Ambiki Billing Modifier Guide

Introduction: Why This Guide Matters

If you've ever had an insurance claim denied because of a missing or incorrect modifier, you know how frustrating and costly billing errors can be. Modifiers might seem like small details—just two characters added to a billing code—but they can make the difference between getting paid promptly and spending hours on claim appeals.

This guide will help you master billing modifiers in Ambiki, ensuring your claims are submitted correctly the first time. You'll learn:

• What modifiers are and why insurance companies require them
• Where to add modifiers in Ambiki (there are multiple places, and choosing the right one matters!)
• Common modifier scenarios you'll encounter in your practice
• Best practices to minimize errors and claim denials
• How to troubleshoot when things go wrong

By the end of this guide, you'll understand exactly how to configure modifiers for different payers, locations, and billing scenarios, saving your practice time and reducing payment delays.

Key Terminology & Definitions

Before diving into the technical details, let's clarify some essential terms you'll encounter throughout this guide:

Billing Code Components

• Procedure code: The code that identifies the specific service you provided (e.g., 92507 for speech therapy treatment)
• Modifier: A 2-character code added to a procedure code that provides additional information about the service (e.g., 59 indicates a distinct procedural service, 95 indicates telehealth)
• Billing code: In Ambiki, this refers to the complete combination of a procedure code plus any modifiers

Where Modifiers Can Be Added in Ambiki

• Billing code: Pre-configured service codes that include built-in modifiers (e.g., 92523-52 - Language only evaluation)
• Service rate: The price you charge for a specific service. Modifiers added here apply automatically when that service rate is used. Can include location-specific modifiers
• Payer-specific service rate: A custom rate for a specific insurance company that can include payer-required modifiers and location-specific modifiers
• Patient payment method modifiers: Modifiers specific to an individual patient's insurance plan that can include location, discipline, and billing code criteria
• Treatment report: The billing record for a session where modifiers can be manually added (affects ALL invoices for that session). Additionally can be edited between primary and secondary claim submissions to change/add a modifier for specific invoices only.

Common Modifiers You'll Encounter

• 59: Distinct Procedural Service—used when billing multiple procedures in one session (applied to the 2nd and subsequent services)
• 95: Synchronous Telemedicine Service—for teletherapy sessions
• GT: Via interactive audio and video telecommunication systems—alternative teletherapy modifier required by some payers
• GN: Services delivered under a speech-language pathology plan of care
• GO: Services delivered under an occupational therapy plan of care
• GP: Services delivered under a physical therapy plan of care
• 96: Habilitative services
• 97: Rehabilitative services
• UB: Services provided by therapy assistant (check payer requirements)

Important Concepts

• Modifier combination: How Ambiki collects and combines modifiers from multiple sources
• Claim: The bill you submit to an insurance company for payment
• Invoice: The financial record in Ambiki that tracks what's owed for services
• Payer: The insurance company or other entity responsible for payment

Overview

In Ambiki, a billing code consists of two essential components:

• Procedure code: The procedure code that identifies the service provided
• Modifier: Additional information that provides more detail about the service

Most billing codes in Ambiki start without modifiers, just the basic procedure code. This is intentional because modifiers are often situational. You might need different modifiers for:

• Different insurance companies (Insurance company A wants modifier GT, while Insurance company B wants 95)
• Different service locations (teletherapy requires modifier 95)
• Different billing scenarios (second procedure in a session needs modifier 59)
• Specific patient requirements (their plan requires modifier 96)

This flexibility is powerful but can be confusing. Where should you add a modifier? If you add it in the wrong place, you might accidentally apply it to claims that don't need it, causing denials. If you don't add it where needed, you'll also get denials.

That's why understanding where modifiers come from—and when each source is appropriate—is crucial for accurate billing.

Understanding Modifier Sources

Billing modifiers in Ambiki can originate from several different places, and understanding how they combine is critical. Here's where modifiers can come from:

1. Pre-Configured Billing Codes: Complete billing codes with built-in modifiers that simplify the process
2. Default Service Rate Modifiers: Base modifiers that apply to all uses of a service, can include location, discipline, and billing code specific rules
3. Payer-Specific Service Rate Modifiers: Custom modifiers required by specific insurance companies, can include location, discipline, and billing code specific rules
4. Patient Payment Method Modifiers: Specific to an individual patient's insurance plan, can include location, discipline, and billing code specific rules
5. Treatment Report Modifiers: Manually added modifiers that are added to all other sources

Initial Setup: Adding Billing Provider and Service Rates

Information You'll Need:

• Your organization's Tax ID number (EIN)
• Contact user information
• NPI number
• Taxonomy number
• Service rates
• Business address

Setup Steps:

1. Navigate to Billing → Provider info and service rates
2. Enter all required billing provider information:
   • Group NPI (or personal NPI if applicable)
   • Business address
   • Business EIN
   • Other company information
3. Add your Default Service Rates:
   • These are your standard rates before insurance negotiations
   • Leave location type blank for at least one rate per service for maximum flexibility
   • Create location-specific rates (e.g., with "Teletherapy" location type) if you need location-based modifiers that apply to all payers
4. Add any necessary modifiers at this stage
   • Note: Modifiers are not added by default—you must add them manually
5. Save your changes before leaving the page

Adding Modifiers to Treatment Reports

When to Use This Method

Use this approach when you need to apply modifiers that should affect all invoices for a specific treatment session.

Steps to Add/Edit Treatment Modifiers:

1. From the main dashboard, click Billing in the left navigation
2. In the Patient billing section, click Go under Treatment reports
3. Locate and open the treatment report you want to edit
4. Click the Actions button and select Edit
5. Click Add service modifier
6. Select the appropriate modifier from the Billing treatment modifier dropdown
7. Click Save treatment report to save your changes

Managing Payer-Specific Modifiers

Different insurance payers often require different modifiers for the same service. Here's how this works in Ambiki:

These modifiers are:

• Specific to their respective invoices only
• Combined with other applicable modifiers
• Applied automatically based on the payer and service configuration

Location-Based Modifiers: How They Really Work

Location-based modifiers in Ambiki can be configured in three different places, giving you flexibility in how broadly or specifically you want to apply them:

1. Service Rates - Applies to all uses of that service rate across all payers
2. Payer-Specific Service Rates (Insurance Rates) - Applies only when billing that specific insurance company
3. Patient Payment Method Modifiers - Applies only to that specific patient's insurance

Method 1: Billing Provider Service Rate Location Modifiers

When you add a location type to a service rate, any modifiers on that rate will only apply when services are provided at that location.

1. Navigate to Billing → Provider info and service rates
2. Edit or create a service rate
3. Set the Location type (e.g., "Teletherapy")
4. Add any modifiers that should apply for that location
5. Save the service rate

Method 2: Insurance Company Service Rate Location Modifiers

Similar to service rates, but these only apply when billing a specific insurance company.

1. Navigate to the specific insurance company's rates
2. Edit or create an insurance-specific service rate
3. Set the Location type if needed
4. Add modifiers required by that insurer for that location
5. Save the insurance rate

Method 3: Patient Payment Method Modifiers

This method provides the most granular control and can include additional criteria beyond just location.

1. Navigate to the patient's payment methods
2. Edit the specific insurance payment method
3. Click "Add Modifier" and configure:
   • Modifier: Select the modifier (e.g., 95 for teletherapy)
   • Location Type: Choose where it applies (e.g., Teletherapy)
   • Discipline: Optionally restrict to specific disciplines
   • Billing Code: Optionally restrict to specific billing codes
4. Save the payment method

Services Provided by Assistants

While Ambiki automatically handles supervisor NPIs for assistants, some payers may require specific modifiers when services are provided by assistants (COTA, PTA, SLPA).

Solution: Create Pre-Configured Billing Codes

1. Navigate to Billing → Billing codes
2. Click New billing code
3. Create specific codes for assistant scenarios:
   • "92507-UB Speech therapy provided by therapy assistant" - includes the UB modifier
   • "97110-UB PT services provided by PTA" - for physical therapy assistants
   • "97530-UB OT services provided by COTA" - for occupational therapy assistants
4. Train assistants to select these specific codes when documenting

Multiple Services in One Session (Modifier 59)

When billing multiple procedures in the same session, the second and subsequent procedures require modifier 59 to indicate they are distinct services. This is NOT a one-time occurrence—it happens regularly when therapists provide multiple service types.

Solution: Create Pre-Configured Billing Codes for Common Combinations

1. Navigate to Billing → Billing codes and rates
2. Click New billing code
3. Create specific codes for your common service combinations:
   • "92526-59 Feeding therapy when billed with speech therapy"
   • "92507-59 Speech therapy when billed with feeding or AAC"
   • "97129-59 Cognitive therapy when billed with speech therapy"
   • "92609-59 AAC therapy when billed with other services"

Why Pre-Configured Codes Are Better Than Manual Entry

• Reduces errors - your admin team can't forget to add the modifier
• Speeds up documentation - one selection instead of multiple steps
• Ensures consistency across all therapists
• Makes it clear which code to use in which situation

Multiple Payer Scenarios

For patients with primary and secondary insurance, you may need different modifiers for each payer. Ambiki allows you to modify the treatment report between claim submissions:

Special Provider Types: Assistants and Students

Ambiki has built-in logic to handle billing for assistants, clinical fellows, and students who may require supervisor information on claims:

Assistants and Clinical Fellows

• When services are provided by an assistant or a clinical fellow, supervisor information may be automatically included on the claim
• The system checks if the treating provider is an assistant or CF based on their credentials
• If a supervisor relationship exists, their NPI and information will be used at the claim level
• Exception for Clinical Fellows (CFs): CFs with an active license can use their own NPI instead of their supervisor's, but this requires specific setup:
  • Organization Setup Required: Contact Ambiki support to enable the "CF license use self NPI" feature for your organization. This is not a setting you can change yourself.
  • Important: Once enabled, this feature applies to ALL Clinical Fellows in your organization who meet the requirements below.
  • Three requirements must be met for a CF to use their own NPI:
    1. Your organization has the CF self-NPI feature enabled by Ambiki support
    2. The CF has entered their license information in their user profile
    3. The license is active (valid) on the date of service being billed
  Note: If any of these requirements are not met, the system will automatically use the supervisor's NPI as normal.

Students

• Student providers typically require supervisor information on all claims
• The supervisor's NPI and taxonomy code will be used instead of the student's

Insurance Billing Automation

Ambiki offers insurance billing automation features that can be configured in your EMR settings:

1. Navigate to Organization menu → Edit Organization → EMR settings
2. Under Insurance Billing, you can:
   • Enable automatic claim submission when visit notes are signed
   • Set claim submission delay times
   • Enable automatic application of modifier 59 when necessary
   • Toggle the "Billing detail" check on/off

Best Practices for Modifier Management

1. Minimize Manual Modifier Entry

• Create specific service rate configurations for common scenarios
• Use descriptive billing codes that include necessary modifiers
• Train staff on which billing codes to select rather than which modifiers to add

2. Understand How Modifiers Combine

• Modifiers from all sources are combined, not overridden
• Treatment report modifiers add to (not replace) other modifiers
• Location-based modifiers can be configured at service rates, insurance rates, or patient payment methods
• Duplicate modifiers are automatically removed

3. Regular Review and Updates

• Periodically review your modifier configurations
• Update payer-specific requirements as contracts change
• Monitor claim denials related to modifier issues

4. Documentation

• Keep a reference guide of which modifiers are required for which payers
• Document any special billing scenarios unique to your practice
• Maintain a list of commonly used modifier combinations

Troubleshooting Common Issues

Denied Claims Due to Missing Modifiers

1. Check if the modifier is configured at the appropriate level (payer, patient payment method, or service rate)
2. For location-specific modifiers, check if they're configured at the service rate, insurance rate, or patient payment method level
3. Verify the modifier is being applied correctly in the claim preview
4. Review payer-specific requirements

Modifiers Applying to Wrong Claims

1. Remember that treatment report modifiers affect ALL invoices for that session
2. Use payer-specific configurations for modifiers that should only apply to certain claims
3. Use patient payment method rules with specific criteria (location/discipline/code) for precise targeting
4. Consider creating separate billing codes instead of relying on manual modifier addition

Billing Modifier Scenarios Reference Table

Scenario	Example	Where to Configure	Notes
Single Payer Requirements	Payer requires modifier GN for all speech therapy	Payer-specific service rate	Only affects a specific payer's claims
Different modifiers across payers	Payer A: 92507 + GN Payer B: 92507 + GO	Each payer's service rate	Modifiers combine with others
Multiple services in one session	First: 92507 (no modifier) Second: 92526-59	Pre-configured billing codes	Create separate codes for "when billed with" scenarios
Services by therapy assistant	92507-UB by SLPA	Pre-configured billing code	Name clearly: "Speech therapy by assistant"
Patient-specific modifiers	Patient's plan requires modifier 96	Patient payment method	Only affects this patient
Co-treatment modifiers	Two therapists, one session	Treatment report	Affects all invoices for session
Group therapy modifiers	Multiple patients, one session	Service rate or treatment report	Billing code method preferred
Assistant/Student billing	COTA providing OT services	Automatic (user credentials)	Supervisor NPI used if configured
CF with license	CF-SLP with active license	Organization setting + user license	May use own NPI if enabled
Location + Discipline combo	Modifier 95 for PT teletherapy only	Patient payment method with criteria	Very specific rule targeting
Location-based modifiers (all payers)	All teletherapy needs modifier 95	Service rate with location type	Create separate rates for each location type
Location-based modifiers (specific payer)	Only ABC Insurance Company needs 95 for teletherapy	Insurance rate with location type	More efficient than patient-by-patient setup

Quick Decision Guide

Conclusion

Effective modifier management in Ambiki requires understanding how modifiers combine from different sources and choosing the appropriate configuration method for each situation. By leveraging Ambiki's automated features, you can ensure accurate billing while minimizing manual intervention and potential errors.

Key takeaways:

• Modifiers combine from multiple sources rather than override each other
• Location-based modifiers can be configured at multiple levels (service rates, insurance rates, or patient payment methods)
• Pre-configured billing codes are the simplest solution for common scenarios
• The system automatically handles supervisor requirements for assistants and students

Remember: The goal is to create a system that makes billing as straightforward as possible for therapists while maintaining compliance with insurance requirements.