Common Behavioral Health Modifiers

Modifiers serve several purposes:

• To provide more specific information about a procedure or service
• To indicate that a service was altered in some way from its original description
• To bypass claim edits that would otherwise result in claim denial
• To indicate that a service was performed by a different provider or in a different setting
  

They can indicate:

• Whether a service was provided by a psychiatrist, psychologist, or other mental health professional
• If the service was part of a group therapy session or individual therapy
• Whether the service was provided in an inpatient or outpatient setting
• If the service was part of a crisis intervention
• Whether the service involved evaluation and management in addition to psychotherapy
  

Here are some of the most frequently used:

1. Modifier 25: Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service
   This modifier is often used when a provider performs a separate evaluation and management (E/M) service in addition to psychotherapy on the same day.
2. Modifier 59: Distinct procedural service
   Used to identify procedures or services that are not normally reported together but are appropriate under certain circumstances.
3. Modifier 95: Synchronous telemedicine service rendered via real-time interactive audio and video telecommunications system
   This modifier has become increasingly important with the rise of telehealth services in behavioral health.
4. Modifier AJ: Clinical Social Worker
   Indicates that a service was provided by a clinical social worker.
5. Modifier HO: Master’s degree level
   Used to indicate that a service was provided by a provider with a master’s degree.
6. Modifier HP: Doctoral level
   Indicates that a service was provided by a provider with a doctoral degree.
7. Modifier HN: Bachelor’s degree level
   Used when a service is provided by a provider with a bachelor’s degree.

In addition to the common modifiers, there are several specialty-specific modifiers used in behavioral health:

1. Modifier AF: Specialty physician
   Used to indicate that a psychiatrist provided the service.
2. Modifier AH: Clinical psychologist
   Indicates that a clinical psychologist provided the service.
3. Modifier HE: Mental health program
   Used for services provided as part of a mental health program.
4. Modifier HF: Substance abuse program
   Indicates services provided as part of a substance abuse program.
5. Modifier HS: Hospital-based substance abuse treatment program
   Used for services provided in a hospital-based substance abuse treatment program.
6. Modifier TD: Registered nurse
   Indicates that a registered nurse provided the service, which can be relevant in certain behavioral health settings.

Here are some general guidelines:

1. Use modifiers only when they are necessary to accurately describe the service provided.
2. Ensure that the documentation in the medical record supports the use of the modifier.
3. Apply modifiers to the most specific code possible.
4. When multiple modifiers are applicable, list the most important modifier first.
5. Be aware of payer-specific guidelines for modifier use, as they may vary.
6. Regularly review and update your understanding of modifier usage, as guidelines can change.
   

Here’s how:

1. Preventing claim denials: Correct use of modifiers can prevent claims from being denied due to apparent coding conflicts.
2. Ensuring appropriate payment: Modifiers can ensure that providers are paid appropriately for all services rendered, especially when multiple services are provided on the same day.
3. Bypassing payment edits: Some modifiers can bypass certain payment edits that would otherwise result in claim denial.
4. Accurately representing services: Modifiers help to accurately represent the complexity of services provided in behavioral health, which can affect reimbursement rates.
5. Supporting medical necessity: Certain modifiers can help demonstrate the medical necessity of services, which is crucial for reimbursement.
   

Several common mistakes occur in the use of modifiers in behavioral health billing:

1. Overuse of Modifier 59: This modifier is often overused or used incorrectly. It should only be used when no other, more specific modifier is appropriate.
2. Incorrect use of Modifier 25: This modifier should only be used when a significant, separately identifiable E/M service is provided on the same day as another procedure.
3. Failure to use telehealth modifiers: With the increase in telehealth services, failing to use appropriate telehealth modifiers can result in claim denials.
4. Inconsistent use of modifiers: Inconsistency in modifier use can raise red flags during audits.
5. Using modifiers when they’re not necessary: This can complicate billing unnecessarily and potentially raise suspicion during audits.

To avoid these mistakes:

• Regularly train staff on proper modifier usage
• Implement a quality assurance process to review modifier use
• Stay updated on changes in coding guidelines and payer policies
• Use electronic health record (EHR) systems with built-in coding assistance when possible
  

To ensure proper use of modifiers in behavioral health billing, consider these best practices:

1. Develop a comprehensive understanding of commonly used modifiers in behavioral health.
2. Regularly review and update coding guidelines and payer policies.
3. Implement a robust documentation system that supports the use of modifiers.
4. Conduct regular internal audits to ensure proper modifier usage.
5. Provide ongoing education and training for staff involved in coding and billing.
6. Use technology solutions that can assist with proper modifier selection.
7. Develop a process for addressing and correcting modifier-related errors promptly.
8. Consult with coding experts or professional organizations when in doubt about modifier usage.
   

Case Study 1: Group Therapy and Individual Therapy on the Same Day

A patient attends a group therapy session in the morning and has an individual therapy session with the same provider in the afternoon. The provider would bill for both services, using Modifier 59 on the individual therapy code to indicate it was a distinct service from the group therapy.

Case Study 2: Psychiatrist Provides E/M Service and Psychotherapy

A psychiatrist provides both an evaluation and management service and 45 minutes of psychotherapy to a patient on the same day. The provider would bill for both services, using Modifier 25 on the E/M code to indicate it was a significant, separately identifiable service.

Case Study 3: Telehealth Services

A psychologist provides individual therapy via video conference. The provider would use the appropriate CPT code for the service and append Modifier 95 to indicate it was a synchronous telemedicine service.

Some trends to watch include:

1. Increased emphasis on telehealth: With the growth of telehealth services, especially in behavioral health, we may see new modifiers or changes to existing ones to better represent these services.
2. Integration of behavioral health and primary care: As behavioral health becomes more integrated with primary care, new modifiers may be introduced to represent these collaborative services.
3. Value-based care: As healthcare moves towards value-based models, we may see new modifiers introduced to represent outcomes or quality measures in behavioral health.
4. Artificial Intelligence in coding: AI may play an increasing role in suggesting appropriate modifiers based on documentation.
5. Expansion of covered services: As insurance coverage for behavioral health services expands, new modifiers may be introduced to represent newly covered services.