All about Medical Billing & Claims Modifiers
Why do we have to know how to properly use the right modifiers? Well, here are the simple
reasons why we need modifiers:
1.The physician performed multiple procedures
2.The procedure performed was bilateral
3.The E/M service was done on the same day of the procedure
4.The procedure was increased or decreased
5.The procedure has both professional and technical component
6.The procedure was performed by other provider (Anesthesiologist,
Surgeon Physical Therapist, Speech Pathologists etc.)
7.Procedure on either one side of the body was performed
8.The E/M service was provided within the postoperative period
9.The E/M service resulted to Decision of Surgery
10.Unusual Circumstance
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 must be appended with an E/M service. This is the modifier you will need to use with
the evaluation and management service done on the same day with other procedure done by the
same physician. It has to be above and beyond the usual preoperative and postoperative
encounter with the procedure. In fact, by using this modifier, it doesn't have to have a different
diagnosis reported. The most important thing is that, the E/M level should meet its key components
or if it is selected based on time with the patient (counseling and coordination). You have to be
careful in using this modifier. It must meet medical necessity. As you know, there are procedures
that already includes all other care and management.
Let's describe this modifier 25:
A patient came in for her monthly follow up for her chronic back pain. At the same time, patient was
complaining with severe headache. The pain doctor performed bilateral occipital block on the
patient at the time of service. You will append modifier 25 for the E/M code to indicate that both
services were rendered on the same day.
You don't use modifier 25 with E/M encounter that resulted to Decision for Surgery (we have
another modifier for this!)
Modifier -24, Unrelated evaluation and management service by the same physician during
postoperative period.
As the modifier indicates, this is another modifier that you can only append with an E/M counter. It
indicates that the E/M encounter is not related during the global perion.
Let's describe this modifier 24:
A pain specialist performed facet nerve destruction for the patient. During the normal, postoperative
global period, the patient came in to the office with severe knee pain due to fall on ice as evidenced
by the patient's subjective information. The pain specialist will then report that E/M encounter with
the patient by appending modifier 24 to indicate that encounter is not related during the
postoperative global period.
This modifier, like modifier 25 has no restriction as with the level of E/M code as long as it meets
medical necessity, all its components or are time-based.
Modifier -57, Decision for Surgery:
An Evaluation and Management service resulted in the initial decision to perform surgery during the
E/M encounter.
Let's describe this modifier:
An OB/GYN sees a patient who complains with severe abdominal pain. It turned out (through ultra
sound, radiology and all other diagnostic testing and documentations), the patient is having an
ectopic pregrancy. The OB/GYN performs the laparoscopic surgery on the same day. The E/M
encounter will then be reported with modifier 57 which resulted to decision for surgery. The
laparoscopic surgery should also be reported as performed on the same day without a modifier.
Modifier -50, Bilateral Procedure
You will append modifier 50 for procedures that are obviously billable as bilateral (or two sides,
both sides), performed on the same day, the same operative session, on identical anatomical
sites, organs (arms, legs, spine).
A Facet Nerve block is unilateral (can be billed as bilateral). When using a modifier 50, make sure
you only bill for one unit on the claim form since there is only 1 procedure is performed bilaterally.
Though guidelines from other payers may differ. They may require you to list it twice (line 1 and line
2 on the claim form). You have to be responsible to clarify this with your payors.
You use this modifier with add-on codes too! Do not use this modifier with procedures which are
already described as bilateral procedures.
Modifier -51, Multiple Procedures
This modifier is used when reporting multiple procedures performed by the same physician on the
same day. Do not use this modifier for "add-on" codes (see appendix D of the CPT Code book). Do
not use this modifier for codes with "modifier -51 exempt" symbol (see appendix E of the CPT Code
book). Do not use this modifier with an E/M code. This modifier can only be used by the same
physician on the same day who performed the procedure.
Coding tip: List the highest reimbursable code (after the main procedure code) based on the fee
schedule.
Modifier -59 Distinct Procedural Service
Description of Modifier -59: Under certain circumstances, the physician may need to indicate that a
procedure or service was distinct or independent from other services performed on the same day.
Modifier 59 is used toidentify procedures/services that are not normally reported together, but are
appropriate under the circumstances. This may represent a different session or patient encounter,
different procedure or surgery, different site or organ system, separate incision/excision, separate
lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or
performed on the same day by the same physician. However, when another already established
modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive
modifier is available, and the use of modifier 59 best explains the circumstances, should modifier
59 be used.
Use this modifier only if the other procedure is a separately identifiable procedure code. Procedure
that is distinct and can be described as independent procedure, on separate anatomical site,
lesion, injury site, different organ system, and different session. Do not use this modifier for E/M
code.
Modifier -26 Professional Component
This modifier is used only for the professional component (physician) of a service or a procedure.
Certain procedures are a combination of both professional and technical component. By using
modifier 26, it indicates that procedure being reported as professional component only.
Professional Component versus the Technical Component. By illustration, procedures rendered at
a facility such as outpatient hospital or ASC, these equipments are facility-owned. The facility will
then report the technical component for such service while the physician will report the
professional component for the that procedure. One very good example, the physician performs
Paravertebral Facet Block under Fluoroscopic guidance using CPT code 77003. The physician will
report the fluoro with modifier 26 for his/her professional component. While the facility will report
the the same procedure with modifier -TC for the technical component.
Modifier -LT or -RT are used to indicate a Left or Right side or anatomical site. So if the pain
specialist performed Left Cervical Facet Block, you will append a modifier -LT to report this
procedure.
Modifier – 73
Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC) Procedure prior to the
Administration of Anesthesia
Modifier – 74
Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC) Procedure After
Administration of Anesthesia