2-09 CPT Modifiers

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CPT MODIFIERS

WHAT ARE CPT MODIFIERS?

● Modifiers are two-character additions to CPT


code that provide additional information
about the procedure without changing the
definition of the procedure
● They affect the reimbursement process by
giving the payer a better picture of what
happened during the procedure
○ For instance, the modifier -22 indicates “increased
professional services”
■ In other words, the provider had to perform more work than
would normally be involved in a procedure
WHAT DO THEY LOOK LIKE?

● Modifiers are always two characters, and


may be numeric or alphanumeric
○ CPT codes are always two numbers
■ Eg, -22 or -51
○ Physical status modifiers (which are used with
Anesthesia codes) are alphanumeric
■ Eg, -P1 or –P4
○ HCPCS modifiers are alphanumeric
■ Eg, -LT or E1
■ These will be covered in depth in Course 2-12
ORDERING MODIFIERS

● Modifiers are always added to the end of the


procedure code with a hyphen
○ Example: A team of surgeons performs surgery to
drain a renal abscess in a patient
○ We’d code 35471 for the drainage of the renal
abscess
○ We’d add the modifier -66 for “team of surgeons”
○ We’d end up with 35471-66
ORDERING MODIFIERS, CONT.

● Unless otherwise specified, you should list


the modifiers that directly affect the
reimbursement process first
● These are called “functional modifiers”
● “Informational modifiers” provide extra data
about the procedure, but may not affect the
reimbursement process
○ These should be listed after functional modifiers
WHY DO WE ORDER MODIFIERS THIS WAY?

● Most claim forms, including CMS 1500 and


UB04, the two most common claim forms,
have room for four modifiers
● But, payers do not always look at modifiers
after the first two, so you have to order your
modifiers accordingly
MODIFIER- 22

● Increased procedural services


○ This modifier lets the payer know that the
procedure required substantially more work than
would normally be expected. This code is not
compatible with E&M.
MODIFIER- 23

● Unusual anesthesia
○ This modifier will alert the payer to the fact that a
procedure that would normally not require
general anesthesia did, in fact, require general
anesthesia.
MODIFIER- 24

● Unrelated evaluation and management


service by the same physician or other
qualified healthcare professional during a
postoperative period
○ If a healthcare provider needs to perform an
evaluation during a postoperative period, but that
procedure is not related to the operation just
performed, this modifier is appropriate. This is
used with E&M codes.
MODIFIER- 25
● Significant, separately identifiable evaluation
and management service by the same
physician or other qualified healthcare
professional on the same day of the
procedure or other service
○ If a patient’s condition requires a separate
examination on the same day as a surgical
operation, and this examination exceeds the usual
pre- or postoperative evaluation required with
the procedure, this modifier may be added to the
CPT code that describes this additional evaluation.
MODIFIER- 26

● Professional component
○ A professional component is the element of a
procedure performed by a licensed medical
professional. This might mean the interpretation
of a diagnostic test, rather than the
administration of it.
MODIFIER- 32

● Mandated services
○ This modifier describes services, consultations, or
evaluations that are required by a third party,
such as an examination that an insurance
company requires of a patient in order to
determine medical necessity.
MODIFIER- 33

● Preventive Services
○ Medical services performed in order to prevent or
detect future illness or injury, including
immunizations, screenings, etc.
MODIFIER- 47

● Anesthesia by surgeon
○ This modifier includes general or regional
anesthesia administered by the surgeon, but does
not include local anesthetic. This modifier would
not be used with CPT codes for anesthesia, either.
MODIFIER- 50

● Bilateral procedure
○ This modifier describes medical procedures
performed on both sides of the body. This only
applies to parts of the body that are, in fact,
bilateral (eg, the kidneys). This code also typically
requires that the bilateral procedure be
performed in the same operating session.
MODIFIER- 51

● Multiple procedures
○ One of the most common modifiers, this indicates
that the healthcare provider performed more
than one procedure in one session. This modifier
is added to the secondary (or tertiary, etc.)
procedure performed after the initial one.
MODIFIER- 52

● Reduced services
○ In the case of a procedure being reduced in scope
or intensity, or in the case of a physician being
unable to complete the procedure, you may use
this modifier. Note that this is different from a
discontinued procedure (which is modifier -53),
but may be used to describe a discontinued
procedure or one that is aborted.
MODIFIER- 53

● Discontinued procedure
○ If extenuating circumstances demand it, a
healthcare provider or surgeon may elect to stop
a procedure in the middle of performing it. In
cases like this, use -53 at the end of the CPT code
to show that the healthcare provider prepared for
and initiated the service, only to stop mid-way
through.
MODIFIER- 54

● Surgical care only


○ If a surgeon is performing the surgery, but is not
responsible for the pre- or postoperative
evaluation or care, you may use this modifier.
MODIFIER- 55

● Postoperative management only


○ If different healthcare providers perform the
surgery and the postoperative care, this modifier
may be added to the postoperative care.
MODIFIER- 56

● Preoperative management only


○ This is identical to -55, but relates to preoperative
care instead of postoperative care.
MODIFIER- 57

● Decision for surgery


○ If, during an evaluation and management
procedure, the physician decides surgery is
necessary, you may add this modifier to the
evaluation and management procedure code.
MODIFIER- 58

● Staged or related procedure or service by the


same physician or other qualified healthcare
professional during the postoperative period
○ This modifier applies to two different
circumstances related to an operation on a
patient. If, during the initial surgical procedure,
the healthcare provider anticipates (or stages) a
postoperative procedure, you may use this
modifier. Similarly, if the healthcare provider
anticipates a postoperative procedure, and this
MODIFIER- 58 CONT.

procedure ends up being more extensive or time-


intensive than initially expected, this modifier lets
the payer know that more work was required
during this procedure.
MODIFIER- 59

● Distinct procedural service


○ If two or more distinct services are performed on
a patient on the same date, this modifier can be
used to explain why two procedure codes are
being reported.
MODIFIER- 62

● Two surgeons
○ In the case of two surgeons operating on a patient
at the same time, you may use this modifier to
explain to the payer why two separate healthcare
professionals are billing for the same procedure
performed on the same patient.
MODIFIER- 63

● Procedure performed on infants less than


4kg
MODIFIER- 66

● Surgical team
○ This modifier alerts the payer to the fact that a
team of more than two surgeons operated on the
patient during the procedure.
MODIFIER- 76

● Repeat procedure or service by same


physician or other qualified healthcare
professional
○ This modifier may be used when a physician
performs the same procedure twice on a patient
on the same date. It may also describe multiple
diagnostic procedures, like X-rays, that are
performed on the same date. This modifier helps
prevent claim denials based on duplicate
procedures.
MODIFIER- 77

● Repeat procedure by another physician or


other qualified healthcare professional
○ This modifier is identical to -76, but applies when
a different physician or healthcare professional
performs the second procedure or diagnostic test.
MODIFIER- 78

● Unplanned return to the


operating/procedure room by the same
physician or other qualified healthcare
professional following initial procedure for a
related procedure during the postoperative
period
○ This modifier indicates that a second operation is
performed during what would normally be the
postoperative period, usually due to
complications with the initial operation.
MODIFIER- 79

● Unrelated procedure or service by the same


physician or other qualified healthcare
professional during the postoperative period
○ This modifier describes a secondary operation or
procedure that is performed during the
postoperative procedure but is not tied to the
initial operation.
MODIFIER- 80

● Assistant surgeon
○ This is a personnel code, which describes a
situation in which an assistant surgeon helped
with the procedure.
MODIFIER- 81

● Minimum assistant surgeon


○ This code describes a procedure in which the
assistant surgeon was only active for part of the
procedure.
MODIFIER- 82

● Assistant surgeon (when qualified resident


surgeon not available)
○ This code is used exclusively in teaching hospitals.
MODIFIER- 90

● Reference (outside) laboratory


○ If a test is performed by a third party other than
the treating physician or that physician’s office,
you may append this modifier to the end of that
procedure code.
MODIFIER- 91

● Repeat clinical diagnostic laboratory test


○ If diagnostic tests are performed more than once
in the same day, this modifier should be added to
the procedure code for that test. Note that this
modifier may be used when clinical tests are done
twice in order to confirm a diagnosis.
MODIFIER- 92

● Alternative laboratory platform testing


○ This modifier describes a laboratory test
performed with a portable kit that consists, either
wholly or in part, of a single-use, disposable
element.
MODIFIER- 99

● Multiple modifiers
○ Most payers only pay attention to the first two
modifiers listed with a procedure code. However,
there may be instances where it’s important for
the healthcare provider’s reimbursement that the
payer acknowledge several modifiers. When this
happens, use the -99 modifier to show that there
are more than two modifiers.
USING CPT MODIFIERS

● Example 1:
○ A surgeon performs a procedure to remove a
bone cyst in the upper arm of a patient. The
procedure also includes obtaining a graft from
elsewhere in the body. Due to minor
complications, the surgeon is unable to fully
excise the bone cyst.
● We’d code
○ 24115, for “excision or curettage of bone cyst or
benign tumor, humerus”
USING CPT MODIFIERS CONT.

● And add the modifier -52


○ Because the procedure was completed but was
not fully successful, a “reduced services” modifier
is appropriate here
USING CPT MODIFIERS, CONT.

● Example 2
● A team of surgeons is performing a closed, or
percutaneous, angioplasty in a patient's renal
system.
● We’d code 35471 for “transluminal balloon
angioplasty, percutaneous; renal or other
visceral artery”
● We’d attach the modifier -66 for “team of
surgeons”
● Finish with 35471-66
USING CPT MODIFIERS, CONT.

● Example 3
● Let’s expand on our previous renal
angioplasty example. The surgical team is
performing the renal angioplasty in the
same procedure as draining a renal abscess.
● We stick with the code for the renal
angioplasty, 35471, and it’s modifier, making
it 35471-66
USING CPT MODIFIERS, CONT.

● The angioplasty code has a note that


explains if it is part of another procedure, it
can be listed with the -52 modifier
● We’d therefore code it as 35471-66-52
● We’d code the drainage of the renal abscess
as 50020, and include the -52 modifier to
show that it was one of two procedures
performed on the same date.
● We’d end up with two codes:
○ 50020-52-66 & 35471-52-66
PHYSICAL STATUS MODIFIERS

● These are used with anesthesia codes to


document the condition of the patient upon
receiving the anesthetic
● They are two-character and alphanumeric
PHYSICAL STATUS MODIFIERS, CONT.

● P1 – a normal, healthy patient


● P2 – a patient with mild systemic disease
● P3 – a patient with severe systemic disease
● P4 – a patient with severe systemic disease
that is a constant threat to life
● P5 – a moribund patient who is not expected
to survive without the operation
● P6 – a declared brain-dead patient whose
organs are being removed for donor
purposes
PHYSICAL STATUS MODIFIERS, CONT.

● Example 4
● The patient from our previous angioplasty
example needed to be anesthetized before
going under the knife.
● Besides his kidney problems, he is in sound
health.
● We’d look up the Anesthesia procedure code
○ 00216: anesthesia for “vascular procedures”
● And add the physical status modifier
○ 00216-P1
MODIFIERS APPROVED FOR
AMBULATORY SURGERY CENTER (ASC)
● ASCs are outpatient facilities that perform
surgical procedures where the patient leaves
that same day
● These CPT modifiers are approved for use in
ASCs
○ -25, -27, -50, -52, -58, -59, -73, -74, -76, -77, -78, -79,
and -91
MODIFIERS APPROVED FOR
AMBULATORY SURGERY CENTER (ASC),
CONT.
● -27
○ multiple outpatient hospital E&M encounters on
the same date
● -73
○ discontinuation of an outpatient surgical
procedure before the administration of
anesthesia
● -74
○ Discontinuation of an outpatient surgical
procedure after the administration of anesthesia
HCPCS MODIFIERS

● Are often used with CPT codes


● Are two characters long and alphanumeric
● May contradict or exclude other CPT codes
○ E.g., CPT modifier -50 for a bilateral procedure
and HCPCS modifier –LT for a procedure
performed only on the left side of the body
● We will discuss these in Course 2-12
SUPPLEMENTAL REPORTS

● It’s common practice to send supplemental


reports with certain modifiers

● Payers want as much information as possible


when evaluating claims, and you will often
need to explain why, for example, a
procedure required increased procedural
services (modifier -22)

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