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 appropriate
The 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 appropriate
The 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 Modifier-52 Modifier-53
matrix
Anesthesia(if applicable) Procedure stopped prior Procedure stopped after
to anesthesia administered anesthesia
Procedure stopped Elective by patient or Physician terminates due
physician 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.
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