NYU School of Medicine
Coding and Reimbursement Seminar Series
MODIFIERS - The Key to
Proper Reimbursement
Presented by the Office of Reimbursement Compliance
Gretchen L. Segado, MS, CPC
Director of Reimbursement Compliance
(212) 263-2446
(212) 263-6445 fax
Gretchen.Segado@med.nyu.edu
Today’s Agenda
 What
are modifiers?
 How are they used?
 Why do I care?
What are modifiers?

Modifiers are two digit codes appended to a
CPT code that indicate that a service or
procedure has been altered by a specific
circumstance, but has not changed in its
basic definition
Three Levels of HCPCS Codes
(Healthcare Common Procedural
Coding System)

Level 1-CPT, Physician’s Current Procedural
Terminology

Level 2-HCPCS National Codes

Level 3-Local Codes assigned and maintained by
individual state Medicare Carriers

Eliminated by HIPAA as of Dec 31, 2003
Modifiers denote that…







A service or procedure has both a
professional and technical components
A service or procedure was performed by
more than one physician
A service or procedure has been increased or
reduced
Only part of a service was performed
A service or procedure was provided more
than once
A bilateral procedure was performed
Unusual events occurred
Examples:



31237-50 (procedure
done bilaterally)
99214-25 (office visit and
procedure on same day)
33208-62 )two surgeons of
differing specialties doing
same procedure together)
Two Ways to Report Modifiers on a
Claim Form
1.
Modifier appended to the CPT code
49500-50
2.
Reported by using separate five-digit
code along with the procedure code.
Example
49500 plus
09950
Method #1 is the most common usage
Why aren’t my claims getting paid?
Why aren’t my claims getting paid?



Appropriate use of modifiers get services
reimbursed that might otherwise be
denied!!!
Claims can be incomplete or inaccurate
without a modifier
Coding to the highest level of specificity
requires modifier use
What is the “Global” Period?




Also known as the global surgical package
No one standard definition
Per CPT guidelines,
The following services are always included in
addition to the operation per se:
local infiltration, metacarpal/metatarsal/digital
block or topical anesthesia;
What is in the Global Period?





subsequent to the decision for surgery, one related
E/M encounter on the date immediately prior to or
on the date of procedure (including history and
physical);
immediate postoperative care, including dictating
operative notes, talking with the family and other
physicians;
writing orders;
evaluating the patient in the post-anesthesia
recovery area;
typical postoperative follow-up care.
Examples of Services Included in the
Global Period



Removal of staples 10 days after a surgical
procedure
A visit with a patient prior to surgery to
answer any last minute questions
A post-operative visit in the office to check
on wound healing
Examples of Services NOT Included
in the Global Package


The visit where the decision to perform a
procedure or surgery was made, even if on
the same day as the procedure
A visit during the post-op period for a
problem unrelated to the surgery
Without a modifier, these service will not get
paid!!!!!!!
Modifier -21
Prolonged E/M Services
Append to E&M code




When face-to-face or floor/unit service
provided is prolonged or otherwise greater
than that usually required for the highest
level of E&M code
Unfortunately, the modifier rarely affects
payment
May only be used with the highest level of
E/M service
NOT a time based modifier
Modifier -22
Unusual Procedural Services
Append to procedure code
Indicates that procedure was more
complicated or complex
 Alerts payers to unusual circumstances or
complications during a procedure
 Increased work effort of 30-50%

Key terms:

Increased risk; difficult; extended; complications;
prolonged; unusual findings; unusual
contamination controls; hemorrhage, blood loss
over 600cc, unusual findings, etc.

Additional physician work due to complications or
medical emergencies may warrant use of -22
Appropriate Use of Modifier -22
Appropriate Use:
Partial colectomy in a
patient with a tumor
adherent to vascular
structures requiring
additional 60 minutes
of dissection (due to
increased risk and
time)
Inappropriate Use:
Partial colectomy with
accidental laceration
of vessel resulting in
additional time for
repair
Modifier -23
Unusual Anesthesia
Append to Procedure Code
Occasionally, a procedure requiring local
or no anesthesia must be done under
general anesthesia due to unusual
circumstances.

Example: Child or adult unable to
cooperate with procedure - requires
anesthesia i.e. CT, MRI, XRT
-23 Unusual Anesthesia

Use the code once on the basic service procedure code

Claim must be accompanied by documentation and
cover letter by physician explaining the need for general
anesthesia

Not for use by the anesthesiologist

Do not use for local anesthesia
Modifier -24
Unrelated E/M Service by Same Physician during a
Postoperative Period
Append to E&M code

Used when a physician provides a surgical service related to
one problem and then during the postoperative period provides
an E&M service unrelated to the problem requiring the surgery.
Diagnosis code selection is critical to indicate the reason for
the additional E&M service.
Modifier -24

Example: Patient came in for post-operative visit. He is
12 weeks s/p diskectomy. During the exam, pt c/o
severe headaches with visual changes, preceded by an
aura. The physician performs an expanded problem
focused exam. His impression is migraine with medical
decision making of low complexity.
Report:
CPT Code 99213 [24] Level 3, established
patient office visit
Services Not Included in Global
Package:



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Initial consultation or evaluation by the surgeon to
determine the need for surgery
Services of other physicians unless a transfer of
care has been arranged
Visits unrelated to patient’s surgical diagnosis
Treatment for the underlying condition or an
added course of treatment that is not part of
normal recovery from surgery
Services Not Included in Global
Package:




Diagnostic tests and procedures
Staged or clearly distinct surgical
procedures during the post-op period
Treatment for post-op complications
requiring a return to the OR
A more extensive procedure when a less
extensive procedure fails
Services Not Included in Global
Package:



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Supplies, such a surgical trays, splints and
casting materials when certain surgical services
are performed in the physician’s office
Immunosuppresive therapy for organ transplants
Critical Care services unrelated to the surgery for
a critically injured patient
Pre-op evaluations outside of the global surgical
period
"Let's hope there‘re no post-op problems-it
complicates the billing."
Clinical Examples for Modifier -24
Appropriate Use:
 Patient 80 - days s/p TURP.
Reports to the office of the
surgeon who performed the
procedure complaining of
right flank pain and
abdominal pain. Diagnostic
work-up reveals a kidney
stone.
 Report 992XX-24 with
diagnosis code for the
kidney stone
Inappropriate Use:
 Patient returns for
complaining of fever and
wound tenderness in the
global period of her CSetion
 Report 99024 post-op visit
Modifier -25
Significant, Separately Identifiable Evaluation and
Management Service by the Same Physician on the
Same Day of the Procedure or Other Service
Append to E&M Code


Indicates that on the day of a procedure or other
service, the patients condition required an
additional E&M service above and beyond the usual
pre and post-op care associated with the procedure
performed.
E&M Service elements must be clearly documented
to justify that a visit took place beyond the elements
necessary to perform the procedure
Modifier -25
EXAMPLE:
An established patient is seen by the physician to
evaluate his general osteoarthritis, benign HTN and
NIDDM. While examining the patient, the physician
determines that an arthrocentesis of the patient’s knee
joint needs to be performed.
REPORT:
CPT Codes
9921X-25 & 20610
Clinical Example
Appropriate Use:
Procedure: Excision, rt. arm lesion
 Visit- Established Pt concerned about
changes to a lesion on right arm. History
taken, examination of arm and additional
body areas for new and suspicious lesions
performed. Physician decides to remove
lesion.
Clinical Example


Inappropriate Use:
Patient presents for scheduled removal of
lesion on right arm. Exam of arm to
determine status of lesion performed and a
general determination of the patient’s
status prior to excision.
Modifier -26
Professional Component
Append to procedure code

Certain procedures are a combination of a physician
component and a technical component. When physician
component is reported separately, add -26 to the CPT
code to identify that the physician’s component only is
being billed.
EXAMPLE: A 72 year old woman comes to the Emergency
Room complaining of chest discomfort. The physician orders
a complete 2D echocardiography using the hospital
equipment. The physician provides the written interpretation.
REPORT:
CPT Codes: 93307-26
Modifier -26





For use by physicians when utilizing
equipment owned by a hospital/facility
Interpretations must be separate,
distinct, written and signed
Not all procedures have a
professional/technical split!
Refer to Medicare Fee Schedule to
determine what procedures are
eligible for this modifier
Common Services billed with -26:
Radiology, Stress Tests, Heart
Catheterizations
Modifier -32
Mandated Services
Append to E&M Code

Attach modifier 32 to mandated
consultation &/or other services.

Usually mandated by courts, government
agencies or an insurance entity
Modifier -47
Anesthesia by Surgeon
Append to Procedure Code



Regional or general anesthesia provided by
surgeon may be reported by adding -47.
Not to be used with local anesthesia
This service is not covered by Medicare or
Medicaid
Do not use this modifier with anesthesia
codes
Modifier -50
Bilateral Procedure
Append to procedure code

Used to report bilateral procedures that are
performed at the same operative session. Used
only to services/procedures performed on
identical anatomic sites, aspects or origins (arms,
legs, eyes, breasts)
Example: Physician removes a foreign body from
each of a patient’s ears without anesthesia.
CPT Code
69200-50
Modifier -51
Multiple Procedures
Append to Procedure Code

Multiple and related surgical procedures,
other than E/M services, performed at the
same session by the same provider.
EXAMPLE: Patient presents for removal of a malignant lesion
on the face with complex repair of the defect
REPORT:
CPT Codes
11641 & 13152-51
Modifier -51



Do not use -51 on procedures that are
components of another procedure
Do not use the -51 on the primary
procedure, only on the secondary
procedures (order procedures by RVU)
Do not use -51 on procedures with a “+”
sign indicated in the CPT Manual
Modifier -52
Reduced Services

Used to identify a procedure or a service that is
partially reduced or eliminated at the physician’ s
discretion.
EXAMPLE: A 50 year old woman presents to have 20
skin
tags removed.
REPORT:
CPT Codes:
11200 - removal of skin tags; up to and
including 15 lesions.
11201-52 - each additional 10 lesions
Modifier -53
Discontinued Procedure
Append to Procedure Code

Used to indicate that a surgical or diagnostic procedure
was started but discontinued, usually because of
extenuating circumstances or those that threaten the
patient’s well-being.

Most often used when a physician elects to terminate a
surgical or diagnostic procedure

Usually used after the induction of anesthesia
Modifier -53

Differs from modifier -52 because in that a lifethreatening condition precipitates the terminated
procedure.

Not used to report elective cancellation prior to induction
of anesthesia or surgical prep, including situations
where cancellation is due to patient instability
Modifier 53
Discontinued Procedure cont.
EXAMPLE:
A 50 year old woman complaining of acute rectal
bleeding. She was given a bowel prep, administered
at home, and returned for a total diagnostic
colonscopy. The procedure proceeds in the normal
fashion, however the patient suddenly develops an
erratic heart beat and the physician elects to
discontinue the procedure.
REPORT: CPT CODE: 45378 - 53
Modifier -54
Surgical Care Only
Append to Procedure Code




Physician service to the patient was only the intraoperative procedure. Another physician(s) will perform
the Pre-operative and Post operative care.
There should be an agreement for the transfer of care
between physicians
Do not use with procedure codes having a zero day
global period
Do not use -54 if physician is a covering physician
(locum tenens) or part of the same group as the surgeon
who performed the procedure
Clinical Example


A neurosurgeon travels to a rural location to
perform a craniotomy for drainage of an
intracranial abscess. He assessed the
patient the day before surgery, and
performed the procedure. Follow-up care
was performed by a local surgeon.
The neurosurgeon would report 61321-54
Modifier -55
Postoperative Management Only


While on vacation in Vail, Anna had a skiing
accident. A local Orthopedist in Vail did the
Pre operative and Intra-operative
procedure and the patient went home.
NYU physician provides all post-op care,
and bills by adding a -55 to the surgical
procedure code.
Modifier -56
Preoperative Management Only
Append to Procedure Code


Pre operative evaluation was performed
and decision was made to have the intraoperative procedure and post operative
care done else where.
Internist does pre-op work-up on a patient
having a laporoscopic cholecystectomy by
a general surgeon who travels to the area
monthly. Internist would bill 47562-56
MODIFIER -57
DECISION FOR SURGERY
•E/M service on the day before or on the day of major
surgery (90 day global period) which results in the
initial decision to perform the surgery is not included
in the global surgery payment.
EXAMPLE: Patient comes to the emergency department
with sudden onset of acute abdominal pain. Gyn physician
evaluates patient & determines that patient has twisted
ovarian cyst. Physician admits patient to OR for right
salpingo oophorectomy.
REPORT: CPT Code
99223-57 & 58720
Modifier –58
Staged or Related Procedure by the Same Physician during
the Postoperative Period
Append to Procedure Code
 Indicates that the procedure or service during the post-op
period was either


planned prospectively at the time of the original
procedure

More extensive than the original procedure

For therapy following a diagnostic surgical procedure
Without the modifier, the third-party payer could reject the
claim because the surgery occurred during the post-op
period
Modifier -58

Example: 32 year old woman with breast cancer undergoes a
mastectomy one week ago. Today, she is scheduled to have
breast implants placed.
Report:

19342-58
Example: Sternal debridement performed for mediastinitis
and it is noted that a muscle flap repair will be needed in a
few days to close the defect
Report:
15734-58 since muscle flap
planned at time of initial surgery
Modifier -59
Distinct Procedural Service
Append to Procedure Code

Indicates that a procedure or service was distinct or
separate from other services performed on the same
day. May represent a different session or patient
encounter, different incisional site, separate lesion, or
separate injury.
Example: An arthroscopic synovectomy was
performed on the right knee for localized synovitis
and a diagnostic arthroscopy was performed on the
left knee for chronic pain syndrome.
Report:
CPT Codes
29875 & 29870 - 59
Modifier -62
Two surgeons
Append to Procedure Code

2 surgeons work together as primary surgeons
performing distinct parts of a single procedure

Each surgeon reports his/her distinct operative work by
adding the -62 modifier to the procedure code and related
add-on codes

Example: Transphenoidal Hypophesectomy

Neurosurgeon and ENT both report 61548-62
Modifier -62
Appropriate Use:
Arthrodesis using anterior
interbody technique,
thoracic level.
Thoracic surgeon performs
a thoracotomy, exposes
and later closes the site
Orthopaedic surgeon
performs the arthrodesis
Both surgeons use CPT
Code
22556-62
Inappropriate Use:
Oncology surgeon
performs a radical
mastectomy. At same
operative session the
plastic surgeon then
performs breast
reconstruction. In this
case, the surgeons are
performing 2 distinct
services and each uses
separate CPT codes and
-62 is not required
Modifier -63
Procedure Performed on Infants less than 4kg
Append to Procedure Code

Procedures performed on neonates and infants up to a
present body weight of 4kg may involve significantly
increased complexity and physician work

Unless otherwise designated, should only be appended
to services in 2000-69999 code series. Should not be
appended to E&M, Anesthesia, Radiology, Path/Lab,
Medicine sections
Modifier -66
Surgical Team

Highly complex
procedures requiring
concomitant services
of several physicians,
often of different
specialties plus other
highly skilled, specially
trained personnel,
various types of
complex equipment



Transplants
Separation of
conjoined twins
Each participating
physicians uses the
modifier
Modifier -76
Repeat Procedure by same physician
Append to Procedure Code
Example: Pt. was brought by an ambulance to the ER with
multiple trauma. Pt. was intubated and chest X-ray was
taken. Results showed tube was not in position, pulled and
re-inserted.
Report:
CPT Codes
31500
31500 [76]
Modifier -77
Repeat Procedure by Another Physician
Append to Procedure Code

Example: A PCP performs a chest x-ray in his office and
observes a suspicious mass. He sends the patient to a
Pulmonologist who, on the same day, repeats the CXR.

The Pulmonologist should submit their claim with the and
provide documentation to support the need for a repeat
CXR.
Modifier 78
Return to OR for a related procedure during
post-operative period
Append to Procedure Code
Example: Pt. brought to recovery room S/P abdominal
surgery. Dressings became saturated, vital signs were
unstable. Pt. brought back to OR for exploration post-op
hemorrhage.
Report:
CPT Codes
35840 [78]
Modifier 79
Unrelated Procedure/Service by same MD
during the post-op period
Append to Procedure Code
Example:
A repair of femoral hernia [49550 (90 day global)] is
performed on Jan. 5. On Feb. 12, the same physician
performs an appendectomy.
Report:
CPT Code
44950 [79]
HCPCS Modifiers


Alpha or alphanumeric
Provide additional information just like CPT
modifiers
Examples




AH- services by Clinical Psychologist
F1-Left hand, second digit
FP-service provided as part of Medicaid
Family Planning Program
GG-performance and payment of a
screening mammogram and diagnostic
mammogram on the same patient, same
day
GC Modifier
Append to both E&M and Procedure Codes


Used to indicate when a service has been
performed in part by a resident under the
direction of a teaching physician.
Also applies to “assistant surgeon” on
operative reports.
GE Modifier
Append to both E&M and Procedure Codes

Service performed by a resident without the
presence of a teaching physician under the
primary care exception
A Quick Self-Test for Compliance
Practices in Your Office
Does your office review all pertinent
documentation prior to appending a
modifier?
 Do you monitor the activities of your billing
office or service with respect to modifier
usage?
 Do you randomly cross-check all billings
performed by your office or service to be
certain that claims submitted with
modifiers are accurate and appropriate?

Compliance Test con’t.
Do you make sure the staff is educated
and updated on Medicare and Medicaid
program changes?
 Are services billed to Medicare and
Medicaid thoroughly documented?
 Are new billing employees and new
physicians oriented on modifier reporting
policies?

The Answer to all those questions
should be YES.
A Quick Self-Test for Complaint
Practices in Your Office


Do you allow your billing office or service to
assign modifiers and subsequently report
services on claims without conducting an
intermittent review of claims?
Does your billing office or service have carte
blanche permission to correct and/or change
codes for services that you have performed?
 Is
there evidence of inappropriate
overpayment by the payer when a
modifier is used?
 Does your billing office or service
answer all Medicare and Medicaid
inquiries regarding your services and
claims on your behalf without your
knowledge?
The Answer to These Questions
Should be NO!!!!!!!!
Remember, Modifiers mean real
money for your practice!!!