Modifier 27 vs 28: A Guide to Medical Coding Modifiers

Many modifiers in medical coding provide additional context for healthcare services billed to insurance companies. Navigating it can be challenging. Among these, Modifier 27, Modifier 28, and Modifier 91 are critical to ensuring accurate billing and avoiding costly errors.

We’ll look at the specifics of Modifier 27 vs 28, as well as how they compare to Modifier 91, in order to help you master their use in medical coding.

What Are Medical Coding Modifiers?

In order to understand Modifiers 27 and 28, it’s important to understand what medical coding modifiers are. A modifier indicates that a service or procedure has been altered in some way without changing its core definition by adding two digits to a CPT or HCPCS code. For payers to correctly interpret and reimburse a service, they are essential for accurate claims processing.

Understanding Modifier 27

Definition and Use in Medical Coding

Specifically, modifier 27 identifies multiple outpatient hospital E/M (Evaluation and Management) encounters on the same day, typically due to unrelated medical conditions.

Specific Scenarios for the Modifier 27 Application

In the event that a patient visits the emergency department for respiratory issues in the morning and then returns in the afternoon for an unrelated injury, Modifier 27 would be added to the E/M code. By using this modifier, the second encounter is recognized as a distinct and separate encounter, warranting additional compensation.

Example of Modifier 27 in Practice

Imagine a patient visiting an outpatient clinic in the morning for a routine check-up. In the afternoon, the same patient has an allergic reaction and returns for treatment. Modifier 27 is applied to the second E/M code, signaling that the encounter is different from the morning visit.

Deep Dive into Modifier 28

Definition and application

This modifier is used to indicate a separate, distinct procedure performed by the same physician on the same day as another procedure. It indicates that the second procedure is a significant, separate service.

How Modifier 28 Differs from Modifier 27

Modifier 27 is applicable to distinct E/M encounters, while Modifier 28 is applicable to multiple procedures by the same physician. The key difference lies in their application: Modifier 27 is applicable to multiple hospital visits, while Modifier 28 is applicable to multiple procedures.

Example of Modifier 28 in Use

Consider a scenario where a surgeon performs an appendectomy in the morning and then needs to perform an unrelated gallbladder removal later that same day. As a separate procedure, the second surgery would have the modifier 28 appended to its CPT code.

Modifier 91: An Overview

Definition and Primary Use Cases

Modifier 91 is used when a medical test or procedure is repeated on the same day for a specific purpose, such as obtaining additional results or verifying initial results. It may not be used for repeated tests due to errors or quality issues.

Comparison between Modifier 91 and Modifiers 27 & 28

Unlike Modifiers 27 and 28, which focus on distinct visits and procedures, Modifier 91 is used exclusively for repeat tests. While Modifiers 27 and 28 indicate separateness in encounters or procedures, Modifier 91 signals that a repeat test is medically necessary.

Example Scenario Involving Modifier 91

The patient undergoes a blood glucose test in the morning, and due to abnormal results, it is repeated later that day to confirm the results. In this case, Modifier 91 would be added to the code.

Modifier 27 vs 28: Key Differences

Usage in medical billing

Modifier 27 is used for multiple encounters, while Modifier 28 is used for multiple procedures. Both ensure that separate services are recognized and reimbursed appropriately.

Impact on reimbursement and claims processing

Using the correct modifier is crucial for timely and accurate reimbursement. Misapplying these modifiers may result in claim denials, delays, or reduced payments. The payer may consider distinct hospital visits as one visit if you fail to apply Modifier 27.

Case Study Comparing Modifier 27 and Modifier 28

Imagine a scenario where a patient visits a hospital for an outpatient procedure in the morning and returns in the afternoon for a follow-up E/M service related to a different issue. The morning procedure would use Modifier 28, and Modifier 27 will ensure that both services are billed and reimbursed separately.

Common Mistakes in Applying Modifiers 27 and 28

Misconceptions about modifier usage

A common mistake is confusing Modifier 27 with Modifier 28, leading to incorrect billing. Some coders might incorrectly use Modifier 28 for a second E/M service or Modifier 27 for a second procedure, which can cause claim rejections.

Tips to Avoid Common Errors

• Know the differences: Understand the distinct purposes of each modifier.
• Review the Medical Record: Verify that the documentation supports the modifier.
• Continuous learning: Keep up to date with your knowledge of coding rules and guidelines to avoid common pitfalls.

Best Practices for Using Modifiers 27, 28, and 91

Ensuring accurate coding

Modifier application requires an understanding of the circumstances that warrant their use. Always ensure that a separate service or procedure is clearly justified in the patient’s medical records.

Documentation requirements

If using Modifier 27 or 28, make sure the medical record clearly indicates the need for a specific service or procedure, along with the medical necessity.

Case Examples of Correct and Incorrect Usage

• Correct Usage: Use Modifier 27 for an afternoon appointment following a morning check-up.
• Incorrect Usage: Modifier 28 is used instead of Modifier 27 for the second E/M service, which could result in a claim denial.

How Incorrect Modifier Use Affects Reimbursement

Denials and Claims Delays

Incorrect use of modifiers can result in denials or delays in claims processing. Payers may require additional documentation or reject claims outright, causing delays in payments and additional administrative burdens.

Financial implications for healthcare providers

In addition to slowing down cash flow, denied claims increase workload due to the need for appeals and resubmissions. Modifier error can significantly impact a healthcare provider’s revenue cycle.

Conclusion

Identifying Modifier 27 vs 28 and how they differ from Modifier 91 is essential for accurate medical coding. Each modifier serves a unique purpose, and applying them correctly assures proper reimbursement and compliance with coding regulations.

Healthcare providers can avoid costly mistakes, reduce claim denials, and improve revenue cycle management by mastering these modifiers.