Modifiers
The Rest of the Story
2011
AAPC
2480 South 3850 West, Suite B
Salt Lake City, Utah 84120
800-626-CODE (2633), Fax 801-236-2258
www.aapc.com
Sponsored by:
Modifiers—The Rest of the Story
Written by:
Jennifer Swindle
RHIT, CPC, CPMA, CEMC, CFPC, CCS-P, CCP
www.aapc.com
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Modifiers–The Rest of the Story
Disclaimer
This course was current at the time it was written. The materials are offered as a tool to assist the participant in understanding how to ensure that code selection decisions are accurate and defensible 100% of the time as a means of improving
reimbursement and avoiding post payment risk. Every reasonable effort has been made to assure the accuracy of the information within these pages. Proper coding may require analysis of statutes, regulations or carrier policies and as a result, the
proper code result may vary from one payer to another. As such, rather than attempt to provide the instructions for each,
this course is designed to educate you on how to find, interpret and apply the guidance available in each and in circumstances where such guidance is not provided, how to evaluate the quality and applicability of persuasive guidance.
This program is not intended to be legal advice and your attendance should not be construed as a legal opinion of the
program developer or as establishing an attorney client relationship with the developer of this program. AAPC employees,
agents, and staff make no representation, warranty, or guarantee that this compilation of information is error-free, and will
bear no responsibility or liability for the results or consequences of the use of this course.
US Government Rights
This product includes CPT® which is commercial technical data and/or computer data bases and/or commercial computer
software and/or commercial computer software documentation, as applicable, which was developed exclusively at private
expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights
to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/
or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS
252.227-7015(b)(2) (November 1995), as applicable, for U.S. Department of Defense procurements and the limited rights
restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provision of FAR 52.227-14 (June 1987)
and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of
Defense Federal procurements.
Notices
CPT® copyright 2010 American Medical Association. All rights reserved. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT®, and the AMA is not recommendation
their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no
liability for data contained or not contained herein.
All Rights Reserved. CPT® is a registered trademark of the American Medical Association (AMA).
CPC®, CPC-H®, CPC-P®, CIRCC® CPCOTM and CPMA® are trademarks of the AAPC
Written by Jennifer Swindle RHIT, CPC, CPMA, CEMC, CFPC, CCS-P, CCP
© 2011 AAPC
2480 South 3850 West, Suite B, Salt Lake City, Utah 84120
800-626-CODE (2633), Fax 801-236-2258, www.aapc.com
All rights reserved.
ISBN 978-937348-01-4
ii
AAPC
1-800-626-CODE (2633)
Modifiers–The Rest of the Story
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Anatomical Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Evaluation And Management Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Modifier 25 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Modifier 24 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Modifier 57 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Repeat Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Modifier 76 and 77 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Modifier 91 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Procedures In The Global Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Modifier 58 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Modifier 78 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Modifier 79 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Pre, Post, or Surgical Only . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Modifier 54 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Modifier 55 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Modifier 56 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Discontinued or Reduced . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Modifier 53 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Modifier 52 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Bilateral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Modifier 50 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Multiple Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Modifier 51 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Assistant at Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Distinct and Separate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Modifier 59 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Increased Procedural Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Modifier 22 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
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Modifiers–The Rest of the Story
Physical Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Modifier 23 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Modifier AA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Advanced Beneficiary Notice or Statutorily Excluded . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Modifier GA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Modifier GZ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Modifier GY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Modifiers Used in the PQRS Initiatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Modifiers Identify Particular Types of Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Physician of Record . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Modifier AI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Other Miscellaneous Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Modifier GG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Modifier GH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Modifier QW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Modifier Q6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12
Hands-on Exercises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Summary of Modifiers Addressed: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Slide Presentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
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Modifiers–The Rest of the Story
Modifiers—The Rest of the Story
Introduction
While coding always acts as a translation from the physician’s documentation to a numeric value identifying the
diagnostic codes and services and supplies provided, it is
not always enough to give a clear and accurate picture.
Status, decisions, distinct, significant-is it supported? Necessary, must use, can’t abuse…when and how? A patient
has a screening mammogram and a diagnostic mammogram on the same day, can both be billed? Primary care
and specialist both see a patient on the date of admission
and both report an initial hospital service to the Centers
for Medicare & Medicaid Services (CMS), what critical
distinction is needed? A patient receives a joint injection in
the orthopedic office; is a visit also reportable? The correct
answer is yes, no, maybe-when, why, what is needed? This
can be very confusing and frustrating.
CPT®, HCPCS Level II, and ICD-9-CM tell most of
the story. Modifiers help tell the rest of the story. Modifiers often must be utilized to further clarify, identify,
or explain more detail about what transpired during the
patient’s encounter.
Modifiers are necessary to achieve the appropriate reimbursement in many instances, but modifiers also can be
misused, overused, or abused and can put a physician or an
organization at risk.
Modifiers also often are frustrating, as not all payers follow
the same or standard rules and not all payers recognize all
modifiers available. All coders, physicians, and facilities
must know their unique payers and how modifiers can
impact their billing. Staff involved in working the denial
process must also be extremely adept at modifier usage, as
often denials indicate that a modifier is needed; however,
this does not mean a modifier can be blindly attached and
the claim resubmitted. What this type of denial is actually stating is that if appropriate for this particular patient,
under the particular circumstance, on the particular day,
and if supported by documentation a modifier should have
been used. Then it should be attached and reprocessed.
There are concerns with electronic health records (EHRs)
“auto attaching” modifiers based on code selection. If the
EHR does not have a mechanism to verify the documentation supports the use and need of a modifier, it should not
be appended. For example, if an EHR attaches modifier 25
to the evaluation and management (E/M) service any time
a minor procedure is captured on the same day, from a
technical standpoint, this is correct. However, there should
be coding oversight and review to determine that the documentation supports both services and that the E/M service
meets the needs of “separate and significant,” which is
required to report both services.
It is certainly recommended that as part of the organization’s internal audit program for compliance, modifier use
is a component that is reviewed. Look at the frequency
by which modifiers are utilized; review a random sample
for the accuracy of modifiers utilized. Track denials for
modifier-related reasons by payer, modifier, and type, and
determine how and which payers are identifying issues
based on modifiers.
While modifiers tell payers the rest of the story, they
should tell the right story. Coding does allow organizations
to obtain reimbursement and they are deserving of the correct reimbursement; coding truly captures the condition,
the severity and the status of the unique patient, and the
quality of care provided.
The content of this presentation is based on the expected
and intended usage of all modifiers; however, all organizations, physicians’ offices, and coders need to know their
payers and if payers do not recognize a specific modifier
or instruct a different means of reporting, this should be
obtained from the payer in writing and followed. If you
have a contract with a specific payer, look to see if the
contract identifies modifier usage. If not, utilize payers’
manuals or on-line payment policies. Get familiar and
know how to find your payer policy regarding modifiers.
For example, Horizon of New Jersey, said in a decision
published in February, 2010 indicated: “the evaluation
and management (E/M) services that are appropriately
appended with modifier 25 will pay at 50 percent of the
applicable Horizon BCBSNJ fee schedule amount.”
http://codingnews.inhealth care.com/tag/payers/
Network Health has published that when utilizing modifier 62, they will reimburse each physician at a rate of
57.50 percent.
www.network-health.org/uploadedFiles/pdfs/payment_
policies/pay_policy_modifier_62.pdf
Blue Cross Blue Shield of Mississippi published a modifier
usage guide for their payment policies.
www.healthymississippi.com/assets/docs/Modifier_
Usage_Guide.pdf
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Modifiers–The Rest of the Story
Anatomical Modifiers
These modifiers are utilized to capture that either a particular side of the body or appendage is involved or a specific
location of the body. These are Level II modifiers, which
are found in the HCPCS Level II book.
These modifiers are informational only and do not impact
payment of the specific service.
Some examples of anatomical modifiers are the RT and
LT to identify whether it is the right (RT) or left (LT) side
or appendage or body part. Other very specific anatomical
modifiers include the TA-T9 modifiers to identify specific
toes and the FA-F9 modifiers to identify specific fingers.
The table below identifies the digit modifiers:
Modifier
TA
T1
T2
T3
T4
T5
T6
T7
T8
T9
Description
Left great toe
Left second digit foot
Left third digit foot
Left fourth digit foot
Left fifth digit foot
Right great toe
Right second digit foot
Right third digit foot
Right fourth digit foot
Right fifth digit foot
FA
F1
F2
F3
F4
F5
F6
F7
F8
F9
Left thumb
Left second digit hand
Left third digit hand
Left fourth digit hand
Left fifth digit hand
Right Thumb
Right second digit hand
Right third digit hand
Right fourth digit hand
Right fifth digit hand
Eyelids also have anatomic modifiers, E1-E4, to identify
which eyelid is involved in a particular procedure.
Modifier
E1
E2
E3
E4
2
AAPC
Description
Upper left eyelid
Lower left eyelid
Upper right eyelid
Lower right eyelid
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Anatomic modifiers can be critical, particularly if the same
service or procedure is performed on more than one area,
these modifiers identify that the services were not a duplicate or were distinct and separate.
For example, if a blepharoplasty is performed on both the
right and left lower lid, the same procedure code is needed
to report the services; however, the appropriate eyelid
modifier with E2 being captured for the left lower lid and
E4 to capture the right lower lid should be attached. This
will identify that the procedures were distinct and separate
as they are performed at separate locations.
Anatomical modifiers should only be utilized on procedures or supply codes. They should not be attached to E/M
services, even if the chief complaint is specific to one side.
These modifiers also should never be attached to a diagnostic code.
A patient presents with right elbow pain and after evaluation has a three-view radiograph done of the elbow,
receives a joint injection in the right elbow and is given a
splint for the right elbow. In this instance, the RT modifier
to identify “right” should be used on three services:
yy The three-view radiograph should have the RT appended to
show the right elbow was X-rayed.
yy The injection given in the joint should have the RT appended
to show the injection was given in a right joint.
yy The splint should have an RT attached to show the splint is
for the right arm.
Clearly and quickly the appending of the modifiers to
the codes paint a clearer picture of the problem of the
patient, the service that was provided, and links the services together to help support the medical necessity of all
services provided.
Evaluation and
Management Modifiers
There are only three CPT® modifiers appropriate for E/M.
These modifiers are very specific in their use and allow for
payment for E/M services that might otherwise be denied
as included in some other service.
Modifier 25
Significant, separately identifiable evaluation and management service by the same physician on the same day of
the procedure or other service—This modifier is a high risk
modifier as it is sometimes perceived to be overutilized.
Modifier 25 should be used any time an E/M service is
separate and significant from another service provided on
Modifiers–The Rest of the Story
the same day that has a global period of 0 or 10 days. This
modifier should also be captured when an E/M service
is provided with services that have an XXX as the global
period, per the National Correct Coding Initiative (NCCI)
policy. This modifier is not necessary on E/M codes billed
with services having a ZZZ as a status to identify the
global period.
The key to proper utilization of modifier 25 is that the
service is separate and significant. There is a component of
E/M included in every procedure and there are occasions
when just a procedure should be reported. Documentation
for the E/M service must still support the documentation
guidelines, must be separate and significant and medically
necessary, and the documentation for the other service
cannot be utilized to support the E/M service, as that documentation must support the other service reported.
For example: A patient presents to the office for wheezing and shortness of breath. During the course of the
examination, the physician notices a suspicious lesion on
the patient’s back. The E/M service was completed and is
separate and significant, but the patient opts to have the
lesion biopsied while in the office. A procedure note for the
biopsy is also documented. In this instance, modifier 25
should be reported on the E/M code.
To change this scenario, the same visit occurred for the
same reason, but the patient scheduled a follow-up visit to
have the biopsy performed. On the follow-up visit a cursory visit was done just to update the patient’s status; but,
the reason for the visit was for biopsy, which was known
prior to the visit and the only service provided. The brief
exam involved inspection of the lesion location only and
was not separate and significant. In this instance, a separate visit would not be reported, and modifier 25 would
not be appropriate.
Modifier 24
Unrelated evaluation and management service by the same
physician during a postoperative period —This modifier
identifies a separate and significant office visit in the postoperative period of a major procedure with a 90 day global
period when the visit is unrelated to the surgery.
Major procedures with a 90 day global period include all
the normal and expected routine follow-up visits during
this period.
However, there are times when a patient presents to the
operating surgeon during the post-op period and the service
is for an unrelated reason. In this instance, failure to utilize
modifier 24 will result in non-payment for the visit, as it will
be denied as being included in the post-operative period.
This modifier must be used to receive proper payment.
For example: A patient has gallbladder surgery by the
general surgeon and is in the post-op period. During the
global period, the patient’s primary care physician identifies a breast mass and refers the patient back to the general
surgeon for evaluation. Since the patient is in the global
period from the gallbladder surgery and the breast concern
is unrelated, modifier 24 must be reported on the visit
code for the surgeon.
Modifier 57
Decision for surgery—This modifier identifies when the
decision to perform major surgery is made and surgery is
going to be the same or next day. The global surgical package includes the admission to the hospital for surgery or
the cursory visit right before surgery to determine that the
patient is cleared and healthy enough to have the surgery.
This visit would not be payable separately and is part of
the global package.
There are instances in which the surgeon sees the patient—
usually in an emergent situation—and performs a complete E/M service, determines at the visit that surgery is
necessary, and decides to perform surgery within the next
24 hour period. This visit is not included in the global
surgical package since the decision to perform immediate
surgery was initially made. When this occurs, modifier 57
must be reported on the E/M code to allow the visit to be
paid outside of the global period.
This modifier can be utilized on any type of E/M code
such as: office visit, hospital admission, observation admission or emergency department visit. This modifier would
be appropriate, for example, if a patient presented to the
emergency department with abdominal pain. The emergency department physician transferred the care to the
general surgeon on call. After monitoring and a complete
E/M service, it was determined that the patient had appendicitis and the appendix should be removed. The patient
was taken to surgery on the same date. The surgeon would
append modifier 57 to his E/M service performed on the
day of the appendectomy.
Modifiers 24, 25, and 57 all should be utilized when
appropriate; however, they should not be routinely added
based on denials without review to determine that the
documentation supports the use of the modifier. While
these modifiers will not change the amount of payment
for the evaluation and management service, they do allow
for payment of this type of service that might otherwise
be inclusive in other services provided. Remember, you are
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Modifiers–The Rest of the Story
telling a unique patient’s story and when modifiers are correctly utilized, they provide significant additional information related to the services billed.
Repeat Procedures
There are instances that for quality patient care the same
service must occur more than one time on a specific day.
This may be a lab service, a diagnostic service, or a procedure. It may be completed by the same physician or a different physician.
The risk when this occurs is that the claim will be denied
inappropriately because it is thought to be a duplicate
procedure. A modifier must be utilized to identify that it
is not a duplicate but was actually a medically necessary
repeated procedure.
Modifier 76 and 77
Modifier 76 and 77 are similar modifiers. Modifier 76
identifies when a repeat procedure is performed by the
same physician, same patient, same day. Modifier 77
identifies when a repeat procedure is performed by different physicians, but on the same patient and the same day.
Modifier 76 and 77 are necessary anytime a repeat procedure is performed on a patient to identify that it is not
a duplicate, but that the actual procedure was performed
more than one time. Choosing between the two modifiers
is dependent upon whether it was the same or a different
physician. When these modifiers are not used, the claim
will often be interpreted as a duplicate and inappropriately
denied.
One example: A patient in the office has a very low pulse
oxygen level and her asthma is exacerbated and a nebulizer
treatment is performed. The oxygen saturation is again
measured and while better is still lower than the physician
would like to see, so a second treatment is given. When
this occurs, modifier 76 is necessary on the second nebulizer treatment to show it was not a duplicate, but a repeat
procedure. Chart documentation must support that it was
medically necessary and support that the service was performed twice during the visit.
Another instance where these modifiers would be necessary is in the case of a patient who is in the emergency
department and has an abnormal electrocardiogram (EKG)
performed at 10 a.m. He has a repeat EKG a few hours
later in the day to compare the results to try to confirm
an abnormality and, possibly, an occurring acute myocardial infarction. The EKG in the morning was interpreted
by Dr. Smith, and Dr. Jones interpreted the EKG in the
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afternoon. These two physicians are partners in the same
cardiology practice. In this instance, modifier 77 would
have to be utilized on the interpretation of Dr. Jones to
capture that it was a repeat procedure performed by a different physician.
Modifier 91
Repeat clinical diagnostic laboratory test—This modifier
identifies a repeated laboratory service. One risk of utilizing this modifier is using it when an incomplete sample is
obtained. This modifier identifies that the same test was
done more than once in the same day and was medically
necessary and most frequently occurs when a physician
wants to have comparative results. When this occurs, modifier 91 must be attached to the additional services.
For example: A patient has an unusually high glucose in
the morning and a repeat test is performed later in the
day to insure that the level is lower. Modifier 91 would be
attached to the second glucose.
Procedures in the Global Period
Major procedures have a 90 day global period. What this
really identifies is that nearly all services provided by the
surgeon in the 90 day global period are included in the
global surgical package and are not paid separately. All of
the following services are included in the global surgical
package, per CMS:
yy Preoperative Visits—After the decision to perform surgery
has already been made. This begins with the day before
major surgery.
yy Intraoperative services—Services that are a usual and
necessary part of a surgical procedure.
yy Complications following surgery—Those which do not
require a return trip to the operating room.
yy Postoperative visits—Follow-up visits that are related to
normal surgical recovery.
yy Postsurgical pain management—Pain management provided by the surgeon.
yy Miscellaneous services—These include supplies, dressing changes, incisional care, removal of packing, removal
of sutures or staples, removal of lines, wires, tubes, drains,
casts and splints, insertion, irrigation and removal of urinary
catheters, routine peripheral IV lines, nasogastric and rectal
tubes, and changes or removal of tracheostomy tubes
When services other than those included in the global
package are performed, and claims are electronically
adjudicated, the payers’ systems usually treat all services
Modifiers–The Rest of the Story
reported by the surgeon as “included in the global package.” Again, modifiers are needed to clarify the story and
to identify when services and items are not included in the
global surgery package.
Modifier 58
Staged or related procedure or service by the same physician during the postoperative period—This modifier
identifies when a staged or related procedure is performed
on a patient that is still in a global period from an initial
service. It should be utilized when there is a planned or
staged procedure that is related to the first but done at a
separate later encounter or used when a related procedure,
usually of a more extensive nature, is performed during the
global period.
For example, a patient has been diagnosed with breast
cancer and has a lumpectomy performed and lymph nodes
are taken. After pathology, the nodes come back positive
for malignancy, so the patient is returned to surgery and a
more extensive total mastectomy is performed. The patient
is still within the global period from the lumpectomy, so
modifier 58 would be attached to show the mastectomy is
a related procedure in the post-operative period. One critical thing to remember is when this occurs, a new 90 day
global period begins and the clock starts again from the
date of the second procedure.
Modifier 78
Unplanned return to the operating/procedure room by the
same physician or other qualified health care professional
following initial procedure for a related procedure during
the postoperative period—This modifier identifies a related
procedure that requires a return to the operating room
performed by the same physician within the post-operative
period. This modifier and modifier 58 are often confusing
as they have very similar features. One key to correct use
of modifier 78 is to append it when there is an unexpected
return to the operating room and, while related, it is not
an extension of the initial procedure. This is used most frequently when a complication arises and causes the patient
to return to the operating room to handle and treat the
complication by means of an additional procedure.
This modifier would be appropriate in a scenario in which
the patient had open heart surgery. The following day
there is still bleeding and seepage around the incision site
and the patient is returned to the operative suite to perform a procedure for bleeding control. It was not staged
and expected, it wasn’t more extensive, but it did require
a return to the operating room. Modifier 78 should be
utilized. One key difference is that when utilizing the 78
modifier, the global period does not change and the 90 day
global period remains from the date of the first procedure.
It also should be noted that a slight change in the wording does allow for modifier 78 to be utilized if there is no
return to a formal operative suite, but any dedicated procedure room or an ASC.
Modifier 79
Unrelated procedure or service by the same physician
during the postoperative period—Unrelated procedure
requiring a return to the operating/procedure room by the
same physician in the global period is identified by modifier 79 and should be utilized when a patient has a second
surgery within the 90 day global period, but it is for an
unrelated event.
For example: A patient has an excision of her gallbladder due to gallstones. During the 90 day post operative
period, the primary care physician identifies a breast mass
and sends the patient to the surgeon for evaluation. The
surgeon performs a biopsy of the breast mass and a modifier 79 must be attached to the biopsy to identify that it is
in the 90 day global period, but unrelated to the previous
surgery.
Pre, Post, or Surgical Only
While the global surgical package includes the preoperative, surgical, and routine post-operative care, there
are times when this service must be split apart and when
a physician performs only a portion of the global surgical
package. When that occurs, modifiers must be utilized to
capture the appropriate service. Each service is reported
with the actual surgical code of the procedure performed,
with the appropriate modifier to identify which component
of the global surgical package was provided.
The allowable amount of the procedure is divided between
the physicians providing the individual component parts
of the surgical package. The surgical component only
reimburses at 70 percent of the allowable, the pre-operative
management is reimbursed at 10 percent of the allowable
and the post-operative management care is reimbursed at
20 percent of the allowable.
Modifier 54
This modifier identifies the surgical care only and when
reported identifies that the pre-operative and post-operative
work are not included.
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Modifiers–The Rest of the Story
Modifier 55
Modifier 52
Post-Operative management only—This modifier should
be used when a patient has had a major surgery performed,
but the physician who performed the surgery is not providing the post-operative management.
Reduced services—This modifier differs from modifier 53
in that a service was not discontinued, it was a reduced
from the total description of the procedure. When modifier 52 is utilized, payers will often request documentation
to determine what portion of the service was reduced. If
significant, they may reduce the allowable payment. One
example would be when a service that is clearly defined
or intended to be a bilateral service is performed unilaterally. If a pure tone audiometry, air, (92552) is performed
only on the left ear, modifier 52 should be appended
(92552-52). This procedure is a bilateral procedure and
was reduced as it was only completed on one ear. Some
services are identified by CPT® to be a unilateral or a bilateral procedure, such as 92227 Remote imaging for detection
of retinal disease with analysis and report under physician
supervision, unilateral or bilateral. Since by definition of
the code, it can be a unilateral procedure, if it is only performed on one eye, a modifier 52 would not be necessary
or appropriate.
Modifier 56
Pre-operative management only—For example, an orthopedic surgeon is called into the Emergency Department
on the weekend and does an emergent surgery to repair a
comminuted fracture of the distal radius. The orthopedic
surgeon does the pre-operative management and also performs the surgery, but is leaving on vacation the following
day and the follow-up care will be assigned to a different
orthopedic surgeon.
The initial physician would report the procedure with a
modifier 56 to capture the pre-operative management and
the same procedure code with a modifier 54 to capture the
surgical component only.
The physician whom the care is transferred to would
then report the same procedure code, date of the original
surgery and attach a modifier 56 to identify that the postoperative management is being provided separately and
should be reimbursed separately.
Discontinued or Reduced
Modifier 53
Discontinued procedure—Modifier 53 is appended to the
CPT® code for a procedure that is started but can’t be completed due to the patient’s condition. The service still needs
to be reported - work was done - but the procedure wasn’t
completed and the patient may very well have to have the
same procedure at a later date. In this instance, modifier
53 should be reported to identify that it was discontinued
and that it was discontinued due to the condition of the
patient. Documentation in the medical record should
clearly identify why the service had to be discontinued.
It should also include a description of the portions of the
service that were completed before it was discontinued. If a
colonoscopy was planned and started; and, due to a tortuous colon, the physician could not pass the scope because
of the splenic flexure, the colonoscopy (45378) would be
reported with a modifier 53 to show the service was discontinued. When modifier 53 is utilized, most payers will
require that documentation be submitted to help them
determine the extent of the procedure that was performed.
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Bilateral
Modifier 50
Bilateral procedure—This modifier identifies a service
that is performed bilaterally. It is only utilized if the exact
procedure is performed on two body areas that come in
pairs (example, ears, legs, hands, etc.). To accurately report
modifier 50, the service should be reported on one line
item with one unit of service. The claim should have the
fee doubled to capture both procedures. Expected reimbursement would be at 150 percent of the allowable, which
is based on 100 percent for the first procedure and 50 percent for the second procedure, following normal multiple
procedure reduction rules.
This modifier is not always accepted by all payers and
some payers would rather you identify two line items
utilizing an RT modifier on one and an LT modifier on
the other. This does identify the exact same information.
Again, you must know your payers to determine how they
want bilateral services reported. For example, if a joint
injection was performed in both the right and the left
knee, it could be reported as:
20610-50 or on two separate line items with 20610-RT and
20610-LT
Modifiers–The Rest of the Story
Multiple Procedures
Modifier 51
Multiple procedures—Modifier 51 is used anytime there
are multiple procedures identified in the same surgical session. It should never be appended on an add-on code where
another code must be reported with the primary procedure
(example, +11101), and it is not appended on codes identified as modifier 51 exempt (example, 31500). For all other
procedure codes, if more than one procedure is performed,
it is appropriate on all procedures but the primary. If a
patient has been injured and has fractures of both the
clavicle and the sternum and both are treated with a closed
reduction, modifier 51 should be added to the second procedure.
23500
Closed treatment of a clavicular fracture, without
manipulation
21820-51 Closed treatment of sternum fracture
Modifier 51 is attached to the procedure of ‘lesser value’
based on the relative value units, and on multiple procedure reduction rules. Payment will be 100 percent of the
first procedure and 50 percent of each additional procedure. Be sure to indicate the procedure of the lesser value
to be the one in which payment is reduced.
Critical to Note: Many payers no longer require this
modifier, including the CMS. Some payers will even deny
claims if the modifier is utilized. If your payers deny payment or do not want this modifier reported, it should not
be submitted. For example: Palmetto GBA strongly recommends that this modifier not be reported.
www.palmettogba.com/palmetto/providers.nsf/DocsCat/
Providers~Jurisdiction percent201 percent20Part
percent20B~Articles~Modifier percent20Lookup~7REK
2L5824?open&navmenu=||
Most Medicare Administrative Contractors (MACs) do not
want providers to use modifier 51 as their claims adjudication software prices multiple procedures automatically.
There have been instances in which the Recovery Audit
Contractors (RACs) have interpreted this modifier differently than noted from CMS, so make certain you know
what your carriers and RACs require.
Assistant at Surgery
There are many modifiers that involve an assistant at surgery. You must know who is assisting, the circumstance,
and the extent to which the assistant is utilized.
80 Assistant Surgeon
81 Minimum Assistant Surgeon
82 Assistant Surgeon (When qualified resident surgeon not
available) The unavailability of a qualified resident surgeon
is a prerequisite for use of modifier 82 appended to the
usual procedure codes.
AS Assistant at surgery performed by a mid-level provider
(PA, CNS, NP)
Clearly the first thing to identify is who the assistant is. A
physician providing the service vs. a mid-level provider will
definitively influence the choice of the appropriate modifier. Also, in a teaching setting it is expected that qualified
residents will be utilized to perform surgical assists, and
their services are not separately billable. In the event that a
resident is not available and a physician is used, the modifier reports that a resident was not available.
When an assistant at surgery service is reported, the
surgery indicators should be known, as not all services
are appropriate to utilize an assistant. The Assistant at
Surgery Indicators published by CMS and found in the
CMS National Physician Fee Schedule Relative Value File
(NPFSRV) identify:
Indicator
Definition
0
Assistant surgeon may be paid with
documentation supporting medical
necessity
1
Assistant surgeon cannot be paid
2
Assistant surgeon can be paid
9
Assistant surgeon concept does not apply
While an assistant surgeon does not need to complete a
separate individual report, the primary surgeon does need
to capture the role the assistant surgeon played in the
procedure and must also identify the assistant surgeon in
the primary operative note. The assistant surgeon must
play a medically necessary role in the performance of the
procedure and not just be an observer. It is not sufficient
documentation to just indicate in the header of the report
the name of the assistant surgeon. It is also not sufficient
to identify terms like “we” and “us” to indicate an assistant
surgeon was present.
Co-Surgeons
62 Two Surgeons—When two surgeons perform distinct
portions of a single procedure and both must capture their
services with the same CPT® code modifier 62 should be
reported on both surgeon services. When two surgeons are
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Modifiers–The Rest of the Story
involved in the same operative episode but their unique
services can be identified with different CPT® codes, this
modifier is not appropriate and not necessary. However, if
the physicians are co-surgeons, one is not simply assisting;
both should be reimbursed for their portion of the service.
When modifier 62 is utilized, the total expected reimbursement would be at 125 percent of the allowable charge
and split between the surgeons with each receiving 62.5
percent of the allowable amount.
For example: CPT® 62223 Creation of shunt; ventriculoperitoneal, -pleural, other terminus often requires the skills
of both a neurosurgeon and a general surgeon for completion. When this occurs, the two surgeons each provide
their unique service; both would report the 62223-62.
It would not be needed, when two surgeons are involved in
the operative episode, but each have a clearly defined separate procedure. One example of this would be when both
an abdomino-vaginal vesical neck suspension is performed
by a urologist and a total abdominal hysterectomy is performed by a gynecologist during the same operative event.
Since the vesical neck suspension can be reported with
51845 and the hysterectomy with 58150; modifier 62 is
not needed, as both physicians have a code to capture their
unique services.
Distinct and Separate
Modifier 59
Modifier 59 is often termed the modifier of last resort as
it is often misused and overused and has a high impact
on reimbursement so is very closely monitored by payers.
The NCCI edits have thousands of procedures that are
bundled together and not separately reportable in most circumstances. However, there are instances for a particular
patient on a particular day by a particular physician, the
services are truly distinct and separate and should be reimbursed separately.
When this occurs and there is no anatomical modifier to
clearly distinguish the distinct and separate nature of the
procedures performed, modifier 59 should be utilized.
The NCCI edits identify a status of 1, 0, or 9 and this
status further clarifies when a 59 may be appropriate. If
the status is a 0, a modifier 59 should never be utilized and
the codes are never reportable for the same patient on the
same date in any circumstance. If a status of 9 is attached,
the NCCI edit is no longer applicable and the codes are no
longer bundled together, so no modifier would be needed.
In those instances in which procedure codes are bundled
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together, but have a status indicator of 1, it identifies that
in certain circumstances a modifier is allowed to receive
separate payment. The article found at: www.cms.gov/
NationalCorrectCodInitEd/Downloads/modifier59.pdf
should be read, as it clearly identifies the needs for modifier 59.
Modifier 59 should be used to identify distinct and separate when the services involve separate excisions, separate
incisions, separate body parts, or different time of day.
This modifier should never be used simply to bypass an
edit to allow for additional reimbursement, which is why it
is a perceived compliance risk.
If it is the “way it is always done” or “we have to do both”
or “we have to use a 59 every time,” there is a high risk
that the modifier is being used inappropriately.
A biopsy service is bundled with an excision, as a biopsy is
not separately reimbursable if the more extensive excision
of the lesion is performed at the same setting. However,
if a biopsy of one lesion on the back is performed and an
excision of a completely separate lesion on the back is performed, modifier 59 would be appropriate on the biopsy
code. This clearly is saying that it is understood that normally these codes are not reportable at the same operative
episode, but on this particular patient the services are distinct and separate.
Another example would be a rhythm strip, which is included
in a 12 lead EKG. However, if a rhythm strip was run on
a patient at 10 am in the morning and a 12 lead EKG was
completed at 3 pm in the afternoon on the same day, the
services were performed at different times of day and are
separately reportable. In this instance, modifier 59 needs to
be attached to the rhythm strip to capture that it is distinct
and separate and should be reimbursed separately.
Increased Procedural Service
Modifier 22
When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code.
Documentation must support the substantial additional
work and the reason for the additional work (e.g. increased
intensity, time, technical difficulty of procedure, severity
of patient’s condition, physical and mental effort required).
This modifier is often not well recognized by payers and
it is nearly always necessary to file the claim on paper so
that a copy of the operative report can be submitted, which
must clearly capture the substantial additional work.
Modifiers–The Rest of the Story
While it is appropriate to increase fees based on the substantial increased work, payers may not increase payment
for the services.
Anesthesia
Physical Status
Physical status is obtained by the anesthesiologist on every
patient prior to surgery. The physical status modifier
identifies the status of the patient and further clarifies the
risk of taking the patient to surgery. Often this may help
identify potential negative outcomes based on significant
risk. This information should be captured in the anesthesiologist’s pre-operative record on all patients. Certainly
appropriate diagnosis codes should support the use of the
physical status modifier used. The systemic diseases and
any co-morbidities documented would help support the
medical needs and severity of the patient.
yy P1 Normal healthy patient
yy P2 Patient with mild systemic disease
yy P3 Patient with severe systemic disease
yy P4 Patient with severe systemic disease that is a constant
threat to life
yy P5 A moribund patient who is not expected to survive without the operation
yy P6 A declared brain-dead patient whose organs are being
removed for donor purposes (this is never billed to the
patient, it is typically seen in a transplant situation)
While the physical status modifiers are not recognized by
all payers, there are payers that will allow additional reimbursement and increase the base units for P3, P4, and P5.
It is critical, to capture this information to allow for proper
reimbursement when payers do allow additional base units.
Documentation and diagnoses must clearly support the
status as noted above.
Modifier 23
Unusual Anesthesia—Modifier 23 is utilized to capture
situations in which a procedure that normally does not
require anesthesia for some particular circumstance, does
require general anesthesia. The medical record must distinctly identify why a general anesthetic is needed.
A cystoscopy, for example, does not usually require a general anesthetic. However, when this procedure is performed
on a young child and the patient is unable to be controlled
to safely perform the procedure, a general anesthetic may
be necessary. When this occurs, modifier 23 should be
attached to the cystoscopy procedure.
Many different types of providers may now be furnishing
or assisting in the anesthesia services during a surgical procedure. Payment for anesthesia services is directly related to
the type of provider performing the services. It is critical to
use the correct modifier to clearly capture the correct identity of the provider performing the anesthesiology services.
The CMS link to captures information on anesthesia services is www.cms.gov/center/anesth.asp. Based on CPT®,
anesthesia services reported without the appropriate modifier can be paid at the lowest allowable percentage, which
would be 50 percent, so modifiers are critical for appropriate payment.
Other modifiers which are utilized in anesthesia come
into play when a physician anesthesiologist is a supervising
physician and directing multiple operative episodes. Based
on CMS, a physician anesthesiologist may also direct up to
four procedures concurrently. However, there are requirements which must be met. The supervising physician must:
yy Perform the initial evaluation
yy Prescribe the anesthesia plan and personally participate in
the most demanding procedures
yy Personally perform induction and emergency services
yy Monitor the course of anesthesia administration and remain
physically present during any emergencies
yy Perform necessary post-anesthesia care
Concurrent procedure reimbursement is made at an
amount equal to 50 percent of the anesthesiologist’s
normal fee schedule.
Modifier AA
Services personally furnished by the anesthesiologist—This
includes those services provided by faculty anesthesiologists that may involve a resident. This service should not be
reported in conjunction with modifier QX.
For example:
When a physician is acting as a supervising physician, there
are also various modifiers which could be reported.
Modifier QX Services provided by Certified Registered Nurse
Anesthetist (CRNA)
Modifier AD Reported when the medical supervision by a
physician is for more than four concurrent anesthesia services. www.aapc.com
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Modifiers–The Rest of the Story
Modifier QK Medical direction of two, three, or four concur-
rent anesthesia procedures involving qualified
individuals. Modifier QS Reported for monitored anesthesia services
Services identified with the QS modifier for monitored
anesthesia services (MAC) are identified by the anesthesiologist giving medications, which helps the patient relax
during a procedure but differs significantly from general
anesthesia because the patient continues to breathe on their
own and does not have a breathing tube. However, the
anesthesiologist is in constant attendance and monitors the
services just the same as he or she would during general
anesthesia. If at any time a breathing tube must be inserted
and a patient cannot maintain appropriate breathing on
their own, the service is reported as a general anesthetic,
even if initially started as MAC.
MAC is most often used for procedures that do not require
general anesthesia but are uncomfortable for the patient,
such as endoscopies and colonoscopies.
Advanced Beneficiary Notice
or Statutorily Excluded
Modifier GA
Waiver of liability statement on file—This modifier is
critical but relies completely on the physician and/or designee to obtain the correct Advance Beneficiary Notice
(ABN)when appropriate. An ABN should be obtained for
CMS beneficiaries when a service may not be covered for
a specific reason. If the service is only considered medically necessary for certain diagnoses or if the service has
frequency limitations and the patient does not fit the
necessary criteria, a complete and accurate ABN should
be obtained. This ABN should identify what service may
not be covered, why it may not be covered, and how much
the patient will owe in the event it is not covered. It allows
patients to make informed decisions for their health care.
After completing all the necessary steps and obtaining a
signed ABN, modifier GA should be attached to the service. In the event that the service is not covered by CMS,
the claim is the patient’s responsibility. If an ABN is not
obtained and the service is considered not medically necessary, the service must be written off and the patient is not
held responsible. Important notes: Blanket ABNs signed
for all services or by all patients for a particular service are
not allowed. Utilizing the wrong form or the form being
completed incorrectly is valid and do not support a GA
modifier.
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For example, if a patient is ordered to have a laboratory
service 83036: Hemoglobin; glycosylated (A1C), but does
not have a known diagnosis that is covered by the NCD
for the service, the patient needs to be informed that the
service may not be covered. If an appropriately executed
ABN was obtained from the patient, this service would
then be reported with a GA modifier which identifies that
you are aware it may not be considered medically necessary, and that you have a complete and appropriate ABN
on file. This will change the type of denial and instead of
being denied as not medically necessary, the service will be
denied as patient responsibility and the patient should be
billed.
Failure to appropriately obtain ABNs and utilize the GA
modifier can result in services being denied as not medically necessary and when that occurs, the service must be
written off, having a significant negative financial impact
to the organization.
Modifier GZ
Item or service expected to be denied as not reasonable and
necessary—Modifier GZ is often not utilized, but is an
important modifier for CMS claims. This modifier is used
on services that have limited coverage issues, either based
on medical necessity, diagnostic reasons, or frequency
limitations when an ABN was not obtained. This modifier should be attached to all services that are anticipated
to be denied for a specific reason, and alerts that there was
not a valid ABN completed. If a significant volume of GZ
modifiers are submitted there is need for education on the
proper use and needs of an ABN.
Utilizing the same example as above, the GZ would be
attached if the 83036 laboratory test was ordered and the
diagnosis of the patient did not meet the medical criteria as identified by the NCD; however, an ABN was not
obtained. If denied as not medically necessary as expected
and without an ABN, the service must be written off and
revenue will be lost for the organization.
Modifier GY
Item or service statutorily excluded or does not meet the
definition of any Medicare benefit—The GY modifier
should be utilized anytime a statutorily excluded service is
going to be filed with CMS. This modifier identifies the
provider understands CMS does not cover the service and
that a denial is expected. Often, particularly if a beneficiary has a secondary policy, the provider needs the denial
before they file it to their other insurance; however, you do
want CMS to understand you do not expect payment so it
Modifiers–The Rest of the Story
does not appear that you are trying to recoup money from
CMS on statutorily excluded services.
Patient transport, for example, is a non-covered service for
CMS and is statutorily excluded from coverage. If however,
patient transport occurs and is going to be included on the
claim form, a modifier GY should be attached to indicate
that you know it is non-covered and expect it to be denied.
Modifiers Used
in the PQRS Initiatives
Many modifiers are utilized for a variety of circumstances
and help create a true and accurate picture of the patient.
Physicians and/or organizations participating in the Physician Quality Reporting System (PQRS), formerly the
Physician Quality Reporting Initiative (PQRI), have needs
involving a different group of modifiers. When a patient
meets the requirements of a PQRS measure but for some
reason the requirement of the initiative cannot be completed, this is also identified by use of the correct exclusion
modifier. Anytime a Performance Measure Exclusion needs
to be identified the following should be utilized:
AK Non Participating Physician
AM Physician, Team Member Service
There are instances in which it is necessary to identify the
type of provider for informational purposes, but can also
impact payment if services are restricted to certain types
of providers. For example, in a critical access hospital, if
nutrition services are rendered by a registered dietician,
modifier AE must be reported and payment will be at 85
percent of the MPFS.
Another example would be to use the AJ modifier any
time the service is provided by a clinical social worker, and
as based on WPS Medicare, the carrier for Iowa, Kansas,
Missouri, and Nebraska, services will be reimbursed at 75
percent of the physician fee schedule or the actual charge,
whichever is less, and only on the basis of assignment. If
the AJ modifier was not attached for a service provided by
a CSW and reimbursement was obtained at 100 percent,
it would be an overpayment based on the WPS Medicare
policy and a refund would be necessary.
Physician of Record
1P Due to Medical Reasons
Modifier AI
2P Due to Patient Choice
This modifier was newly created and became necessary
when CMS excluded payment of all consultation codes
to allow the physician of record for a hospitalization to be
clearly identified. The AI modifier should be attached to the
initial hospital service code by the physician who is the physician of record or attending physician for that hospital stay.
3P Due to System Reasons
8P Action not performed, Reason not otherwise specified
If a patient meets the criteria for a PQRS measure, such
as the patient is a diabetic and should have an A1C performed, but refuses to have the test performed, modifier
2P should be appended to the PQRS measure code. This
clearly identifies that the measure is known, but the
patient chose not to have the necessary services to meet the
measure’s criteria.
Modifiers Identify
Particular Types of Providers
Modifiers can also identify the type of health care provider
that is providing a particular service to a patient:
AE Registered Dietician
For example: A patient presents to the ER and their congestive heart failure is completely out of control; there is a
high level of fluid build-up and patient is extremely short
of breath. The hospitalist comes to assume care of the
patient in the ER and admits the patient. The hospitalist
then calls in the cardiologist and both the hospitalist and
the cardiologist report a 99223 for their individual initial
hospital service.
The hospitalist claim should also include the AI modifier,
captured as 99223-AI, which distinguishes that the hospitalist is the primary physician and the physician of record.
AF Specialty Physician
Other Miscellaneous Modifiers
AG Primary Physician
Modifier GG
AH Clinical Psychologist
Performance and payment of a screening mammogram
and diagnostic mammogram on the same patient, same
day—If a screening mammogram is performed and com-
AJ Clinical Social Worker
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11
Modifiers–The Rest of the Story
pleted on the same day, following the radiologist’s recommendations in which a diagnostic mammogram is also
completed, modifier GG must be utilized. This modifier
should be attached to the diagnostic mammogram service
code. In this circumstance, both services can and should
be covered. The key element to remember is the screening
service was not converted during the test, but both were
separately performed.
Modifier GH
This modifier is very similar to modifier GG and understanding the difference is necessary in utilizing the correct
modifier. If a screening mammogram is started and following the radiologist’s recommendation is converted to a
diagnostic mammogram and the diagnostic mammogram
is completed, modifier GH should be utilized. This identifies that the mammogram began as a screening service.
In this circumstance, only the diagnostic mammogram is
covered. GH would be appended to the diagnostic mammography code.
Modifier QW
CLIA waived test—If the physician’s office performs
in-office laboratory services and has a CLIA waived
certificate which allows them to provide CLIA waived
testing, the QW modifier may be needed. The QW
modifier simply identifies specific laboratory services
as being CLIA waived. CMS publishes an accurate list
of all services that meet the criteria for a CLIA waived
service and indicates which of these services requires the
QW modifier. This information can be found at www.
cms.gov/CLIA/downloads/waivetbl.pdf. For example, a
prothrombin time test provided in the physician’s office
with a CLIA waived certificate, the service should be
reported with 85610-QW.
Modifier Q6
Service furnished by a locum tenens physician—Locum
tenens physicians often are utilized to cover when a physician is out on medical leave or away on an extended vacation or a sabbatical of some type. When a locum tenens
physician is being utilized, the NPI number of the regular
physician that is out for whatever reason is reported for
the service and modifier Q6 is attached to the billed CPT®
and HCPCS Level II codes to identify that a locum tenens
physician provided the service. There are clearly defined
rules for locum tenens services, which must be followed.
The following apply when utilizing a locum tenens:
yy The physician must be absent from the practice due to illness,
vacation, CME, or the physician may have left the practice
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yy The regular physician must be unavailable to provide the
service
yy This is a physician rule and may not be utilized for mid-level
providers
yy There is a limit of 60 days for each locum physician,
counted from the first day the locum sees a patient. This 60
days includes days that the locum does not see patients,
such as his or her day off.
yy After 60 days, the locum may no longer bill for that locum.
If services are still needed, a different locum must be
obtained
yy Bill for the locum under the NPI of the physician who is not
there and use the Q6 modifier on the claim
yy A list of patients seen by the locum should be retained
yy The locum is paid on a per-diem or a fee-for-time basis
Conclusion
Modifiers add to the story making it better because they
further explain, identify, clarify, and capture additional
information to make it complete. While there are many
modifiers and this is not a comprehensive list of every
modifier available, coders should review all modifiers in
both CPT® and HCPCS Level II to determine what modifiers may pertain to the services they are reporting.
Modifiers when used appropriately will help organizations
and physicians obtain accurate reimbursement for the services they provide. While modifiers should never be used
just to get paid, they should always be utilized when necessary to allow for payment. Know your payers, know what
they want. Track modifier denials to help understand your
payer needs.
Talk to the physicians! Help them understand documentation needs to support the various modifiers and how modifiers clarify coding and proper utilization. Documentation,
as with all coding, is the key to the services being supported and the services being billable. Anytime a modifier
is utilized, the record must support the use of the modifier.
Modifiers: use them wisely, use them well.
Modifiers–The Rest of the Story
DISCLAIMER
This is not an all inclusive list of every modifier; this
is an overview of many modifiers and their intended
usage.
This material is designed to offer basic information
on the use of modifiers in coding. This information is
based on the experience, training and interpretation of
the author. Although the information has been carefully
researched and checked for accuracy and completeness,
the instructor does not accept any responsibility or liability with regard to errors, omission, misuse or misinterpretation. This handout is intended as an educational
guide and should not be considered a legal/consulting
opinion.
RESOURCES
There are many references and resources that you should
be familiar with to assist you with questions on coding.
Staying on top of the rules and regulations, utilizing
resources and networking are critical to the success of
the coder.
The Centers for Medicare & Medicaid Services (CMS)
has a very useful website that includes bulletins and
updates on coding, past and current fee schedules,
copies of the official 1995 and 1997 Evaluation and
Management Documentation Guidelines.
www.cms.gov
Also at the CMS site you can download the most current
CCI edits available, free of charge:
www.cms.hhs.gov/physicians/cciedits
The fee schedule, which is able to be searched by code or
code-range, is found at:
www.cms.hhs.gov/physicians/mpfsapp/default.asp
Another valuable service is the user friendly publications
provided at MedLearn Matters, which gives you up to date
news and changes:
www.cms.hhs.gov/medlearn/matters
AAPC is a valuable resource to coding staff and their
membership a bevy of qualified coders to assist, advise, and
guide:
www.aapc.com
Check out your local carrier, both for CMS and Medicaid. Stay abreast of all changes. Utilize information
provided from the American Medical Association.
www.aapc.com
13
Modifiers–The Rest of the Story
Hands-on Exercises
Work through the examples below for discussion:
It should be noted that multiple codes or multiple modifiers may be needed to capture the correct information, so if it asks is a
modifier needed, know that in some instances more than one may be necessary.
1. A patient presents to the general surgeon’s office as gallstones have been identified by ultrasound and the patient’s
primary care physician referred the patient to a surgeon. The general surgeon completes a detailed history; expanded
problem focused exam, and determines that the patient does need to have surgery for removal of the gallbladder. Surgery is scheduled for the following week:
What type of service should be reported?
Is a modifier needed?
Why or why not?
The day before surgery the patient returns for a brief visit, to insure that there is no infection, that all pre-operative
services necessary were performed and to review the needs for the following day.
What type of service should be reported?
Is a modifier needed?
Why or why not?
2. An asthmatic patient is seen in the office in severe exacerbation. The patient’s pulse Ox is taken and is low, so a nebulizer treatment is given in the office. Following the treatment another pulse Ox is taken and is higher, but still not satisfactory and another treatment is given. The patient also receives a therapeutic injection during the visit. A complete
evaluation and management service is completed.
What services should be reported?
Is a modifier needed?
Why or why not?
3. A patient has hip replacement performed by the orthopedic surgeon. During the 90 day global period, the patient slips
and falls and tries to catch herself and fractures her wrist. The orthopedic doctor who performed the hip replacement
surgery is called into the Emergency Department to assume care and after a comprehensive evaluation and management service; the decision is made to take immediately to surgery for repair of the wrist.
What services should be reported?
Is modifier needed?
Why or why not?
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Modifiers–The Rest of the Story
4. A physician goes on a 3 month sabbatical and a locum tenens physician is obtained from a locum service to cover for
the physician in his absence. The locum does have a license in the state, but is not credentialed for the group. He does
cover all services of the physician that is not there.
How are services reported?
What NPI number is utilized?
Can the locum’s services be billed?
Is a modifier needed?
Can the locum cover the entire absence?
5. After a fall from a tree, a patient presents with fractures of the left thumb, left first and left middle finger. All of these
fractures are identified by a three view X-ray and set with manipulation and splinted. A two view X-ray also identified
a subluxed left elbow, which is treated.
What types of services should be reported?
Is a modifier needed?
Why or why not?
6. A patient with severe osteoarthritis presents to the orthopedic office and has significant pain in both knees and the
right shoulder. The patient has not had any therapeutic treatment, but the pain is worsening. After a complete evaluation and management service, the physician determines that joint injections may help relieve some of the patient’s
pain. They discuss the procedure and the risks of the procedure and the patient opts to have the injections on the
same day and all three joints causing the most pain are injected.
What services should be reported?
Is a modifier needed?
Why or why not?
7.
In a teaching facility a physician is performing surgery which requires an assistant at surgery. He utilizes a resident to
assist him in surgery.
How are the resident’s services captured?
Is a modifier needed?
Why or why not?
In the above scenario, if a resident is not available and another physician must assist.
How are these services captured?
Is a modifier needed?
Why or why not?
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Modifiers–The Rest of the Story
8. A patient presents to the Emergency Department on Saturday and a general surgeon is called in due to severe abdominal pain. The surgeon determines the patient needs to have an appendectomy, but this cannot be performed until the
following day. The surgeon that saw the patient is not available the following day as he is going on a week-long vacation, but his surgical partner will perform the surgery. He does indicate to the patient that he will be back and will
follow in the office during the post-operative recovery time?
How is the initial service reported?
How does the physician that performs surgery report his service?
Is a modifier needed?
Why or why not?
When the original physician performs post-operative services in the global period, what is reported?
Is a modifier needed?
Why or why not?
9. A CMS beneficiary presents to have a Pap smear. While this service is only covered once every two years and the
patient had this service one-year prior, the service will not be covered. She is informed and Advanced Beneficiary
Notice (ABN) is obtained.
How should the service be reported?
Is a modifier needed?
Why or why not?
If an Advanced Beneficiary Notice is not obtained does it change the way the service is reported?
How should the service be reported in this instance?
Is a modifier needed?
Why or why not?
10. A patient has a mastectomy performed by the general surgeon. During the 90 day global post-op period of the surgery,
the patient develops a sinusitis and sees her primary care physician for an evaluation and management service.
How should this service be reported for the primary care physician?
Is a modifier needed?
Why or why not?
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Modifiers–The Rest of the Story
Summary of Modifiers Addressed:
Modifier Description
18
1P
Performance measure exclusion; due to medical reasons
2P
Performance measure exclusion; due to patient choice
3P
Performance measure exclusion; due to system reasons
8P
Performance measure exclusion; reason not specified
AA
Services personally furnished by anesthesiologist
AD
Reported when the medical supervision by a physician is for more than four concurrent anesthesia services. AE
Registered dietician
AF
Specialty physician
AG
Primary physician
AH
Clinical psychologist
AI
Physician of record
AJ
Clinical social worker
AK
Non participating physician
AM
Physician, team member service
AS
Assistant at surgery by non-physician provider (NP, CNS, PA)
E1
Upper left eyelid
E2
Lower left eyelid
E3
Upper right eyelid
E4
Lower right eyelid
F1
Left second digit hand
F2
Left third digit hand
F3
Left fourth digit hand
F4
Left fifth digit hand
F5
Right thumb
F6
Right second digit hand
F7
Right third digit hand
F8
Right fourth digit hand
F9
Right fifth digit hand
FA
Left thumb
GA
Certificate of waiver obtained (ABN executed)
AAPC
1-800-626-CODE (2633)
Modifiers–The Rest of the Story
GH
Performance and payment of a screening mammogram and diagnostic mammogram on the same patient, same
day
Diagnostic mammogram converted from screening mammogram on same day
GY
Item or service expected to be denied as statutorily excluded or not a benefit
GZ
Item or service expected to be denied as not reasonable and necessary, no waiver obtained
P1
Normal healthy patient
P2
Patient with mild systemic disease
P3
Patient with severe systemic disease
P4
Patient with severe systemic disease that is a constant threat to life
P5
A moribund patient who is not expected to survive without the operation
P6
A declared brain-dead patient whose organs are being removed for donor purposes
Q6
Services provided by a locum tenens physician
QK
Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals. QS
Reported for monitored anesthesia services
QW
CLIA waived service
QX
Services provided by Certified Registered Nurse Anesthetist
T1
Left second digit foot
T2
Left third digit foot
T3
Left fourth digit foot
T4
Left fifth digit foot
T5
Right great toe
T6
Right second digit foot
T7
Right third digit foot
T8
Right fourth digit foot
T9
Right fifth digit foot
TA
Left great toe
22
Increased procedural service
23
Unusual anesthesia services required
24
Unrelated evaluation and management service in the post-operative period
25
Separate and significant evaluation and management service
50
Bilateral procedure
51
Multiple procedure
52
Reduced service
53
Discontinued procedure
GG
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Modifiers–The Rest of the Story
20
AAPC
54
Surgical care only
55
Post-operative services only
56
Pre-operative evaluation only
57
Decision to perform surgery
58
Staged or related procedure in the post-operative period
59
Distinct and separate procedures
62
Co-surgeons
76
Repeat procedure by the same physician
77
Repeat procedure by a different physician
78
Related procedure in the post-operative period
79
Unrelated procedure in the post-operative period
80
Assistant at surgery
81
Minimum assistant at surgery
82
Physician assistant at surgery when no qualified resident is available
91
Repeat laboratory service
1-800-626-CODE (2633)
Modifiers–The Rest of the Story
Slide Presentation
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21
Modifiers–The Rest of the Story
Modifiers
The Rest of the Story
1
Disclaimer
This is not an all inclusive list of every modifier; this is an overview of many
modifiers and their intended usage.
This material is designed to offer basic information on the use of modifiers in
coding. This information is based on the experience, training and interpretation
of the author. Although the information has been carefully researched and
checked for accuracy and completeness, the instructor does not accept any
responsibility or liability with regard to errors, omission, misuse or
misinterpretation. This handout is intended as an educational guide and should
not be considered a legal/consulting opinion.
2
22
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1-800-626-CODE (2633)
Modifiers–The Rest of the Story
CPT® Coding
• CPT® codes identify a particular procedure or
service
• If a specific CPT® does not exist that identifies
the procedure or service, an unlisted code must
be utilized
• Coding is the translation between the
physician’ss written word and the dictionary used
physician
by payers to interpret them into numbers
3
What Do the Codes ‘Say’?
• A patient comes in for a reason which translates into the
diagnosis(s) code
• A service is provided or supply is given which translates into
a CPT® or HCPCS Level II code
– This tells the story to the payer about what was done and
why it was done
THE CODING NEEDS TO TELL THE RIGHT STORY
4
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23
Modifiers–The Rest of the Story
Lost in the Maze
• Don’t know which way to go
• Instructions vary
• Even the carrier seems unsure
• Learn how and when to apply
5
The Role of the Modifier
•
•
•
•
•
•
Provide more information
Cl if
Clarify
Expand upon
Enhance Specificity
Identify separation
…they
y add to…or CHANGE the storyy
6
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Modifiers–The Rest of the Story
Types
•
•
•
•
Informational Modifiers
Payment impacting modifiers
Status of patient modifier
Type of service
– Both CPT® modifiers and HCPCS Level II modifiers
• Many commercial payers do not require HCPCS Level II
modifiers
• All modifiers have a vital role in accurate coding.
g
• NOT all payers recognize modifiers
• KNOW your payers!
7
Payment
• Adding a modifier may get a claim paid
• MUST make sure the modifier should be added
• Adding a modifier JUST to get it paid, if not
supported, is fraud
Failure to use a modifier when appropriate may risk lost reimbursement;
over-utilizing or using a modifier for payment when not appropriate can put
the physician and practice at risk.
8
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25
Modifiers–The Rest of the Story
Denials
• Monitor and track denials that occur due to modifier
issues; to identify how your payers recognize modifiers
and when
– When a denial is received that indicates a modifier is
needed
• EASY fix: apply modifier
• NOT correct
– This denial really states that if a modifier was utilized, if appropriate and
supported by documentation on this particular day for this particular
patient for a particular reason, this claim may have been covered
» Staff working denials MUST be very familiar with the use and
needs of modifiers
9
Let’s Get Started
10
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Modifiers–The Rest of the Story
Anatomical Modifiers
Modifiers TA-T9, FA-F9: To identify that
procedures were done on separate fingers or toes
– ONLY appropriate on procedures and services, NOT
diagnosis codes or E/M codes
– If hammertoes are repaired on all toes, you could
report the same code 10 times, identifying each toe
individually with a modifier
11
Anatomical Modifiers
Modifier RT, LT: To identify that procedures were
done on separate ‘sides’
sides of the body
– ONLY appropriate on procedures and services, NOT
diagnosis codes or E/M codes
– Some payers would also rather see an RT, LT, and not the
50 for bilateral, must know what the payers want
– Lesion removed from right arm, excision taken from left
arm modifier RT and LT will identify that they were from a
arm,
different location
12
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27
Modifiers–The Rest of the Story
Anatomical…and the Eyelids
• E1 Upper left
• E2 Lower left
• E3 Upper right
• E4 Lower right
13
Examples of Anatomical Modifiers
•
Blepharoplasty done on the right and left upper eyelid during the same
operative episode
– The procedure should be reported on two separate line items; one with an
E1 and
d one with
ith an E3 modifier
difi
•
•
•
While reimbursement would face multiple procedure reduction rules; expected reimbursement would
be 100% for the first and 50% for the second.
Failure to use a modifier could result in a denial of the second procedure; as can appear to be a
duplicate
Hammertoe repair done on the right second, third, and fourth toe
– T6, T7, T8 should be reported with the hammertoe repair, each on a
separate line item
•
Again, this clarifies that it is not a duplicate, but three distinct and separate procedures
– Expected
p
reimbursement would be 100% of the first and 50% of both the second and the third
procedure
– Without the modifiers; there is a potential risk of only being paid for the initial procedure and the
others denied as a duplicate claim
14
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Modifiers–The Rest of the Story
Surgical Modifiers
58
Staged or related procedure in the post-op period by the same
physician
Patient had a lumpectomy and after pathology, it was determined that mastectomy
needed to be performed. Mastectomy, more extensive and related to the initial surgery,
modifier 58, identifies that it is staged/related in the post-op period.
78
Return to the OR for a related procedure during the post-op
period
Patient had open heart surgery, during hospitalization, began bleeding and had to be
taken BACK to the OR for more surgery. It was NOT ‘STAGED,’ it is NOT more extensive
than initial surgery, modifier 78 identifies a return to the OR.
79
Return to the OR for an unrelated procedure during the postop period
Patient had surgery to repair a fractured hip. During recovery, he slipped and fell
fracturing his wrist and had to have an ORIF performed, modifier 79 must be utilized.
15
Impact of Payment
of Surgical Modifiers
The primary and main concern of failure to use the
appropriate and necessary surgical modifiers is complete
denial of the 2nd procedure, as ‘inclusive’ as it may be
automatically denied, due to being in the global period.
Based on the procedure completed, this can be quite costly
– Appeals and resubmissions are expensive to any organization;
as failure to capture the right information the first time is the most
effective and efficient ‘cleans claim’ billing process
16
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29
Modifiers–The Rest of the Story
Global Days
National Physician Fee Schedule Relative Value File
HCPCS Mod
20612
20615
20650
20660
20661
Description
Global
Days
Aspirate/inj ganglion cyst
000
Treatment of bone cyst
010
Insert and remove bone pin 010
Apply rem fixation device
Apply,
000
Application of head brace
090
http://www.cms.gov/PhysicianFeeSched/01_Overview.asp#TopOfPage
17
Splitting the Global Surgical Package
54
55
56
– Surgical Care ONLY
– To identify that a provider ONLY did the surgery, that someone
else will be billing the post-op care (OPHTH-OPTOMETRY for
‘comanaged cataract patients)
– Post-op Management ONLY
– Physicians can SHARE the post-op care as well
– Reported with procedure code,
code original date of surgery,
surgery NOT the
date the patient was seen
– Pre-op Management ONLY
18
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Modifiers–The Rest of the Story
Example of Splitting
the Global Package
Let’s split the global package of the extracapsular
cataract surgery; 66984 (allowable $742.38)
$742 38)
66984-56
66984-54
66984-55
Pre-operative service provided by the
ophthalmologist doing the pre-operative work-up
($74.24)
Surgery only, by the ophthalmologist performing
surgery ($519.67)
Post-op follow-up
follow-up, provided by the optometrist that
the ophthalmologist referred patient to, for follow up
and glasses ($148.48)
19
Multiple/Bilateral Procedures
Modifier 51
–
–
Modifier ONLY recognizes that it is a multiple procedure
Iss NOT
O a pricing
p c g modifier,
od e , a
although
t oug many
a y paye
payers
s reduce
educe reimbursement
e bu se e t for
o multiple
utpe
procedures. 100% paid for the highest physician fee schedule amount and 50% of the fee
schedule for each additional procedure.
• MANY payers do not require this modifier; Medicare no longer requires it. In some
areas, claims will be denied if the modifier is utilized.
Modifier 50
–
–
–
–
Bilateral modifier, to indicate that the EXACT same procedure was performed on both sides
of the body.
Only appropriate for those areas, where you have ‘two’
Bilateral knee replacement
Also, NOT a pricing modifier
• Expected reimbursement is 150% but this is based on multiple procedure reduction
rules
• Some payers would rather have RT and LT on separate line items
20
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31
Modifiers–The Rest of the Story
Example of Bilateral
and Payment Impact
Bilateral modifier 50 and the RT and LT modifier to those payers,
nott recognizing
i i the
th modifier
difi 50 will
ill have
h
th
the same paymentt
impact
– Sticking with the extracapsular cataract 66984 service code; if
done on both eyes, a modifier 50 would be appropriate
• 66984-50 with 1 unit on one line item would be reimbursed at 150%:
$1113.57
• If reported with an RT and LT, it would be two separate line items
– 66984
66984-RT
RT
– 66984-LT
» Reimbursement would be 100% for the first; 50% for the second, still
resulting in 150% of $1113.57
21
Additional Work or Discontinued
Modifier 22
– When a procedure/service took more work
work, more time,
time or
was unusual from what was expected
– May charge more, when modifier is used
– May not be reimbursed more by payers
– Will expect documentation
Modifier 53
– Di
Discontinued
ti
d procedure,
d
when
h a procedure
d
HAD tto b
be
stopped, due to the condition of the patient. Still bill the
code of the procedure that was being attempted.
22
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Modifiers–The Rest of the Story
Examples of Additional Work
or Discontinued Procedures
• Patient is prepped and the plan is for a diagnostic colonoscopy; when the
sigmoid junction is reached, the blood pressure of the patient increases
dramatically; causing the physician to discontinue the procedure
– The colonoscopy 45378 should be reported with a modifier 53
• The procedure was not completed, it was discontinued due to the condition of the
patient.
– BILL at full fee; anticipate submitting with the operative report; payment may be reduced, in this
example to the allowable for a sigmoidoscopy, as that is the level reached; however, do not
reduce claim, not all payers will reduce payment.
• Due to a patient’s morbid obesity and the tremendous amount of
y the abdominal surgery
g y took 3 hours
adhesions from a prior colectomy;
longer than expected for a very common appendectomy
– In this instance a modifier 22 would be appropriate
• Increasing fees is also appropriate; however, not all payers will increase payment
23
Reduced Services
from Code Description
Modifier 52
– Reduced services
– If for some reason, the entire service was not provided, but only
a portion of it, this modifier may be used
– Physician should determine how much of the procedure/service
was done, and how much the fee should be reduced
– NOT TO BE USED JUST TO REDUCE THE FEE
Example: If a pure tone audiometry, air, CPT® 92552 is performed
only on the left ear, modifier 52 should be appended (92552-52).
This procedure is a bilateral procedure and was reduced because it
was only performed on one ear.
24
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Modifiers–The Rest of the Story
Physician Identifier
AI: Physician
y
of record
This modifier became necessary for Medicare when consultation
codes become non-reimbursable to distinguish the attending
25
Example of AI Modifier
A patient presents to the ER and their CHF is completely out
g level of fluid build-up
p and p
patient is
of control;; there is a high
short of breath.
– The Hospitalist comes to assume care of the patient in the
ER and admits the patient
– The Hospitalist then calls in the Cardiologist
• Both the Hospitalist and the Cardiologist report a 99223 initial
hospital service
– The Hospitalist claim should also include the AI modifier, captured as
99223-AI, which distinguishes that the Hospitalist is the primary
physician and the physician of record
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Modifiers–The Rest of the Story
Physical Status
Anesthesiologists must capture the ‘status’ of the patient which
identifies the risk of putting the patient to sleep
P1
P2
P3
P4
Normal healthy patient
Patient with mild systemic disease
Patient with severe systemic disease
Patient with severe systemic disease that is a constant threat to
life
P5 A moribund patient who is not expected to survive without the
operation
P6 A declared brain-dead
brain dead patient whose organs are being removed
for donor purposes
• Helps clearly identify the risk; also some payers increase the base units
based on the risk, so may impact payment
27
Anesthesia
Modifier 23
If a procedure that does not usually require anesthesia
anesthesia, but
because of circumstance requires general anesthesia; this modifier
should be utilized
Record must clearly indicate why general anesthesia was required
Example: A cystoscopy does not usually require general
anesthetic. However, if performed on a young child who cannot be
controlled, general anesthetic may be necessary. Append modifier
23 in this case.
28
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35
Modifiers–The Rest of the Story
Repeats
Modifier 91
– FOR use on REPEAT LAB TESTS, ONLY.
– Iff the exact same test is done, on the same date, because they
want to compare data, this is appropriate.
Modifier 76
– Repeat procedure by same doctor, same date.
– Chest X-ray done at 10 am, 1 pm, and 3 pm.
– Modifiers needed on the 1 pm and 3 pm service.
Modifier 77
– Repeat procedure by different doctor, same date.
– Works just like the 77 modifier, but identifies that it is a different
physician.
29
Payment Impact and
Use of ‘Repeat Modifiers’
•
•
•
Patient presents to the office and two nebulizer treatments are given to try to get the pulse
oximetry measurement to be satisfactory,
satisfactory due to a severe asthma attack
– The second nebulizer would be reported with a modifier 76
An inpatient has two EKGs during the same hospital day, as first shows abnormalities; and
separate Cardiologists read the two tracings; 93010 would be reported by the first and 93010-77
would be reported for the second cardiologists reading
A blood glucose was taken in the morning and was repeated every 4 hours throughout the day; to
insure that the glucose levels were stabilizing
– Each repeat lab would be submitted with modifier 91
• Why? Impact without?
• It is important
p
to identify
y to the p
payer
y that these are ‘repeat’
p
services, so that each service is separately reimbursable
• Failure to utilize the modifiers can result in claims being denied as
duplicate procedures
30
36
AAPC
1-800-626-CODE (2633)
Modifiers–The Rest of the Story
CLIA Waived
QW CLIA waived laboratory service
Should be attached to most CLIA waived services
when POS testing done in the office that has a CLIA
waived certificate
• Some CLIA waived tests do not require the modifier
– CMS publishes
bli h an active
ti lilistt off th
those ttests
t considered
id d
CLIA waived and which require the modifier
31
Assists
80 Surgical assistant services may be identified by adding modifier 80 to
the usual procedure number(s).
81 Minimum surgical assistant services are identified by adding modifier
81 to the usual procedure number.
82 The unavailability of a qualified resident surgeon is a prerequisite for
use of modifier 82 appended to the usual procedure code number(s)
AS Physician assistant, nurse practitioner, or clinical nurse specialist
services for assistant at surgery
Assistant does not need to dictate a separate operative report, but
operative report of primary must capture the medical necessity of the
assistant and the role the assistant played in the surgery. Cannot just
show ‘assisted by’ in the header and use terms like ‘we’ and ‘us.’
32
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37
Modifiers–The Rest of the Story
Assists Example
At a teaching hospital a patient undergoes a
hysterectomy All qualified residents are
hysterectomy.
assisting in other cases. A physician is required
to assist on this case. Modifier 82 is appended.
33
Assistant Reimbursement Impact
•
•
•
While reimbursement for assistants at surgery may change somewhat by payer; if a
physician is providing the assistant, the CMS allowable is 16% of the allowable for the
procedure
Reimbursement changes, when an AS is used to identify that the assistant is a mid-level
provider and is at 13% of the allowable for the procedure
When an 82 modifier is utilized, it is reimbursed the same as when the 80 modifier is
used, at a rate of 16%; however, this modifier differs in that it allows for payment in a
teaching facility for an assistant. When a qualified resident is available, no separate
reimbursement is allowed
– If the modifiers are not utilized appropriately and the code is reported by both the
primary and the assistant; a duplicate denial will occur
– If a duplicate denial does not occur; and full fee happens to be paid for both the
primary
i
and
d th
the assistant;
i t t an overpaymentt h
has been
b
made
d and
d a refund
f d is
i required
i d
Regence in Oregon for example: reimburses at 20% for the 80 and 82 and 10% for the AS and the 81:
http://www.or.regence.com/provider/library/policies/reimbursement-policies/modifiers/modifier-80-81-82-and-as-assistant-atsurgery.html
Medicare rarely pays for modifier 81/Minimal assist
34
38
AAPC
1-800-626-CODE (2633)
Modifiers–The Rest of the Story
Co-Surgeons
62 Co-surgery should only be reported when 2 surgeons work together on the
same procedure and each provides distinct parts; where the surgery for
each would have to be reported with the same CPT® code.
– If surgeons perform surgery together, but each does a uniquely
identified procedure; they each would report their own procedure code
• Based on the CMS National Physician Schedule Relative Value
File; the values include
Value
Description
0
Co-surgeon not permitted
1
Co-surgeons may be paid; supporting documentation required to establish
medical necessity
2
Co-surgeons permitted; no documentation required if 2 specialty
requirements met
9
Co-surgeon concept does not apply
35
Co-Surgeon Reimbursement
• When utilized, both surgeons have to be
completing a primary portion of the same
surgical code
– Reimbursement would be based at 125% of the
allowable, with each physician receiving 62.5% of the
allowable
– When the Value is a 0 or a 9, it is never appropriate to
utilize modifier 62
36
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39
Modifiers–The Rest of the Story
New Modifiers as Things Change
33 The US Preventive Services Task Force as
part of the evidence based service created
the need for a modifier 33 to be utilized when
reporting a service that the intent was
preventive in nature.
– If the code description already identifies it is a
preventive service, this modifier is not necessary
37
More on Modifier 33
While this modifier is not in the CPT® book, it was announced
p of 2011 and made retroactive to January
y 2011.
in April
– If a screening colonoscopy is being provided (to a non-Medicare
patient) and CPT® code 45378 would be appropriate, but during
colonoscopy a polypectomy was performed and CPT® 45383
was actually completed; the modifier 33 is necessary to show
that it started as a screening service
• While modifier 33 does not have an impact on the allowable
amount; it has a significant impact on the patient responsibility,
as preventive services, based on the new piece of legislation
have no cost-share
38
40
AAPC
1-800-626-CODE (2633)
Modifiers–The Rest of the Story
Mandated Services
32 This modifier should be attached when the
service is mandated by a third party: legal,
legal
insurance company, etc.
– Since the disseverment of confirmatory consults,
when insurance needs a second opinion, on occasion
this modifier must be utilized to capture the service
was mandated.
39
Example of Modifier 32
• A cardiologist determines that a patient needs a mitral valve
replacement
p
for a mitral valve prolapse;
p
p ; however,, the p
patient
has had this condition for several years.
• The insurance company does cover mitral valve repair, but
requires a second surgical consolation prior to surgery.
– The cardiologist providing the second opinion, should report his
service with a modifier 32 to show that it was mandated by the
insurance company
• Failure to report the modifier can result in a denial
denial, based on not
medically necessary; as another physician has already provided this
service
– This alerts the insurance company that this was a requirement of their policy and
the service should be covered
40
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41
Modifiers–The Rest of the Story
Why ‘G’??
GA Waiver of liability statement issued as required by
payer policy, individual case
Should
Sh
ld b
be used
d only
l when
h a properly
l executed
d ABN iis completed
l d ffor the
h
service
GZ Item or service expected to be denied as not
reasonable and necessary
Utilized for those services in which an ABN should have been obtained, the service
is expected to be denied, but an ABN was not garnered
GY Item or service statutorily excluded
excluded, does not meet the
definition of any Medicare benefit or for non-Medicare
insurers, is not a contract benefit
41
Examples of GA, GY, GZ,
and Impact to Reimbursement
Medicare reimburses for a screening colonoscopy in a high risk
patient every
p
y 23 months. A patient
p
chooses to have this service
every year. It is explained to the patient that it will be outside the
frequency parameters and will not be covered every year and if
denied, the patient would be responsible and an appropriate
ABN is executed.
– A GA modifier is attached to the colonoscopy code, which alerts
Medicare that it is expected to be denied as not reasonable and
necessary and that the patient was informed.
• CRITICAL to denial, as when the GA is attached, the service will be
denied as ‘patient responsibility’ instead of ‘not medically necessary’
– If denied as not medically necessary, the service cannot be balance billed to the
patient, resulting in lost revenue to the organization.
42
42
AAPC
1-800-626-CODE (2633)
Modifiers–The Rest of the Story
GA,GY, GZ continued…
• In the colonoscopy example, where the service is outside the
frequency parameters, but no ABN was obtained, a GZ modifier
should be attached
– While this is a modifier you do not wish to utilize; as it implies you know
the service may not be covered, you do not have an ABN; and expect a
denial. LOST REIMBURSEMENT, when a denial is received, patient
cannot be billed because no ABN was obtained
• Some services are never covered, when this occurs, an ABN is not
necessary, but the claim also should not be billed to CMS; however,
if a denial is needed and wanted, it can be filed and a modifier GY
should be attached. This clearly tells CMS that you know the
service is statutorily excluded and will not be covered.
– Patient can be balance billed or can be filed with a secondary policy if
one exists
43
G…I don’t know
GG Performance and payment of a screening
mammogram and diagnostic mammogram on the
same patient, same day
Done as completely separate services, but on the same day, as a direct result of
Radiologist findings
44
Both services will be covered
GH Diagnostic mammogram converted from screening
g
on same dayy
mammogram
Done at one setting and the plans changed based on Radiology
determination
•Only diagnostic mammogram will be covered
44
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43
Modifiers–The Rest of the Story
E/M Modifiers
Modifer 25
– Very common modifier
– For use on an E/M code ONLY
– Identifies that the E/M service is separate and significant
from any other service provided on that date
– Documentation MUST support
• DO NOT have to have a different diagnosis
• DO HAVE to show that it was separate and significant
45
Example of Modifier 25
•
Patient presents to the office for upper respiratory symptoms, and following
chest X-ray a pneumonia is identified. During the course of the examination, a
suspicious lesion is identified on the back and it is recommended that a biopsy
be taken, which is done during the visit. The E/M service was separate and
significant from the biopsy.
–
–
–
–
Modifier 25 must be attached to the E/M service
The diagnoses should be linked appropriately with the upper respiratory symptoms or definitive diagnosis if
determined with the visit and the unspecified skin lesion for the biopsy
If the modifier 25 is not attached to the E/M service, often the visit will be denied as included or bundled in
the procedure
Financial impact can be lost revenue of the E/M service, based on the level of service medically necessary
and supported
y, that based on the medical necessityy of the visit and the final diagnosis
g
of p
pneumonia a level
• Let’s say,
four service was supported and no modifier was used, the potential lost reimbursement could be about
$75.00 per visit
– Easy to see, that if failure to use this modifier, over time and frequent occurrences, could have
an impact to a physician’s practice financially
46
44
AAPC
1-800-626-CODE (2633)
Modifiers–The Rest of the Story
E/M Modifier
Modifier 24
– For use on an E/M service
service, when it is provided during
the ‘global surgical package,’ but is unrelated
• Patient had knee surgery. Total Knee Replacement has 90
day global period. During 90 days, sprained ankle. Modifier
24 needs to be attached on the office visit to show it was
part of the g
global surgical
g
p
package
g
NOT related and not p
47
Reimbursement Impact
of Modifier 24
• If the modifier 24 is not attached to the E/M
service the E/M service will be denied as
service,
‘inclusive in the global package’
• The financial impact to the organization would
be determined by the level of service which had
been reported, as medically necessary and
supported
– Lets say that the sprained ankle was of low
complexity and a 99213 was reported; this would be
potential lost revenue of about $50.00
48
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45
Modifiers–The Rest of the Story
E/M Modifier
Modifier 57
– For use when an E/M service is within 24 - 48 hours
of a MAJOR SURGICAL procedure, but was the visit
when it was determined that surgery was necessary
• Patient with severe abdominal pain, was sent to General
Surgery for evaluation. During the visit, the surgeon
determined that the patient needed surgery immediately and
y Modifier 57 needed
it was scheduled for later that same day.
on the visit, or it will be included in the ‘global surgical
package’
49
Reimbursement Impact of Modifier 57
• If the E/M when the initial decision to perform
surgery is submitted without modifier 57; it will be
considered ‘inclusive to the global package’ and
not separately reimbursable
– The impact of total dollars would be based on the
type of E/M service involved and the level of service
involved
• For example, if this visit occurred as a level four ER visit, lots
revenue would be about $115; if this visit was a level three
hospital admission, it might be $194 in lost revenue
50
46
AAPC
1-800-626-CODE (2633)
Modifiers–The Rest of the Story
Risky Modifier
Modifier 59
– Modifier of LAST RESORT
– Only use if an anatomical modifier
can not clearly identify that it was
separate and significant
– NOT just to be attached to bypass
an edit
– Must be DISTINCT AND
SEPARATE (separate incision,
separate excision, separate time
of day, etc)
– MUST be supported by chart
documentation
http://www.cms.gov/NationalCorrectCodInitEd/Downloads/modifier59.pdf
51
Reimbursement, Use,
and Affect of Modifier 59
• 17000 for destruction of a pre-malignant lesion is ‘bundled’ in the
NCCI edits
dit with
ith 17110 ffor d
destruction
t ti off b
benign
i llesions
i
((up tto 14)
14); it
is not expected that both procedures will be done at the same visit
– However, if destruction of an actinic keratosis occurs on the back and
destruction of 3 warts occurs on the hand; the procedures are clearly
distinct and separate
• 17000
• 17110-59
– MUST be reported to clearly capture that the services were not bundled, as they
identified distinct and separate services based on separate lesions
– The ‘indicator’ in the NCCI edits is that a modifier is allowed, when appropriate
» Will allow for separate reimbursement of both services
» If modifier is not utilized; only one procedure will be covered, losing the full
reimbursement of the second procedure to the organization.
52
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47
Modifiers–The Rest of the Story
Modifier 59, continued
• Do not use modifier 59 if there is a more appropriate modifier
• Review NCCI edits for Medicare and payers who use CCI Edits
http://www.cms.hhs.gov/NationalCorrectCodInitEd/NCCIEP/list.asp#
TopOfPage
– Status indicator “0” cannot be submitted separately. Modifier 59
can not be used, no exceptions
– Status indicator “1” can submit modifier if supported by the
documentation.
– Status indicator “9” not subject to CCI edits
53
NCCI Example
Column
1
AAPC
Effective
D t
Date
Deletion Modifier
D t
Date
11006
64550
20090401
20090401 9
11006
69990
20050101
*
0
11006
93000
20090401
*
1
54
48
Column
2
1-800-626-CODE (2633)
Modifiers–The Rest of the Story
Thank You
Jennifer Swindle
Swindle, RHIT
RHIT,CPC,
CPC CPMA
CPMA,
CEMC, CFPC, CCS-P, CCP-P, PCS
Vice President Coding/Compliance
PivotHealth, LLC
55
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49