What Was Modifier ME in Medical Billing?

Medical coding modifiers serve a function in healthcare billing by providing additional information about a service or procedure without altering its fundamental definition. These two-character codes, which can be numeric, alphanumeric, or a combination, are appended to Current Procedural Technology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes. Modifiers help clarify specific circumstances, such as whether a service was altered, performed under unusual conditions, or was part of a multiple procedure scenario.

Understanding Modifier ME

Modifier ME, a HCPCS Level II modifier, indicated that “The order for this service adheres to the appropriate use criteria in the clinical decision support mechanism consulted by the ordering professional.” This modifier was part of the Medicare Appropriate Use Criteria (AUC) program for advanced diagnostic imaging services, mandated by the Protecting Access to Medicare Act (PAMA) of 2014. The AUC program aimed to promote the appropriate use of imaging services like computed tomography (CT), magnetic resonance imaging (MRI), nuclear medicine, and positron emission tomography (PET). Modifier ME connected to a Clinical Decision Support Mechanism (CDSM), an electronic tool designed to guide ordering professionals by communicating appropriate use criteria. When an ordering professional consulted a qualified CDSM and the imaging order aligned with criteria, Modifier ME was applicable, becoming effective January 1, 2020, initiating an educational and testing period.

Applying Modifier ME

Modifier ME was used when billing for advanced diagnostic imaging services furnished to Medicare beneficiaries, including CT, MRI, nuclear medicine, and PET scans. For Modifier ME to be applied, the ordering professional was required to consult a qualified Clinical Decision Support Mechanism (CDSM) prior to ordering the imaging service, and the CDSM provided a determination on the order’s adherence to criteria. On claims, Modifier ME was appended to the CPT or HCPCS code for the advanced diagnostic imaging service. A separate claim line was necessary to report a corresponding HCPCS G code, which identified the qualified CDSM consulted by the ordering professional. Exceptions existed where CDSM consultation was not required, such as in emergency medical conditions.

Importance for Reimbursement and Compliance

Accurate use of modifiers like Modifier ME was important for healthcare providers to facilitate claims processing and secure correct reimbursement. Modifiers communicate specific details about a service to payers, reducing the likelihood of claim denials and payment delays. For the AUC program, Modifier ME demonstrated adherence to Medicare regulations established under the PAMA Act, which aimed to improve advanced imaging services. During the initial testing phase of the AUC program (starting January 1, 2020), claims were not denied for misreporting AUC information; however, the intent was for compliance to become mandatory, with claim denials or payment adjustments for non-adherence once the penalty phase began. The application of Modifier ME, along with the required G codes, was intended to help providers avoid audits or recoupments related to the AUC program, but as of January 1, 2024, the Centers for Medicare & Medicaid Services (CMS) paused the AUC program and rescinded related regulations, with plans to officially terminate Modifier ME and associated G codes by December 31, 2024.