MODIFIERS

INTRODUCTION Modifiers are two-character suffixes

(alpha and/or numeric) that are attached to a procedure code.

CPT modifiers are defined by the American Medical Association (AMA)

HCPCS Level II modifiers are defined by the Centers for Medicare and Medicaid Services (CMS).

A modifier provides the means to report or indicate that a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code.

Modifiers also enable health care professionals to effectively respond to payment policy requirements established by other entities.

Modifiers are intended to communicate specific information about a certain service or procedure that is not already contained in the code definition itself. Some examples are:

To differentiate between the surgeon, assistant surgeon, and facility fee claims for the same surgery

To indicate that a procedure was performed bilaterally

To report multiple procedures performed at the same session by the same provider

To report only the professional component or only the technical component of a procedure or service

To designate the specific part of the body that the procedure is performed on (e.g. T3 = Left foot, fourth digit)

To indicate special ambulance circumstances

MODIFIER-22(INCREASED PROCEDURE)

Specific circumstances that may support modifier-22 include: Excessive blood loss relative to the procedure Presence of excessively large surgical specimen Trauma extensive enough to complicate the

particular procedure and not billed as additional procedure codes

Other pathologies, tumors, or malformations that interfere directly with the procedure but are not billed separately

Other factors that might support modifier-22 include morbid obesity, low birth weight, converting a laparoscopic procedure into open procedure.

Examples of modifier-22:-The patient lost 1000 cc’s of blood rather than the more usual 100-200 cc’s of blood for a procedure of this type.

MODIFIER-23(UNUSUAL ANESTHESIA)

Under unusual circumstances general anesthesia may be given for procedures that typically required local or regional or no anesthesia.

The modifier “23” should be submitted with the appropriate code to report unusual anesthesia.

This modifiers should not be reported with the procedure codes which includes the term “without anesthesia”in the description or that are normally performed under general anesthesia

The payer will review unusual anesthesia claim submissions on an individual consideration basis and will provide payments for medically necessary services

Documentation to support the reported services must be provided with the claim.

MODIFIER-24 Unrelated E/M service by same physician

or other qualified health care professional during a postoperative period.

During a postoperative period E/M service performed for a reason unrelated to the original procedure.

Each CPT code has a global period that varies from zero-90 days(some carriers have longer period of time=120 days)

Example: A surgeon performs a hernia repair on May 20. The procedure has a 90-day global period, so all related post-op care is included in the payment for the hernia. But, on July 1, the patient returns to have a breast lump evaluated. Report the E&M service with modifier 24 attached and use the new diagnosis — breast lump — as the reason for the visit.

MODIFIER-25 Modifier -25 is important because it

allows physicians to obtain reimbursement for services rendered that would otherwise be denied if the modifier was not attached. It alerts payers that another significant, separately identifiable evaluation and management (E/M) service was performed by the same physician on the same day.

Examples of a zero global period with an E/M service provided the day of include bronchoscopy, esophagogastroduodenoscopy, and impacted cerumen in one or both ears.

Examples of a 10-day global period are minor surgical procedures that include complications related to the procedure and cannot be billed separately for 10 days after the procedure, such as the excision of a benign lesion on the trunk, arms, or legs; pressure equalizer tubes inserted under local or topical anesthesia; and debridement.

MODIFIER-26(PROFESSIONAL COMPONENT)

Certain procedures and services have both a professional and a technical component.

Use modifier 26 when only the professional (physician) component is being billed.

Use modifier TC when only the technical component is being billed.

MODIFIER-32(MANDATED SERVICES) Modifier -32 (Mandated services) describes procedures or

services required by a third-party payer, governmental or legislative agency, or regulations. The modifier is often used when college athletes present for preseason physicals. 

Example Orthopedist A has determined a patient needs an arthroscopic SLAP repair (29807, Arthroscopy, shoulder, surgical; repair of SLAP lesion). Before the carrier approves the surgery, it requires Orthopedist B to conduct a physical examination of the patient. That visit, e.g., 99243 (Office consultation for a new or established patient )

MODIFIER-33(PREVENTIVE SERVICES)

When the primary purpose of the service is the delivery of an evidence based service in accordance with the US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (Legislative or regulatory), the service may be identified by adding 33 to the procedure.

Examples 88141 – Cytopathology, cervical or

vaginal 45378 – Colonoscopy 80061 – Lipid panel 77080 – Dual energy X-ray

absorptiometry, bone density study 97802 – Medical nutrition therapy

MODIFIER-47(ANESTHESIA BY SURGEON)

Regional or general anesthesia provided by the surgeon(does not include local anesthesia)

Example 1 - modifier 47 appropriateThe surgeon will be performing an endometrial biopsy. Prior to surgery, the surgeon initiates a regional block. The surgeon may bill using the CPT code for the biopsy, followed by modifier 47. 

Example 2 - modifier 47 not appropriateThe physician injects lidocaine into surrounding tissue prior to repairing a superficial laceration to the patient's index finger. 

MODIFIER-50(BILATERAL PROCEDURE)

It should be performed at the same operative session should be identified by adding 50 to the appropriate five digit code.

Example: surgery done on both eyes is a bilateral procedure whereas on only one eye is a unilateral procedure

MODIFIER-51(MULTIPLE PROCEDURES)

When multiple procedures, other than E/M services, performed at the same session by the same provider. report the primary procedure as listed and add modifier 51 to the additional codes.

Example: The physician performed an epidural injection of the cervical spine(62310) and an epidural injection of the lumbar spine(62311-51)

Modifier 51 does not apply to procedures classified as "add-on" or "Modifier 51 exempt."

MODIFIER-52(REDUCED SERVICES)

Report modifier 52 when a component of a CPT code definition is reduced or eliminated. Append modifier 52 to the CPT code that represents the basic service to indicate that the basic service was performed but a one component of the service/CPT code definition was not.

Example: bilateral procedures(vasectomy is done only for one side)

MODIFIER-53(DISCONTINUED PROCEDURE)

Use modifier 53 when a service is terminated due to circumstances beyond the physician or health care provider's control. This may include conditions that threaten the patient's health.

Do not use modifier 53 for an elective cancellation of the procedure.

Modifier52/53 decision matrix

Modifier-52 Modifier-53

Anesthesia(if applicable)

Procedure stopped prior to anesthesia

Procedure stopped after administered anesthesia

Procedure stopped Elective by patient or physician

Physician terminates due to patient risk

MODIFIER-54(SURGICAL CARE ONLY)

When a physician performs only surgical services for a member, the appropriate surgical CPT codes should be reported along with modifier 54. Modifier 54 indicates that only the surgical component of the global package will be performed by this provider.

Report modifier 54 when it is known that post-operative care will be performed by or transferred to another health care provider.

MODIFIER-55(POSTOPERATIVE MANAGEMENT ONLY)

When a physician provides and/or co-manages post-operative care for a member, report the appropriate surgical CPT code along with modifier 55. Modifier 55 indicates that only post-operative services of the global surgical package were rendered by this provider.

Do not use this modifier when there is no global surgical period (10 or 90 days) associated with the CPT code.

MODIFIER-57(DECISION FOR SURGERY)

This modifier may be used to indicate that an evaluation and management (E/M) service performed on the same day or the day before a major surgery (090 global days) by the surgeon resulted in the decision to perform the procedure. Documentation in the patient's medical record must support the use of this modifier.

Example: A surgeon receives a request to evaluate a patient for acute upper quadrant pain and tenderness. following a full evaluation,the surgeon decides to remove the gallbladder and schedules an immediate laparoscopic cholecystectomy

MODIFIER-58 The modifier 58 is defined by CPT as “staged or

related procedure or service by the same physician during the post-operative period.” It may be necessary to indicate that the performance of a procedure or service during the post-operative period was

a) planned or anticipated (staged); b) more extensive than the original procedure; or

c) for therapy following a surgical procedure. This circumstance may be reported by adding modifier 58 to the staged or related procedure.

MODIFIER-59(DISTINCT PROCEDURE)

A health care provider may need to use modifier 59 to indicate that a procedure or service was distinct or independent from other services performed on the same day.

This commonly means a different location, different anatomical site, and/or a different session.

MODIFIER-62(TWO SURGEONS) When two surgeons work together as

primary surgeons performing distinct parts of a procedure, each surgeon should report the co-surgery once using the same procedure code and report his/her distinct operative work by adding modifier 62 and any associated add-on code(s) for that procedure.

If additional procedure(s), including add-on procedures, are performed during the same surgical session, separate codes may also be reported with modifier 62 added.

As Per the AMA rules, you cannot append modifier 62 to the instrumentation or grafting codes.

If a co-surgeon acts as an assistant in performing 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.

Do not report an 80 modifier with a 62 modifier when two surgeons are working together on co-surgery. It is implied within the description of the 62 modifier that each surgeon will be "assisting" with the procedure.

Report both the 62 modifier and the 50 modifier (bilateral procedure) when co-surgery is done by surgeons of the same specialty.

MODIFIER-66(SURGICAL TEAM)

Modifier 66 (Surgical team) applies when a team of surgeons (three or more) works together to complete a procedure reported using a single CPT code.

Important: Two surgeons working together with the aid of one or more surgical assistants does not qualify as a surgical team as defined by modifier 66. The team must consist of three or more primary surgeons.

MODIFIER-76 Denotes a repeat procedure by the

same physician. Should be submitted only when a procedure is repeated on the same date of service by the same physician.

Example: When two physicians are within the same group or same specialty = same physician Used for surgeries, x-rays and injection

MODIFIER-77 Modifier -77 is used to indicate that

another physician repeated a procedure or service in a separate operative session on the same day. Service originally performed by another physician. Documentation must include reason for repeat procedure        E.g., suspicious findings in original x-ray or EKG

MODIFIER-80 Assistant surgeon:surgical assistant

services may be identified by adding modifier 80 to the usual procedure number.

Example: one physician is done harvesting for CABG procedure it involves venous grafts only. The graft procurement performed by the assistant at surgery is reported using modifier-80

MODIFIER-81 Minimum surgical assistant services are

identified by adding modifier-81. This includes MD, DO, and DPM provider

types and is an assistant surgeon providing minimal assistance to the primary surgeon. This modifier may be used when more than one assistant is involved or if one person assists during a portion of the surgery. This modifier is not intended for use by non-physician assistants (e.g., RN, PA).

MODIFIER-82 Assistant at surgery when a qualified

resident surgeon is not available to assist the primary surgeon. This includes MD, DO, and DPM provider types.

https://www.medesunglobal.com

THANK YOU