EDI Claims

HIPAA Compliant Modifiers

HIPAA Compliant Modifiers are the means by which the reporting physician can indicate that a service or procedure that has been performed has been altered by some specific circumstance, but not changed in its definition or code. Although many procedure codes require a modifier, some procedures do not need further clarification via a modifier. The inappropriate use of a modifier may result in the EDI claim being denied.

Multiple Procedures

In general, only one visit or consultation per specialty is reimbursed for the same date of service. When two or more visits/consultations are billed for the same date of service, remarks should be made and they will be reviewed for individual consideration. Please ensure to use the appropriate member ID, rendering physician NPI (s), dates of service, service code(s) and modifiers when billing for more than one service on the same date of service.

Multiple surgery procedure codes (CPT 10000-69999) for the same patient, for the same date of service, are required to be coded following Medi-Cal guidelines. When a service is legitimately rendered more than once on the same date of the service (before and after X-rays, glucose tolerance testing, ova and parasite tests, etc.), providers must include documentation with the claim explaining why the service was rendered more than once. This information may be entered in the Reserved for Local Use field (Box 19) or on an attachment to the claim. When billing electronically via EDI, enter the statement in the Remarks area. Include the rendering physicians NPI number in box 24I. A statement indicating, “this service is not a duplicate” is not sufficient to clarify why the service was rendered more than once.

By Report Service/HCPCS Codes

The following applicable information must be included in either Box19 of the CMS 1500, Box 84 on the UB04 form or provided as an attachment to the claim form:

  1. Invoice should include item description, manufacturer name, model number, catalog number, manufacturer suggested retail price (MSRP), if applicable.
  2. Operative report, operating time or procedure report including a description of the actual procedure performed and the results of the procedure.
  3. Number, size and location of lesions (if applicable).
  4. Time involved, the nature and purpose of the procedure or service and how it relates to the diagnosis. Description of and justification for any special features, custom modifications, etc.
  5. The reason a listed code was not used. Itemization of miscellaneous supply codes, etc.

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