I didn't find it difficult. The problem that we ran into was cosmetic vs medical and unfortunately the dr that we billed for (we terminated our service to him for various reasons) ended up getting in deep trouble for fraud. Which explains why we terminated our contract with him. We just didn't like certain things.....enough said.
There is nothing wrong with cosmetic but it has to be billed as such and is not usually covered by insurance. What you don't want to see is a dr saying it's medical when it's not. But there are many very good and honest plastic surgeons out there!
As far as modifiers, they certainly do use them, but in my opinion it was not a lot or difficult. They were given to us with the billing.