ClaimRev Support Documentation

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====== Modifier Rules ======

Add, remove, or replace modifiers on claim service lines. Filter by payer and CPT codes. This module replaces the need for hardcoded modifier logic — you can configure any modifier change per payer.

**Applies to:** Professional (837P), Institutional (837I), Dental (837D)

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===== When to Use This =====

  * A payer requires modifier 25 on E/M codes when billed with a procedure
  * You need to replace modifier 59 with the appropriate X-modifier (XE, XP, XS, XU) per payer
  * Telehealth claims need modifier GT, 95, or FQ depending on the payer
  * A payer rejects a specific modifier and you need to remove it
  * You need to add modifier 26 (Professional Component) for specific CPT codes

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===== Fields =====

^ Field ^ Required ^ Description ^
| Start Date | Yes | When this rule becomes active |
| End Date | No | When this rule expires |
| Payer Number | No | Only apply for a specific payer. Blank = all payers |
| Action | Yes | **Add Modifier** (1), **Remove Modifier** (2), or **Replace Modifier** (3) |
| Modifier Value | Yes | The modifier to add, remove, or find (for replace) |
| Replacement Modifier | Only for Replace | The modifier to replace with (only visible when Action = Replace) |
| CPT Codes | No | Comma-separated CPT codes. Only apply to service lines with these codes. Blank = all service lines |
| Modifier Position | No | **Auto/Any** = first available slot for Add, any matching position for Remove/Replace. Or pick a specific position (1-4) |
| Notes | No | Your reference notes |

==== Actions Explained ====

  * **Add** — Puts the modifier in the specified position. If "Auto", finds the first empty modifier slot. Won't overwrite existing modifiers in Auto mode.
  * **Remove** — Finds the modifier on the service line and clears it. If position is "Any", removes it from whichever slot it's in.
  * **Replace** — Finds the modifier on the service line and swaps it with the replacement. If position is "Any", replaces it wherever it's found.

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===== Examples =====

=== Example 1: Add Modifier 25 for E/M Codes ===

Add modifier 25 to all E/M codes for Aetna.

^ Field ^ Value ^
| Payer Number | 60054 |
| Action | Add Modifier |
| Modifier Value | 25 |
| CPT Codes | 99211,99212,99213,99214,99215 |
| Modifier Position | Auto |

=== Example 2: Replace Modifier 59 with XE ===

Medicare wants modifier 59 replaced with XE (Separate Encounter).

^ Field ^ Value ^
| Payer Number | 00882 |
| Action | Replace Modifier |
| Modifier Value | 59 |
| Replacement Modifier | XE |
| Modifier Position | Any |

=== Example 3: Add Telehealth Modifier ===

Cigna requires modifier 95 on telehealth E/M codes.

^ Field ^ Value ^
| Payer Number | 62308 |
| Action | Add Modifier |
| Modifier Value | 95 |
| CPT Codes | 99211,99212,99213,99214,99215 |
| Modifier Position | Auto |

=== Example 4: Remove Modifier ===

A payer rejects claims with modifier TC on certain codes.

^ Field ^ Value ^
| Payer Number | 00621 |
| Action | Remove Modifier |
| Modifier Value | TC |
| CPT Codes | 80053,80061 |
| Modifier Position | Any |

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===== What Happens on the Claim =====

  - For each service line (Loop 2400), checks the SV1 segment (Professional/Dental) or SV2 segment (Institutional)
  - Modifiers are in the procedure code composite element: positions 2-5 correspond to modifiers 1-4
  - **Add:** Sets the modifier in the specified or first empty position
  - **Remove:** Clears the modifier from the matching position(s)
  - **Replace:** Swaps the old modifier with the new one in the matching position(s)
  - A warning is logged for each service line modified (e.g., "Added modifier 25 on 99213")
  - Shows in Applied Validation Modules as "ModifierRuleModule"

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