Modifiers may seem like small details, but they play a role in preventing claim denials. Below are the key modifiers used in cognitive health billing.
Individual Codes
If you are billing 96136, 96138, or 96132 independently on their own date of service (DOS), no modifier is required.
Codes Billed Together
When 96136, 96138, and/or 96132 are billed on the same date of service, a modifier is not required. These codes can be billed together without additional modifiers.
When an Office Visit Is Also Billed
If 96136, 96138, or 96132 are billed alongside an office visit, a -59 modifier should be added to the BrainCheck codes to indicate that the services are distinct from the office visit.
Modifier Tip
Some payers, including Aetna, BCBS, and Humana, may also require a -25 modifier on the office visit. Review payer-specific requirements to help prevent claim denials.
ICD-10 for Medical Necessity
ICD-10 codes are used to support medical necessity. They help demonstrate that the test being billed is appropriate for the patient’s clinical condition.
Check Your Medicare MAC Carrier
Always review your Medicare MAC carrier’s Local Coverage Determination (LCD) policy and billing article to confirm that the ICD-10 codes you are using align with covered services.
Payer Requirements
Many payers follow Medicare guidelines, but payer policies can vary. Confirm requirements with your billing team when needed. When there is uncertainty, Medicare policies are often used as a reference point.
Summary
No modifiers are required when codes are billed alone or together.
Add a -59 modifier when codes are billed alongside an office visit.
Some payers may require a -25 modifier on the office visit.
Confirm that ICD-10 codes align with Medicare or payer coverage policies.