All You Ever Need to Know About The HO Modifier

If you are new to billing insurance you may not have heard of the HO modifier. The HO modifier is a HCPCS modifier used to allow for greater accuracy in coding in a claim. For instance, in this case the HO modifier is used to specify the provider’s degree level. Another HCPCS modifier, HJ is used to signify EAP (Employee Assistance Program) visits. These are always two letters and differ from CPT modifiers which are two digits.

What Does the HO Modifier Signify? What About HN or HP?

The HO modifier signifies that the provider has a master’s level degree and should only ever be billed if the provider has the appropriate degree level. Similarly, HN indicates a bachelor’s degree level and a HP indicates a doctoral degree level. If you’re not sure what applies and you use us as a billing service we can verify on your behalf if you need to bill with a modifier and which one to use.

Is This a Common Requirement? Do I Need to Bill All My Claims with A Modifier Signifying My Degree Level? 

No. For the vast majority of commercial insurance plan billing with a modifier is not a requirement. Most insurance companies already have your licensing and degree level on file already so from their perspective it isn’t necessary.

Does Medicare Require the HO Modifier?

This can vary state by state, but typically the HO modifier is not required on Medicare claims.

Does Medicaid Require the HO Modifier?

This depends on the state and company. Not all Medicaid companies require a modifier, but some do! In our experience as a professional mental health billing company, the majority of companies that require this modifier are Medicaid companies! They’ll typically outright deny the claim if the appropriate modifier is not included. In order to find out for sure, you should review the provided documentation and give the insurance a phone call.

How Does HO differ from AJ and AF Modifiers?

AJ and AF modifiers are similar to the HO modifier but are a part of A series HCPCS modifiers. These modifiers signal license-level as well, AF indicating “Specialty Physician” and AJ indicating “Clinical Social Worker”. Similarly AH indicates “Clinical Psychologist”. In this case, it is very possible to be a clinical social worker with a Master’s Degree Level. In other words AJ, AF, and HO could possibly all apply! So which one should you use? Should you use all three?

The answer is unfortunately neither straightforward or consistent. It is highly dependent on the protocol the insurance asks for claims to be filed. If a modifier is required, depending on how you bill the insurance company may allow a different rate. For instance, Amerigroup, a company that handles many Medicaid policies, reimburses 75% of their normal rate for a clinical social worker. On the other hand, Medicaid Vermont has slightly different definitions than the norm of when to use AH, AJ, HO, and HN and will reimburse differently for each!

Medicaid Vermont

Medicaid Vermont Modifier Requirements (differs depending on insurer).

Source: http://www.vtmedicaid.com/assets/manuals/GeneralBillingFormsManual.pdf

This is all quite confusing and again we recommend both reviewing the contract documentation, provider handbook, and giving the insurance a phone call in order to be 100% certain. If you use TheraThink as a billing service, we will do this for you.

Where Do I Put the HO Modifier on My Claims?

The HO modifier should be used under the 24d field on the CMS 1500. See below.

HO Modifier CMS 1500

HO Modifier CMS 1500.

Does the CPT Code Matter?

It does not. You can use an HO modifier with all of the standard procedure codes for mental health. 90791, 90834, 90837, etc.

Reimbursement

Does the HO modifier impact reimbursement? In cases where a modifier is required, it can absolutely impact the reimbursement. In order to find out exactly how it impacts that, contact the insurance company.

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