1. CHAPTER 14
MODIFIERS 1

2. CPT Modifiers Used to describe alterations to CPT code
Full list, CPT, Appendix _ A
These codes tell the third-party payer that circumstances exist that should alter the way in which payment is made.
What will happen if a service is coded without use of an appropriate modifier? (Reimbursement will be based on the standard service deliverable, which may result in overpayment or underpayment.) 2

3. Modifier Functions Altered (i.e., more or less) Bilateral Multiple
Only portions of service (i.e., professional service only)
More than one surgeon
Unusual service
What would happen if a modifier code was not used when a patient received a service that was performed bilaterally on the same day? (The third-party payer would assume that the billing for the second service was a duplicate of the billing for the first service and would not pay it.) 3

4. -22 Increased Procedural Service
Indicates services significantly greater than usual
Accompanied by ___________ with supportive documentation
Describes increased physician work
written report
What type of documentation would support use of the modifier -22? (Increased risk to the patient caused by complications, difficulty of the procedure, excessive blood loss, or other circumstance that significantly altered the delivery of the service. When the modifier -22 is used, a report must be sent to document why this is an unusual practice.)
Because this modifier is overused and because it increases payment by as much as 20%-30%, it is subject to special scrutiny by third-party payers. 4

5. -23 Unusual Anesthesia Only used with _________ codes
Use of anesthesia where no anesthesia or ____ would be the norm
Example: Highly agitated senile patient
Only used with _________ codes
Written report with submission of modifier may be required
local
anesthesia
Why is a written report required when this modifier is used? (It explains the unusual circumstances of why general anesthesia was needed and used.)
Note that this modifier applies only to the delivery of anesthesia services by the anesthesiologist, and only when codes from the Anesthesia section of the CPT are used. 5

6. -24 Unrelated E/M Services by Same Physician or Other Qualified Health Care Professional During a Postoperative Global Period
E/M Service not related to surgery is separately billable
Use -24 on ___ code only
If E/M provided during post-op global period, no separate payment for E/M related to surgical procedure
Example: Patient is in global period for hip surgery and is now seen for a fractured collarbone
E/M
Although most often used for surgical services, the modifier -24 may also be used with the General Ophthalmological Services codes , which are used to code medical examinations for new and established patients.
Suppose a patient is treated for bronchitis during the global postoperative period for arthroscopic surgery to repair a torn meniscus. Is it appropriate to use the modifier -24? Why, or why not? (Yes, because the diagnosis is not related to the surgery.)
How might complications be coded? (With a postoperative “No Charge” code) 6

7. -25 Significant, Separately Identifiable E/M Service, Same Physician or Other Qualified Health Care Professional and Same Day of Procedure or Other Service
Documentation must support service
Example: Patient seen for sinus congestion, provider performs H&P, prescribes decongestant, notes lesion on back, and removes
Code: Procedure + E/M-25
Example: A patient seen on consultation by pain management and subsequent to rendering an opinion was given a nerve injection. Modifier -25 is placed on E/M code
Suppose a patient is treated for both a cough and sinus congestion on the same day by the same individual. Would use of the modifier -25 be appropriate in this case? Why, or why not? (No, because only 1 E/M level for that day was done regardless of the diagnosis being treated. The 2 visits could be combined to up-code the level billed for that day depending on the documentation.) 7

8. -26 Professional Component
Professional component (physician, ___)
Technical component (technician + equipment, ___)
Example: Radiologist reviews x-rays (-26) taken by supervised technician (-TC)
-TC
The modifier -26 is added to a procedure code when it is used. Will reimbursement be greater or less if the coder fails to correctly add this modifier to the code submitted? (It would be greater, because this modifier is used only when services have both professional and technical components.) 8

9. -32 Mandated Service
Mandated by payer, workers’ comp, or official body
Not request of patient, patient’s family, or another physician
Example: Workers’ Comp requests examination of person currently receiving disability benefits
What is the purpose of the modifier -32? (The modifier -32 is used when the service is provided because a third-party payer has mandated that it be provided. Second opinions required by the third-party payer, Workers’ Comp evaluations, insurance examinations, and the like should be coded with this modifier. Requests made by the patient or family are not mandated and should not use this code.) 9

10. -33 Preventive Services
Patient Protection and Affordable Care Act of 2010 requires coverage without cost
United States Preventive Services Task Force grades preventive services
Grade A: substantial
Grade B: moderate

11. -47 Anesthesia by Surgeon
Physician administers regional or ______ anesthesia
Acts as surgeon & anesthesiologist
Only used with Surgery codes
No separate payment when used on Medicare patients
general
Why is the modifier -47 used rather than the appropriate anesthesia code? (This modifier describes the rare situation in which the physician delivers regional or general anesthesia. The surgeon is compensated for the time spent administering the anesthesia. This will not be the same as the compensation received by an anesthesiologist who is compensated for time spent preparing, monitoring, and evaluating the patient.) 11

12. -50 Bilateral Procedure Bilateral
Example: Procedure on hands
Caution: Some codes describe bilateral procedures; in these cases do not apply modifier -50
When a procedure is performed bilaterally, it is often necessary to use the modifier -50 to document the fact that the procedure was performed on both sides of the body. The exception would be cases in which the code itself reflects the bilaterality of the procedure.
Suppose that an arthroplasty (total knee replacement) was performed on both knees during the same operative session. What would happen if the modifier -50 were not used? (If the modifier were not used, reimbursement would be made as if only one knee had been replaced.) 12

13. -51 Multiple Procedure—Three Types
Same Procedure, Different ____
Example: Multiple lacerations repaired
Multiple Operation(s), _____ Operative Session
Procedure Performed _______ Times
Example: Trigger point injections (20552)
Sites
Same
Multiple
Have students describe a situation in which multiple procedures are performed and use of the modifier -51 is not appropriate. (Some CPT codes include provisions for multiple procedures in their descriptions. Use of the modifier -51 would not be appropriate in these cases, as the procedures are already bundled into the surgical package.)
(Cont’d …) 13

14. -51 Multiple Procedure
(…Cont’d)
List most resource intense first (highest RVU value)
Next other procedure(s) (unless code is -51 exempt or an add-on code)
Usual payment: 1st procedure 100%, 2nd 50%, 3rd 25%
Medicare: 1st procedure paid 100%, 2nd–5th paid 50%, more than 5, priced manually
Why is it important to always list the most significant procedure in terms of resources used first in these cases? (The order in which procedures are listed will determine the level of reimbursement received. Full reimbursement will generally apply to the first procedure listed, and partial [perhaps 50%] reimbursement to additional procedures listed. Optimizing reimbursement requires that the most significant procedure be listed first.) 14

15. -52 Reduced Services Service reduced from code description
Physician directed reduction
Documentation substantiates reduction
Not for patients unable to pay fee
Submit full charge, payer will adjust
Example: Lip shave (40500) but advancement flap not performed =
How is reimbursement affected by use of the modifier -52? (The provider is reimbursed for the portion of the service actually provided. The documentation provided will substantiate the reduction.)
Additional documentation may include operative reports and/or physician explanation of the reason for the reduced service. A reduced service would be coded if a surgical procedure was begun but was terminated without completion because of previously unforeseen circumstances, such as the discovery that a cancerous lesion cannot be excised because of extensive metastases. 15

16. -53 Discontinued Procedure
Surgical/diagnostic procedures
Started then stopped due to patient’s condition
Does not apply to presurgical discontinuance
(Cont’d…)
How does a discontinued procedure differ from a reduced procedure? (Both result in termination of the procedure at the direction of the physician. In the case of a reduced procedure, the reason for the termination relates to findings during the course of delivering the procedure rather than to the patient’s condition.)
Correct use of modifier -53 requires that the patient be anesthetized and the procedure begun before the decision is made to terminate. The modifier would be used to code termination of a surgical or diagnostic procedure because the patient developed arrhythmia during the procedure that could not be controlled. Terminating the procedure would be necessary in this case in order to stabilize the patient. 16

17. -53 Discontinued Procedure
(…Cont’d)
DO NOT USE -53 WHEN:
Patient cancels scheduled procedure
With E/M codes
With time-based code
Why is it inappropriate to use the modifier -53 in these instances? (The modifier -53 is appropriate only when the patient has been anesthetized and the procedure begun. If the patient cancels the procedure before it starts, this code will not be appropriate. E/M codes are also inappropriate because they pertain to evaluation and management services, not to surgical procedures. It should not be used with time-based codes because time spent will determine reimbursement in these cases, regardless of the extent to which the procedure was completed.)
See Chapter 17 for an explanation of the surgical package. 17

18. -54 Surgical Care Only Physician provides only procedure (___________)
Documented patient ______ must be in record
Some payers require copy of transfer
intraoperative
transfer
The modifiers -54, -55, and -56 are used when preoperative, intraoperative, and postoperative care are provided by different physicians. A transfer order or orders moving responsibility from one provider to another are required before these codes can be used.
When is the modifier -54 used? (It is used by a physician who provides intraoperative care only. A transfer order is required to assign responsibility to the surgeon for this period.) 18

19. -55 Postoperative Management Only
Physician provides only care after hospital discharge
If transferred while patient hospitalized, report postop management with subsequent hospital codes
Documentation of transfer in medical record
Surgery code billed with -55 modifier and surgery date of service
Bill after first postoperative visit
When is the modifier -55 used? (When the physician provides care for the operative patient only after discharge from the hospital. Use of this code requires documentation of the transfer of responsibility to be included as part of the patient’s record.) 19

20. -56 Preoperative Management Only
Physician provided only preoperative care
Not acceptable for Medicare
Requires surgical code with modifier -56
When is the modifier -56 used?
When the physician provides care for the operative patient only during the preoperative period.
It is not acceptable for use with Medicare billing because Medicare considers the preoperative service to be part of the surgery.
Billing an E/M service for each visit is not appropriate; billing should include the surgical code with this modifier. 20

21. Usual Reimbursement for Portions, Surgical Package
10% preoperative
70% intraoperative
20% postoperative
Each _____ determines portions
payer
How is the reimbursement level for a surgical package determined when different portions of the surgical period are managed by different physicians? (Typically, the preoperative period will receive 10%, intraoperative 70%, and postoperative 20% of the available reimbursement. However, each third-party payer may make its own determination as to how payment will be apportioned.) 21

22. -57 Decision for Surgery Used With
E/M,
Medicine, ____________ services
Medicare: Only for preop period of major surgery (day before or day of)
90 day global
ophthalmologic
What is the purpose of the modifier -57, and when may it be used? (The modifier -57 is used to indicate when the decision to perform surgery was made. It is appropriate for use only with E/M and ophthalmologic services. When reimbursement from Medicare is requested, guidelines state that this code may be used only on the day of or the day before surgery.) 22

23. -58 Staged/Related by Same Physician or Other Qualified Health Care Professional During Postoperative Period
Subsequent procedure planned or related to the first surgery
During postop of previous surgery in series
Example: Multiple skin grafts completed in several sessions
Global period starts over
(Cont’d…)
Under what conditions would it be appropriate to use the modifier -58? (The modifier -58 is used when before or during the first surgery, the decision is made to stage the procedure over time or to perform multiple procedures. Multiple skin grafts completed over several sessions because the patient required time to heal between treatments would be a situation in which use of this modifier would be appropriate. A radical mastectomy performed during the post-surgical period for a breast biopsy would be another example if the treatment decision was made at the time of the first surgery.) 23

24. -58 Staged/Related by Same Physician or Other Qualified Health Care Professional During Postoperative Period
(…Cont’d)
Do not use when code describes a session
Example: 67208: lesion destruction of retina, ___ or ____ sessions
one
more
Why would it be inappropriate to use the modifier -58 with the code 67208: lesion destruction of retina, one or more sessions? (The code description provides for multiple procedures; the modifier -58 would be inappropriate in this case.) 24

25. -59 Distinct Procedural Service
Different session or encounter
Different procedure
Different site
Separate incision, excision, lesion, injury
Do not use when another HCPCS modifier is appropriate
(Cont’d…)
How will the separate procedures be reimbursed if the modifier -59 is not used? (If the modifier is needed and is not used, only the primary service will be reimbursed because the other services will be assumed to be part of the primary service. Note that if a modifier code exists that more specifically addresses the nature of the additional service provided, it should be used instead of the modifier -59.)
What are the differences between the modifier -51 and the modifier -59? (Modifier -51 is for multiple procedures performed at the same setting that are not bundled together. Modifier -59 is used for unbundled services to show that they are mutually exclusive.) 25

26. -59 Distinct Procedural Service
(…Cont’d)
Example: Physician removes several lesions from patient’s leg, also notes and biopsies a mole of torso
Biopsy code for mole + -59
Indicates biopsy distinct procedure, not part of lesion removal
What is the primary procedure in this case? (The primary procedure is the removal of lesions from the patient’s leg. The secondary procedure, which is the biopsy of the mole on the torso, should be coded with the modifier -59 to indicate that it is a distinct procedure and not part of the removal of the lesion.) 26

27. -62 Two Surgeons co-surgeons Both function as __________ (equals)
Usually different specialties
Each surgeon reports same surgery code appending -62
Each surgeon dictates his/her portion of procedure
co-surgeons
When one physician assists another with a surgical procedure, is use of the modifier -62 appropriate? (No, use of the modifier -62 requires that the surgeons acted as co-surgeons, working together as primary surgeons to perform separate parts of the surgical procedure.)
Reimbursement will generally total 125% of the amount that would be available if the procedure were completed by a single physician, and it will be shared by the two surgeons acting as co-surgeons. 27

28. -63 Procedure Performed on Infants Less Than 4 kg
Kilogram: 2.2 lb (4 kg = ___ lb)
Small size increases complexity
Use with all Surgery section codes except Integumentary and those exempt by parenthetical notes
8.8
Why is a special modifier code used when procedures are performed on infants weighing less than 4 kg? (Procedures performed on these infants are significantly more complex than they would be when performed on other patients.)
Note that it is appropriate to use this modifier with every surgical procedure except for those from the Integumentary section, if the procedure is performed on an infant with weight under 4 kg. 28

29. -66 Surgical Team
Team: Several physicians (3 or more) with various specialties plus technicians and other support personnel
Very complex procedures
Payers may increase payment
Transplant surgeries are one example of this class of procedures.
How will reimbursement be divided among participants when a surgical team is coded? (Participants in the surgical team will have worked out an arrangement for the distribution of funds prior to the surgery and this will generally be reflected in their contract with the third-party payer.) 29

30. -76 Repeat Procedure/Service by Same Physician or Other Qualified Health Care Professional
Note: “Same Physician or Other Qualified Health Care Professional”
Used to indicate necessary repeated service, not ___________ error
Example: X-rays before and after fracture repair
Aerosol treatment for an asthma attack repeated in 90 minutes ( )
typographical
What would happen if a patient’s arm was x-rayed before and after a fracture repair but the modifier -76 was omitted when the procedure was coded? (The third-party payer would assume that a duplicate bill had been sent in error, and no payment would be made.)
When is the modifier -76 used? (To report procedures or services that are repeated by the same individual on the same day out of medical necessity) 30

31. -77 Repeat Procedure/Service by Another Physician or Other Qualified Health Care Professional
Note: “Another Physician or Other Qualified Health Care Professional”
Performed by one individual, repeated by another individual
Submitted with a written report to establish ______ necessity may be requested
medical
How does use of the modifier -77 differ from use of the modifier -76? (With the modifier -77, the same procedure is performed on the same day, but different individuals perform it in each case. With modifier -76, the same procedure is performed on the same day by the same individual.)
Documentation of medical necessity is required when the modifier -77 is used. There must be a medical need to repeat the procedure and to obtain a second set of information in order for its use to be appropriate. 31

32. For complication of first procedure
-78 Unplanned Return to Operating/Procedure Room Same Physician Following Initial Procedure for a Related Procedure During Postoperative Period
For complication of first procedure
Example: Patient has outpatient procedure in morning, was returned to operating room in afternoon with severe hemorrhage
Indicates not typographical error
Does not change global period time
Consider the example provided here. What would happen if the modifier -78 were not used in this case? (The third-party payer would assume that an error had been made and would not reimburse the follow-up procedure.)
The modifier -78 is used to explain the need to return to the operating room to treat a postoperative complication that occurs during the postoperative period. Use of the modifier will result in payment for the unexpected but necessary second surgical intervention. 32

33. -79 Unrelated Procedure or Service by Same Physician or Other Qualified Health Care Professional During Postoperative Period
Example: Several days after discharge for procedure, patient returns for an unrelated procedure/service
Diagnosis would be different
Remember the ___ code would have -24
If surgery is unrelated to original procedure, a new global period starts
E/M
Example: A patient who had an appendectomy initially but later required gallbladder removal would have his or her gallbladder surgery coded with the modifier -79.
How does use of the modifier -79 differ from the use of the modifier -24? (The modifier -79 is used for unrelated surgical interventions that occur during the postoperative period. The modifier -24 is used for unrelated E/M services that are provided during the postoperative period.) 33

34. -80 Assistant & -81 Minimum Assistant Surgeons
Reimbursed at 15–30%
Payers identify procedures for which they reimburse assistant
-81 Minimum Assistant Surgeon
Services at a level less than that described in -80 (________ Surgeon)
Reimbursed at 10%, if at all
Assistant
Will preauthorization indicate whether an assistant surgeon is allowed by the third-party payer? (It will generally indicate whether the assistant surgeon’s services will be recognized, but final determination will not occur until the claim is processed. Even if preauthorization is given, there is no guarantee that the claim will be accepted.)
What is the difference between a minimum assistant surgeon and an assistant surgeon? (The level of assistance is less in the case of the minimum assistant surgeon, and the level of reimbursement is somewhat less as well.)
Note that some third-party payers do not allow minimum assistant surgeons. Medicare will pay for the minimum assistant only in rare instances for which medical necessity is demonstrated. 34

35. -82 Assistant Surgeon Teaching hospitals:
Have residents who assist as part of education—no fee, no modifier -82
Must demonstrate no _______ resident available
Unavailability documented in written report
qualified
When would modifier -82 be used? (When a qualified resident is not able to assist a surgeon so another surgeon needs to)
Note that Medicare does not allow use of this code.
What are teaching hospitals? (Those affiliated with a medical school) 35

36. -90 Reference (Outside) Laboratory
Physician has business relationship with outside lab
Physician pays lab
Physician bills payer for lab services
Cannot use for Medicare
When is use of the modifier -90 appropriate? (The modifier -90 is appropriate when the physician bills for laboratory services that are performed by an outside laboratory. Reimbursement is made to the physician, and the physician, in turn, pays the laboratory for those services. Medicare does not allow this type of billing to occur, but other third-party payers may allow this practice.) 36

37. -91 Repeat Clinical Diagnostic Laboratory Test
Repeat same laboratory tests on same day for multiple test results
Not tests ____ to confirm original test results
Not _________ of equipment or technician error
rerun
malfunction
When is use of the modifier -91 appropriate?
It is used when it is medically necessary to repeat a test on the same day.
It should not be used when the procedure code describes a series of test results, as would be the case with a glucose tolerance test.
It cannot be used when a test is repeated simply to confirm the original test results or because of equipment malfunction. 37

38. -92 Alternative Laboratory Platform Testing
Indicates kit or transportable instrument
Usually single use, disposable
Example: 86701, HIV test kit
When is the modifier -92 used? (When test is a single use or portable instrument)

39. -99 Multiple Modifiers
Used when service needs more than one modifier but payer only allows for one modifier with each code
When should the modifier -99 be used? (When multiple modifiers are required for a procedure and the third-party payer’s claims processing system does not allow for coding of multiple modifiers) 39

40. CMS-1500 CMS-1500 has places for multiple modifiers Figure: 14.2 40
On the CMS-1500 form how many modifiers can you use? (4)
In what order should multiple modifiers fall? (Third-party payers vary on how they want modifiers reported, so be certain to check with the payer before submitting multiple modifiers. For the purposes of this text, CPT modifiers are listed first in highest to lowest, followed by HCPCS modifiers in ascending alphabetical order.)
(Courtesy U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services)
CMS-1500 has places for multiple modifiers 40

41. Conclusion CHAPTER 14
MODIFIERS 41