Modifier Logic

Turquoise will include modifiers in a Machine Readable File (MRF) in accordance with CMS guidelines, which are as follows:

• Include any hard coded modifiers found within the CDM impact gross charge and/or cash pay prices.
  • Note: not all hospitals include hard coded modifiers in their CDM. If none are available, it is acceptable to exclude them.
• Only include soft coded modifiers that impact payment.
  • Note: this means lists of statistical modifiers (ex: RT, LT) will not be included within the file.
• Modifiers only included in contracting scenarios that impact payment. This generally applies to fee schedule based reimbursement.
  • For example, a soft coded modifier typically would not have bearing on a fixed case rate or percent of charge reimbursement calculation.

Turquoise will identify contracting scenarios that would be impacted by soft coded modifiers using the modifier logic sourced from the contracts themselves of publicly posted payer policies/manuals, rather than claims data. In the event that we are not able to identify payer specific logic, we will default to Medicare modifiers.

Presentation of Modifiers Within your MRF

When viewing modifiers in the MRF itself, you will find the following:

• Hard coded modifiers will appear alongside the charge in the CDM it is associated with.
• Per CMS requirements, soft coded modifiers are reported as standalone rows in the MRF, not associated with any charges.
• The MRF generation code does not sort the rows in the MRF by default, many of the soft coded modifier rows get listed at the bottom.