Modifiers

The entity specifies the domain of available modifiers. Modifiers are essentially labels that can be attached to a claim line.

Modifiers reflect any number of things that may affect the way a claim is processed. A modifier may signify that a procedure was rendered under unusual circumstances or that the procedure is claimed in multiple components, e.g., a technical and a professional component.

A modifier has the following attributes:

Table 1. Modifiers

Field	Description
Code	The unique code for this modifier
Description	The description for this modifier.

Consider the following scenarios on how to use a modifier.

Scenario 1

Because a serviced person received two surgical procedures in a single surgery session, the hospital saves significantly on overhead costs in preparing the operating room. The claim line that specifies the second surgical procedure reflects this by an attached modifier 'OV' that signifies the overhead cost reduction. The payer can then set up Claims in such a way that whenever the a surgical procedure is encountered in combination with the 'OV' modifier, another coverage regime is applied, e.g., a lower copay for the person.

Note that this scenario requires a dynamic condition on the 'OV' modifier, specified under a coverage specification.

Scenario 2

Payer HealthSecure requires a 10% coinsurance on the technical component of surgical procedure 12.34 and a 20% coinsurance on the professional component of surgical procedure 12.34.

Because of this, the payer requires two separate claim lines whenever procedure 12.34 is rendered. In order to differentiate between those two lines, one line must have a modifier attached that signifies the technical component, while the other line must have a modifier that signifies the professional component.

Note that this scenario requires a dynamic condition on the technical an professional component modifiers, specified under a coverage specification.