Surgery – Billing with Modifiers
| Date: | May 15, 2024 |
| From: | Health Plan |
| To: | Health Plan of San Joaquin/Mountain Valley Health Plan (Health Plan) Providers |
| Type: | Regulatory |
| Subject: | Surgery – Billing with Modifiers |
| Business: | Medi-Cal Managed Care |
As you are aware, Health Plan is changing to a new Claims Editing System (CES). Health Plan has identified the most significant changes and would like to share those with you.
When billing surgical procedures, the required modifier is missing, or the modifier billed is inappropriate for the code.
The Medicaid NCCI program defines modifiers that may be appended to HCPCS/CPT codes to provide additional information about the services rendered. Modifiers consist of two characters which can be alpha, numeric, or alphanumeric.
Modifiers may be appended to HCPCS/CPT codes only if the clinical circumstances justify the use of the modifier. A modifier should not be appended to a HCPCS/CPT code solely to bypass an edit if the clinical circumstances do not justify its use.
The Centers for Medicare and Medicaid Services (CMS) policy for HCCS modifier code guidelines states, “A modifier provides the means by which the reporting physician or provider 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.”
Please use the following link for additional information on modifier billing for surgical procedures: https://mcweb.apps.prd.cammis.medi-cal.ca.gov/assets/4CF63390-6C16-47E5-A11E-5394B01EF278/workbook_surgmod_io.pdf?access_token=6UyVkRRfByXTZEWIh8j8QaYylPyP5ULO
If you have any further questions, please contact your Provider Services Representative, or call our Customer Service Department at 1-888-936-PLAN (7526). You may also visit https://www.hpsj.com/alerts/ for online access to the documents shared. The most recent information about Health Plan and our services is always available on our website WWW.HPSJ-MVHP.ORG
