CODING WITH
MODIFIERS
PRESENTED BY BARBARA PARKER, CMA, CPC
SLIDES PREPARED BY LORI DAFOE, CPC
MODIFIER OBJECTIVES
At the conclusion of this session, you should be able
to:
• Explain what CPT modifiers are and their
importance to receiving correct reimbursement
• Identify when and how to use CPT modifiers.
MODIFIERS
• In today’s regulatory environment, it can be a real
challenge to obtain reimbursement for procedures
and services rendered
• Accurate coding is the most crucial step in the
reimbursement process
MASTERING MODIFIERS
• Coders need to use all the “tools” at their disposal
to facilitate the reimbursement process
• Modifiers are overlooked tools
WHAT IS A MODIFIER?
• A Modifier provides the means by which the
rendering physician may indicate that a service or
procedure has been performed, or has been
altered by some specific circumstances, but not
changed in its definition of code
• They are essential ingredients to effective
communication between providers and payors
WHAT IS A MODIFIER?
• Just as “modifiers” in the English language provide
additional information, CPT modifiers also answer
questions such as:
•
•
•
•
•
which one
how many
what kind
when
what
WHAT IS A MODIFIER?
• Modifiers are essential tools in the coding process
• They are used to enhance a code narrative to
describe
1.) the circumstances of each procedure or
service
2.) how it individually applies to the patient
PRIMARY FUNCTIONS
• Show that a service has been modified but not
changed in its identification or definition
• Explain special circumstances or conditions of
patient care
• Indicate repeat or multiple procedures
• Method to show cause for higher or lower costs
while protecting charge history data
MODIFIERS
• A complete listing of CPT modifier is found in
Appendix A of CPT
• Two or more modifiers may be used with one code
to give the most accurate description possible for
the service rendered
MODIFIERS
• Not all modifiers can be used in every section of
CPT
• Consult with carriers regarding the use of two-digit
modifier
STEP BY STEP GUIDANCE
• Review CPT (AMA) Guidelines
• Review individual carrier guidelines
• Reference the practitioner’s or facilities patient
medial record and/or visit note prior to appending
modifiers
• Use only 2 digits when appending modifiers (unless
instructed otherwise by an individual carrier)
STEP BY STEP GUIDANCE
• Provide training for physicians, staff, clinicians, etc.
and update training regularly
• Take a proactive approach and find the errors in
modifier application before the claim is submitted
to the insurance carrier
• Understand that the insurance carrier
interpretations are not always the same as CMS or
CPT
• Review the National Correct Coding Initiative
(NCCI) each quarter for correct usage for each CPT
code that your organization uses
MODIFIER TIPS
• Always have the most recent edition of the CPT
book on hand
• Have your billing staff regularly attend coding
workshops
• Remember that modifiers are often used differently
for physician services and hospital outpatient
services
• Learn as much as you can about using coding
modifiers so you can help your billing staff with
coding questions
MODIFIER 21 – PROLONGED EVALUATION
AND MANAGEMENT (E/M) SERVICE
• Only use with E&M codes.
• Use when the service exceeds the highest level
within a given category
• Recommend sending a written report to the carrier
MODIFIER 22 – UNUSUAL PROCEDURAL
SERVICES
• Do not use this modifier on E&M codes
• Use this modifier when the service provided is
greater than that described by the procedure
code
• Specific examples of unusual
circumstances include:
•
•
•
•
Increased risk
Severe respiratory distress
Excessive bleeding (more than 500 cc)
Friable tissue
APPROPRIATE USE OF MODIFIER -22
• Extensive trauma that requires additional work
• Significant scaring requiring extra time and work
• Extra work due to morbid obesity
• Increased time due to extra work by the physician
INVALID USE
• Modifier 22 is not valid when there is also a “reoperation” code used with the primary code.
• Modifier 22 is not valid if the purpose of the
complication is based on the surgeon’s choice of
approach (e.g., open vs. laparoscopic)
• Modifier 22 is not valid to describe an average
amount of lysis or division of adhesions between
organs and adjacent structures.
CONSIDERATIONS FOR MODIFIER 22
• The additional time and work must be significant.
• The surgeon’s documentation should be thorough!
• The documentation should be submitted with the
claim.
• Any additional fees should be charged up front to
payers, which are unlikely to raise fees on their own
just because modifier 22 is appended.
MODIFIER 24 – UNRELATED E/M SERVICE BY
THE SAME PHYSICIAN DURING A
POSTOPERATIVE PERIOD
• Only use with E&M codes.
• To use this modifier, the E&M service must be unrelated to the
surgery, but provided within the global care postoperative
period.
• Use when patient care is by the same physician for surgery.
• Medicare Carrier Manual (MCM 4822 and 4824) indicate that
an evaluation and management service(s) submitted with
modifier 24 must be sufficiently documented to establish that
the visit was unrelated to the surgery.
• In order for critical care services (CPT 99291 and/or 9292) to be
paid for services furnished during the preoperative or
postoperative period, with modifier -24, the documentation
submitted must support that the critical care was unrelated to
the specific anatomic injury or general surgical procedure
performed.
MODIFIER 25 – SIGNIFICANT SEPARATELY IDENTIFIABLE
E/M SERVICE BY THE SAME PHYSICIAN ON THE SAME
DAY OF THE PROCEDURE OR OTHER SERVICE
• Only use with E&M codes.
• Patient care is by the same physician for procedure
and E&M service
• Documentation should indicate that the patient’s
condition required a significant separately
identifiable E&M service on the day a procedure or
service identified by a CPT code was performed
above and beyond the other service provided
• This modifier is not used to report E&M service that
resulted in a decision to perform major surgery
MODIFIER 25: CMS POLICY
• Modifier 25 should be used only when a significant,
separately identifiable E&M visit is rendered on the same
day as a minor surgical procedure. Payment for
preoperative and postoperative visits is included in the
payment for the procedure. For minor procedures,
where the decision to perform the minor procedure is
typically made immediately before the service (e.g.,
whether sutures are needed to close a wound, whether
to remove a mole or wart, etc.), the E/M visit is
considered to be a routine preoperative service and
should not be billed in addition to the minor procedure.
• The policy applies only to minor surgeries and endoscopies for
which a global period of 0-10 day applies.
MODIFIER 25: CMS POLICY GUIDANCE
• If the patient’s clinical record documents that extra
pre-op and/or post-op work beyond what is usually
performed with the service was performed, then it is
proper to use the 25 modifier to indicate that extra
work.
• The clinical record should clearly document the
extra or unusual work performed.
• The provider should determine if the E&M service for
which he/she is billing is distinct from the procedure.
MODIFIER 25?
• Medicare patient presents with complaints of left
knee pain. The physician evaluated the knee and
determines the patient would benefit from
arthrocentesis. The patient declines the injection at
this time, but calls back two days complaining of
continued pain.
• At the follow-up visit, the physician performs a
cursory exam of the knee and proceeds to perform
the large joint injection that was recommended at
the previous visit.
• 25 or not?
NOT!
• In this example, it would not be appropriate to bill
the E&M service.
• Correct coding: CPT 20610 – Arthrocentesis,
aspiration and/or injection; major joint or bursa (eg,
shoulder, hip, knee joint, subacromial bursa)
MODIFIER 25?
• An established Medicare patient visited her internist for a
follow up for hypertension and diabetes. The patient also
complains of several skin tags along her bra area that are
painful, itching, and bleeding due to the location. The
physician performs a problem-focused history and
examination, evaluates the patient’s hypertension, and
determines the blood pressure is higher than it should be and
adjusts medications. The patient’s blood sugar is doing well
and the diabetes is well controlled with the current insulin
regimen. During the encounter, the physician also evaluates
the 6 skin tags and determines the patient would benefit from
removal. This is performed in the office suite.
• 25 or not?
YES!
• Correct coding: CPT 99212-25 – Office visit for an
established patient level two, and CPT 11200 –
Removal of skin tags, any area; up to and including
15 lesions.
MODIFIER 26 – PROFESSIONAL
COMPONENT
• Some procedures can be divided into a professional only
component (performed by a physician) and a technical only
component (technician’s portion). Modifier -26 is used to describe
the portion of the service that is performed by a physician.
• The technical component includes:
 providing the equipment
 supplies
 technical personnel
 costs attendant to the performance of the procedure, other than
the professional services
• The professional component includes:
 the physician’s work in providing the services (e.g., reading films,
interpreting diagnostic tests, etc)
 interpretation and written report provided by the physician
performing the service
MODIFIER 26 – PROFESSIONAL
COMPONENT
• Some CPT codes are indicated to be the
professional component only, or the technical
component only. No modifiers would be
appended to these codes.
• A facility performs a 12 lead ELG and has an
independent physician read the strip
93005 Tracing only (facility)
93010 Interpretation and report only (physician)
MODIFIER 26: EXAMPLE
• If the physician owns the x-ray machine, buys the
supplies, and pays the personnel in addition to
reading the x-ray, the modifier -26 would not be
used.
• A physician has x-ray equipment in his office and
performs a PA and lateral chest x-ray. The physician
also reviews the x-ray and dictates a report.
• Correct Coding: CPT 71020
MODIFIER 32: MANDATED SERVICES
• Many third party payors and professional review
organizations require an independent evaluation of
a patient prior to procedures being performed. This
modifier describes the visit required by the payor or
review organization.
• This modifier is not for a consultation with another
physician for patient comfort or reassurance.
• This modifier is also not used when another
physician evaluates a patient for medical
clearance prior to a procedure.
MODIFIER 47: ANESTHESIA BY
SURGEON
• This modifier is to be used when the surgeon
performs and administers regional or general
anesthesia in addition to the surgical procedure.
• Do not use this modifier for local anesthesia.
• Do not use this modifier with anesthesia procedures
00100-01999.
• Do not use this modifier if the surgeon is monitoring
general anesthesia performed by an
anesthesiologist, CRNA, resident or intern.
MODIFIER 50: BILATERAL PROCEDURES
• Most of the bilateral procedures listed in the Surgery
section have been deleted.
• This modifier is to be used when surgeries are
performed bilaterally during the same operative
session.
• Some carriers prefer a “two code listing”, (i.e. 64721,
64721-50). Others prefer it listed on one line, while
others want –LT & -RT.
• The bilateral surgery may be performed
Through the same incision
Separate body parts
MODIFIER 51: MULTIPLE PROCEDURES
• This modifier is used to identify the secondary
procedure or when multiple procedures are
performed on the same date or during the same
operative session by the same physician.
• The procedures may be in the same operative
incision or at a different anatomical site.
• Always list the major procedure (highest dollar
value) first and append the modifier to the
subsequent procedures.
MODIFIER 51: MULTIPLE PROCEDURES
• Some of the listed procedures in CPT are commonly
carried out in “addition to” the primary procedure
performed.
• All add-on codes found in CPT are exempt from
the multiple procedure concept.
MODIFIER 52: REDUCED SERVICES
• Used to identify when a service or procedure is less
extensive than the description given in CPT would
indicate it to be.
• To develop a reduced fee, try calculating the
reduced service by time.
• Calculate the amount (cost) per minute of the
complete procedure; times the amount per minute
by the time it took to do the reduces procedure.
• Many carriers reduce the amount automatically, so
the preferred method is to bill the carrier the full
amount and let the insurance carrier determine the
value of the service.
MODIFIER 53: DISCONTINUED
PROCEDURE
• This modifier describes procedures that have been
discontinued due to extenuating circumstances.
• Usually the patient’s well-being is threatened,
thereby precipitating the physician’s decision to
terminate the procedure.
• This modifier should not be used if a
surgical procedure is canceled prior to t
the patient’s anesthesia induction and
/or surgical preparation in the
operating room.
MODIFIERS 54, 55, 56
CPT GLOBAL SURGICAL PACKAGE
MODIFIER 54: SURGICAL CARE ONLY
• Used when the surgeon provides the surgical care
only without pre- or postoperative services.
• Fees and reimbursement should be reduced to
represent the surgical portion
of the global service.
MODIFIER 56: PREOPERATIVE
MANAGEMENT ONLY
• To be used when the physician provides only the
preoperative care.
• May be used when the physician prepares the
patient for surgery performed by another physician.
• Fees and reimbursement should
be adjusted accordingly.
MODIFIER 55: POSTOPERATIVE
MANAGEMENT ONLY
• Used when the physician provides only the followup care during the global period.
• Surgery was performed by a different physician
• The physician providing the followup care does not perform, nor
assist with the surgical procedure.
• Fees and reimbursement should be
reduced to represent “postoperative” management only.
GLOBAL SPLIT
MODIFIER 57: DECISION FOR SURGERY
• This modifier is appended to the appropriate E&M
service to denote the visit where the decision to
perform major surgery (90 global days) was made.
• Modifier is used when the decision for major surgery
is made the day of or the day prior to performing
the procedure.
• Assists in recouping payment for this visit because
many payors will reimburse the visit where surgery is
decided, but will not pay for other preoperative
visits.
MODIFIER 57: DECISION FOR SURGERY
• Modifier indicates to the payor that additional time
and effort was necessary and all necessary
counseling, including risks and outcomes were
discussed with the patient.
• There is no increase in fee for use of this modifer.
MODIFIER 58: STAGED OR RELATED
• Physician may need to indicate that the
performance of a procedure or service during a
post-operative period was:
Planned prospectively at the same time as the original
procedure (staged)
More extensive than the original procedure
For therapy following a diagnostic surgical procedure
MODIFIER 59: DISTINCT PROCEDURAL
SERVICE
• Under certain conditions the physician may need to
indicate that a procedure or service was distinct or
independent from other services performed on the
same day:
A different session or patient encounter
Different procedure or surgery
Different site or organ system
Separate incision/excision
Separate lesion
Separate injury (or area of injury in extensive injuries) not
ordinarily encountered or performed on the same day by
the same physician
CCI GUIDANCE
• The 59 modifier is often misused. The two codes in a
code pair edit often by definition represent different
procedures. The provider cannot use the 59
modifier for such an edit based on the two codes
being different procedures.
• However, if the two procedures are performed at
separate sites or at separate patient encounters on
the same date of service, the 59 modifier may be
appended.
• The 59 modifier cannot be used with E&M services
(CPT codes 99201-99499) or radiation treatment
management code 77427).
MODIFIER 62: TWO SURGEONS
• Used when skill of two surgeons (usually of different
skills) may be required in the management of a
specific surgical procedure.
• Surgeon each performs a separate portion of one
procedure.
• Each physician would bill same CPT code with 62
modifier.
• If a co-surgeon acts as an assistant in the
performance of additional procedure(s) during the
same surgical session, those services may be
reported using separate procedure code(s) with
the modifier 80 or modifier 82 added, as
appropriate.
MODIFIER 63: PROCEDURES
PERFORMED ON INFANTS LESS THAN
4KG
• Procedures performed on neonates and infants up
to a present body weight of 4 kg may involve
significantly increased complexity and physician
work commonly associated with these patients.
• This circumstance may be reported by adding the
modifier 63 to the procedure number.
• Unless otherwise designated, this modifier may only
be appended to procedures/services listed in the
20000-69999 series. Modifier 63 should not be
appended to any CPT codes listed in the Evaluation
and Management Services, Anesthesia, Radiology,
Pathology/Laboratory, or Medicine Sections.
MODIFIER 63: PROCEDURES
PERFORMED ON INFANTS LESS THAN
4KG
• Modifier 63 is appended only to invasive surgical
procedures and reported only for neonates/infants
up to a present body weight of 4kg, cut off. With
this group of neonates/infants, there is a significant
increase in work intensity specifically related to
temperature control, obtaining IV access (which
may be required upward of 45 minutes), and the
operation itself, which is technically more difficult
with regard to maintenance of homeostasis.
MODIFIER 66: SURGICAL TEAM
• More than two surgeons.
• Used for highly complex or intricate procedures,
which require multiple concomitantly operating
physicians.
• Usually of different specialties.
• May require assistance of specially trained ancillary
personnel or specialized equipment.
• Approved procedures for modifier 66 include most
of your transplant codes (heart, lung, kidneys,
including live donor procedures)
MODIFIER 76: REPEAT PROCEDURE BY
SAME PHYSICIAN
• Modifier 76 is used when a physician repeats a
procedure on the same day.
• May be used for multiple diagnostic testing
performed on the same day.
• Modifier assists in prevention of denials or duplicate
claims messages from carriers.
• Modifier used for radiology, lab, and minor surgical
procedures (repeat blood sugars).
CMS EXAMPLES OF REPEAT
PROCEDURES:
• Follow up x-rays after chest tube placement,
central venous line placement, s/p setting of
fracture.
• Repeat electrocardiograms for evaluation or
treatment of arrhythmia or ischemia
• Repeat coronary angiogram or coronary artery
bypass following abrupt closure of previously
treated vessel.
MODIFIER 77: REPEAT PROCEDURE BY
DIFFERENT PHYSICIAN
• Identical to modifier 76 except the repeat
procedure is performed by another physician.
• Used when physician repeats a procedure that
another physician performed on the same day.
• Multiple diagnostic testing performed on same day
by more than one physician.
MODIFIER 78: RETURN TO THE OR FOR
RELATED PROCEDURE DURING POST-OP
PERIOD
• Indicates second operative session is used and
occurs during the postoperative period.
Second procedure is related to the first procedure usually
due to complication or other problems related to initial
surgery
MODIFIER 79: UNRELATED PROCEDURE OR
SERVICE BY SAME PHYSICIAN DURING THE
POSTOP PERIOD
• Used to report unrelated procedure performed
during postoperative period that is unrelated and
not a result of the first surgery.
Second surgery should be submitted with 79 modifier to
explain surgery/procedure.
Carrier may deny service without 79 modifier.
ASSISTANT SURGEON MODIFIERS
Modifier
Definition
80
Assistant Surgeon
81
Minimum Assistant Surgeon
82
Assistant Surgeon (when qualified resident surgeon is not
available)
AS
Physician assistant, nurse practitioner, or clinical nurse
specialist services for assistance at surgery
MODIFIER 80: ASSISTANT SURGEON
• Modifier 80 attached to surgical procedures when:
Surgical procedures are performed by an assistant at
surgery.
Assistant is usually paid a small portion of the surgical fee by
the carrier.
Generally private payors pay 20-25% of the surgical fee to
the assistant.
(not allowed when two surgeons or team surgeons are
indicated)
An assistant at surgery serves as an additional pair of hands
for the operating surgeon.
MPFSDB INDICATOR TABLE FOR
ASSISTANT SURGERY
Indicator
Definition
0
Assistant surgeon may be paid with documentation. Use 80
modifier.
1
Assistant surgeon cannot be paid.
2
Assistant surgeon can be paid. Use 80 modifier.
9
Assistant surgeon concept does not apply.
MODIFIER 81: MINIMAL ASSISTANT
SURGEON
• Used when the assisting surgeon participated only
for a portion of the procedure.
Can be used when a second or third assistant surgeon is
required during a procedure.
Medicare, Medicaid and commercial payors have lists of
procedures codes that they do not allow minimal assistant
surgeons.
CMS rarely recognizes modifier 81 except in extreme cases,
and does not appear on the Medicare Physician Fees
Schedule Date Base (MPFSDB).
When modifier 81 is used with a procedure code that has a
maximum allowable payment, the payment for the
procedure shall be no more than 13% of the maximum
allowable listed or the billed charge, whichever is less.
MODIFIER 82: ASSISTANT SURGEON
WHEN QUALIFIED RESIDENT NOT
AVAILABLE
• Modifier -82 used in teaching facility when a
qualified resident or fellow is not available to assist.
• Use this modifier:
In a teaching facility.
When an appropriate training program for the medical
specialty is not available.
The unavailability of a qualified resident surgeon is a
prerequisite for use of modifier 82 appended to the usual
procedure code number(s)
EXCEPTIONAL CIRCUMSTANCES
• Payment is made for the services of assistants at
surgery in teaching hospitals despite the availability
of a qualified resident to furnish the services in the
following circumstances:
In emergency or life-threatening situations where multiple
traumatic injuries require immediate treatment.
If the primary surgeon has an across-the-board policy of
never involving residents in the preoperative, operative or
post-operative care of his or her patients.
MODIFIER 90: OUTSIDE LAB
• This modifier is used to indicate that although the
physician is reporting the performance of a
laboratory test, the actual testing component was
a service from a laboratory.
• When the physician bills the patient for lab work
that was performed by an outside or (reference)
lab, add the 90 modifier to the lab procedure
codes. Physicians use this modifier when laboratory
procedures are performed by a party other than
the treating or reporting physician.
CMS GUIDELINES
• Physicians should NEVER bill Medicare or Medicaid
patients for lab work done outside their office.
• The laboratory performing the service will bill for the
laboratory procedure. CMS does not recognize the
use of modifier 90. (We will not address billing
purchased services in this session)
MODIFIER 91: REPEAT LABORATORY
PROCEDURE
• In the course of treatment of the patient, it may be
necessary to repeat the same laboratory test on the
same day to obtain subsequent (multiple) test
results. Under these circumstances, the laboratory
test performed can be identified by its usual
procedure number and the addition of the modifier
91.
MODIFIER 91: REPEAT LABORATORY
PROCEDURE
• This modifier may not be used when other code(s)
describe a series of test results (eg, glucose
tolerance tests, evocative/supression testing). This
modifier may only be used for laboratory test(s)
performed more than once on the same day on
the same patient.
MODIFIER 91: REPEAT LABORATORY
PROCEDURE
• Modifier 91 is not intended to be used when:
Laboratory tests are rerun to confirm initial results
Due to testing problems encountered with specimens or
equipment
For any other reason when a normal, one-time, reportable
result is all that is required
MODIFIER 99: MULTIPLE MODIFIERS
• Used when 2 or more modifiers are necessary to
correctly report a procedure