Modifiers are codes that are adopted by the physician to reaffirm to the carrier that the procedure performed was altered or modified due to certain unavoidable circumstances. More than one Modifier may apply to a claim depending on the service rendered. Modifiers can be classified into two categories, they are Pricing Modifiers and Informational Modifiers.
PRICING MODIFIERS
These modifiers indicate that the service was increased or decreased to some extend, then the actual level as in the CPT or HCPCS. Accordingly, the pricing of the service will vary in the presence of these modifiers.
E.g. :- 21, 22, 26, 50,etc.
These modifiers indicate that the service was increased or decreased to some extend, then the actual level as in the CPT or HCPCS. Accordingly, the pricing of the service will vary in the presence of these modifiers.
E.g. :- 21, 22, 26, 50,etc.
These Modifiers provide some additional information on the service rendered but do not affect the pricing of the service. These Modifiers give information like where or when or how the service was rendered and do not talk about the extent or quantity of the service.
E.g. :- RT, LT, GA, etc.
The physician seeing a diabetic patient and he is providing the highest level of E&M service. In this case, the physician meets the patient's family to discuss the treatment plan and future care and he is taking a total time of 55 minutes. But the normal amount of time to be spent for 99205. But he has spent extra 20 minutes providing that E&M service. Hence this E&M service is considered as prolonged E&M service and the modifier 21 would be added to the code 99205.
Correct coding: 99205-21
CPT Modifier 21 is applicable only for the following E&M codes CPT 99205, CPT 99215, CPT 99223, CPT 99233, CPT 99245, CPT 99255, CPT 99263, CPT 99285, CPT 99303, and CPT 99313.
22-Unusual Procedural Service.
22-Unusual Procedural Service.
If a patient is admitted for surgery (ex: Gastrectomy, total, 43620) and the surgery is carried out. During the surgery, the blood loss is very high for this particular patient. Hence prolonged hemostasis (stopping the blood loss) is done. In this case, the service provided is more than normally provided for that particular surgery. Hence time involved in that surgery is greater than the usual time required for that surgery. In this case, modifier 22 is used with this particular surgery code (43620) to denote that this procedure is prolonged due to unusual circumstances.
Correct coding: 43620-22
A child has fallen onto the glass and the glass pieces to be removed from the patient hand. This procedure, it doesn't actually require general anesthesia. But the child is panic, unmanageable, and doesn't cooperate with the surgery, then general anesthesia should be given to carry out that surgery. In this condition, modifier 23 is appended to the anesthesia code.
Correct coding: 01810-23.
24-Unrelated E&M service during the postoperative period by the same physician.
If the patient has undergone surgery (Appendectomy), and now he is in his postoperative period. Now he has developed a common cold and cough. This cold and cough is not related to the condition (Appendicitis) for which the surgery was carried out and E&M service (99212) is provided by the same surgeon for cold and cough during his postoperative visit. In this condition, The E&M service provided is accompanied by modifier 24 to denote that it is an unrelated E&M service during the postoperative period by the same
Physician.
Correct coding: 99212-24.
day of a procedure.
A patient is seen for the re-evaluation of hypertension, and the physician provides E&M service (99214)
for hypertension. But the patient states another problem that he is having hearing trouble. Then the physician examines his ear and finds out there is an extensive amount of earwax. The physician provides a surgical service of removing the earwax. Both the E&M and wax removal has been done on the same day and there is no relation between the earwax removal and the re-evaluation of hypertension. Hence the E&M service provided should be appended with modifier 25 to denote that as a significant, separately identifiable E&M service on the same day of another procedure (wax removal, 69210).
Correct coding: 99214-25, 69210.
A patient is injured in his left knee. The patient is seen by the radiologist for possible fractures in the knee. The radiologist orders two views, an x-ray of the left knee (73560) and he supervises and interprets the radiologic examination. To bill only for the physician component other than the technical component, modifier 26 is appended to the 73560.
26-Professional Component.
A patient is injured in his left knee. The patient is seen by the radiologist for possible fractures in the knee. The radiologist orders two views, an x-ray of the left knee (73560) and he supervises and interprets the radiologic examination. To bill only for the physician component other than the technical component, modifier 26 is appended to the 73560.
Correct coding: 73560-26.
A worker's compensation carrier requested a confirmatory consultation E&M service for a woman who injured on the job three years ago. Her hand has caught up in rotating machinery parts. Recent examinations have not confirmed total loss of hand function, contradicting the patient's subjective complaints. Therefore, the carrier wishes to have the patient evaluated prior to reducing compensation benefits. The patient is scheduled for evaluation by an orthopedic surgeon and he is providing the E&M service (99205). If the surgeon wants to bill for that service, he has to attach modifier 32 since it is mandated by the workers' compensation carrier. Modifier 32 is never to be used for services related to immunizations.
Correct coding: 99205-32
TC-Technical Component
A patient is injured in his left knee. The patient is seen by the radiologist for a possible fracture in the knee. The radiologist orders two views, x-ray of the left knee (73560). To bill only for the technical component other than the professional component, modifier TC is appended to the 73560.
Correct coding: 73560-TC.
If a surgeon is performing a surgery (carpal tunnel release), in which if the surgeon is personally administering the regional or general anesthesia, modifier -47- would be appended to CPT code 64721.
A patient presents with bilateral knee pain. He is seen by the radiologist and the radiologist orders three views bilateral knee exam. In this case, modifier -50- is appended to the CPT code 73562 since 73562 is a unilateral code and the exam is done on both knees
51-Multiple procedures.
A patient presents to the ED department for multiple lacerations after walking into a glass door. He is having lacerations on his forearm and eyelid. The physician performs the repair of the lacerations on the forearm(13120) and eyelid (12051). Since these procedures are done at the same session, modifier -51- is appended to the minor procedure i.e., 12051.
Correct coding: 64721-47
50-Bilateral procedure.
A patient presents with bilateral knee pain. He is seen by the radiologist and the radiologist orders three views bilateral knee exam. In this case, modifier -50- is appended to the CPT code 73562 since 73562 is a unilateral code and the exam is done on both knees
Correct coding: 73562-50
51-Multiple procedures.
A patient presents to the ED department for multiple lacerations after walking into a glass door. He is having lacerations on his forearm and eyelid. The physician performs the repair of the lacerations on the forearm(13120) and eyelid (12051). Since these procedures are done at the same session, modifier -51- is appended to the minor procedure i.e., 12051.
Correct coding: 13120, 12051-51.
A patient presents with foot ulcers due to diabetes. The physician starts the initial assessment, takes a comprehensive history, but before he can complete the E&M service, the patient becomes adamant about leaving the facility and leaves with her family against medical advice. In this case, the service was not completed and it is a reduced service.
Hence modifier -52- is appended to the E&M service (99303).
Correct coding: 99303-52
Correct coding: 99303-52
53-Discontinued services.
A patient presents with a stone in the kidney and he is undergoing surgery (nephrolithotomy). During surgery, his blood pressure was recorded at 140/70 and subsequently dropped to 100/50, which is abnormal, so the physician discontinued the procedure. In this case, modifier-53 would be added to the procedure code 50060 to denote that the procedure was discontinued due to an abnormal decrease in blood
Pressure.
Pressure.
Correct coding: 50060-53
A patient presents for heart valve replacement (33410) and the cardiac surgeon provides only the intraoperative portion of the surgery. In this case, modifier 54 would be added to 33410 to denote that only an intraoperative portion of the surgery was provided by this surgeon.
Correct coding: 33410-54
55-Postoperative management only.
If the postoperative care is provided by a surgeon other than the surgeon who provided the intraoperative care for the heart valve replacement (33410), then this surgeon has to report the same CPT code (33410) with modifier 55 appended to it.
Correct coding: 33410-55.
56-Preoperative management only.
If the patient's primary care physician provides only the preoperative evaluation for the heart valve replacement (33410), then he would report his service using CPT code 33410 by appending modifier 56.
Correct coding: 33410-56
A patient presents with wrist pain after falling at home. The Physicians confirms the fracture of the wrist through an x-ray. He performs the E&M service (99283) to assess the patient and rule out any additional fractures. Following E&M service, He decides to perform the surgery and he performs the surgery for wrist fracture (25530). In this case, modifier 57 would be appended to 99283 since this E&M service resulted in major surgery for the wrist fracture. If the E&M service results in minor surgery (0-10 follow-up days) and if the surgery is done on the same day of the E&M service, modifier 25 would be added to the E&M service.
Correct coding: 99283-57, 25530
A patient is in his postoperative period after surgery (44140) for cancer in the intestine. After this surgery, the patient needs further treatment (chemotherapy-treatment by drugs) within a 90-day follow-up period. Hence a device is fitted (36533) for that treatment (chemotherapy) in the patient's blood vessel. This procedure has been decided at the time of surgery itself. Since this is a staged procedure modifier 58 is appended to 36533.
58-Staged or related procedure or service by the same physician during the postoperative period.
A patient is in his postoperative period after surgery (44140) for cancer in the intestine. After this surgery, the patient needs further treatment (chemotherapy-treatment by drugs) within a 90-day follow-up period. Hence a device is fitted (36533) for that treatment (chemotherapy) in the patient's blood vessel. This procedure has been decided at the time of surgery itself. Since this is a staged procedure modifier 58 is appended to 36533.
Correct coding: 36533-58.
A patient presented for the removal of skin tags (a skin abnormality)(11200) from his back. At the same session, the physician noted two small lesions (not skin tags) on the patient’s neck area. Biopsies (tissue samples)(11100) were taken of each lesion, as each appeared different in its shape and size. In this case, modifier 59 would be appended to 11100 to denote that this is the independent procedure from 11200 since
the anatomic sites and the type of procedures are different from each other.
Correct coding: 11200, 11100-59.
62-Two surgeons.
When insertion of a pacemaker is performed by a surgeon and a cardiologist, both physicians should use 33206 with the addition of a 62 modifier to indicate that co-surgery was performed.
Correct coding: 33206-62.
66-Surgical Team.
If a surgical team involving three surgeons is performing a complex surgery such as 63087(Vertebral
corpectomy), then each physician should report 63087 with modifier 66 appended to it.
Correct coding: 63087-66.
A patient presents with ankle pain due to injury. The radiologist orders an ankle two views exam (73600) and confirms the ankle fracture. An orthopedic surgeon performs the surgery for reducing that fracture. After the surgery is over, again if the radiologist orders (73600) to see if the fracture is aligned correctly or not, then the post-surgical ankle exam must be appended with modifier 76.
Correct coding: 73600, 73600-76.
77- Repeat procedure by another physician.
A smoker presents with chronic cough and sputum production. The physician orders a chest x-ray (71020) for evaluation of the lung. The x-ray is positive for suspicious mass in the lung which highly concerning for cancer. Hence this physician sends this patient to a pulmonologist on the same day and the pulmonologist again orders the same chest x-ray (71020). Since this is a repeat procedure by another physician on the same day,
modifier 77 would be added to the second procedure.
Correct coding: 71020, 71020-77
A patient has undergone a bypass surgery (33510). During that evening, the patient is observed that he is bleeding at the site where the surgery occurred. Hence the patient was returned to the operating room to rectify the bleeding at the surgical site (35820). Since, Controlling of bleeding at the surgical site is related to the bypass surgery, modifier 78 is appended to 35820.
Correct coding: 33510, 35820-78
79-Unrelated procedure or service by the same physician during the postoperative
period.
A patient has undergone total knee replacement (27447), which has 90 day follow up period. Within this 90- day follow up period, he is treated for a fracture in the wrist (25620). The wrist fracture is not related to the total knee replacement surgery. Hence, the wrist fracture reduction 25620 is appended with modifier 79 to denote this as an unrelated procedure during his postoperative period.
Correct coding: 27447, 25680-79
A patient is presenting for bypass surgery and during this surgery, an assistant surgeon takes part in the entire surgery, then the primary physician has to submit the CPT code 33510 and the assistant surgeon has to report his services using the same CPT code 33510 with modifier 80 appended to that.
Correct coding: 33510, 33510-80
81-Minimum Assistant Surgeon
A patient presents for heart valve replacement (33410) and the physician planned to perform this surgery alone, but during operation, circumstances may arise that require the services of an assistant surgeon for a relatively short time. Since the assistant surgeon is not present throughout the surgery and he provided minimal assistance, modifier 81 would be added to his part of the service.
Correct coding: 33410, 33410-81
82-Assistant surgeon when a qualified resident is not available.
A neurosurgeon, who is a teaching physician in a teaching facility, has a new patient with multiple brain tumors that are life-threatening. The physician elects to perform the surgery in an attempt to save the patient's life. Since the operation is one that requires an assistant at surgery and the neurosurgeon realizes that no resident is qualified to assist him with this type of surgery, another neurosurgeon is called to assist. In this case, the assistant surgeon would append modifier 82 with the surgery code when he bills for his service
90-Reference outside the laboratory.
A patient presents for his routine examination, and his physician orders a blood test. The physician has contracted with a laboratory to perform the testing, as he has found that performing his own laboratory tests is not cost-effective. The medical assistant draws the blood and sends it to the outside laboratory. In this case, the test was done by an outside laboratory (i.e. 85025-90), the physician will bill the patient for the service, and the laboratory in turn will bill the physician.
Correct coding: 85025-90
91-Repeat clinical diagnostic laboratory test
A patient presents with diabetes and he undergoes a glucometer test (82962) in the physicians’ office. The results of this test reveal an extraordinary blood sugar confirms the suspicion of uncontrolled diabetes. Hence, he again undergoes the glucometer after ingestion of 1000 mg Glucophage in the office and he is observed for some time. The repeat test revealed that there is a decline in blood sugar. In this case, a repeat laboratory test was performed. Hence the second test would be added with modifier 91.
Correct coding: 82962, 82962-91
A patient presents for heart valve replacement (33410) and the physician planned to perform this surgery alone, but during operation, circumstances may arise that require the services of an assistant surgeon for a relatively short time. Since the assistant surgeon is not present throughout the surgery and he provided minimal assistance, modifier 81 would be added to his part of the service.
Correct coding: 33410, 33410-81
82-Assistant surgeon when a qualified resident is not available.
A neurosurgeon, who is a teaching physician in a teaching facility, has a new patient with multiple brain tumors that are life-threatening. The physician elects to perform the surgery in an attempt to save the patient's life. Since the operation is one that requires an assistant at surgery and the neurosurgeon realizes that no resident is qualified to assist him with this type of surgery, another neurosurgeon is called to assist. In this case, the assistant surgeon would append modifier 82 with the surgery code when he bills for his service
90-Reference outside the laboratory.
A patient presents for his routine examination, and his physician orders a blood test. The physician has contracted with a laboratory to perform the testing, as he has found that performing his own laboratory tests is not cost-effective. The medical assistant draws the blood and sends it to the outside laboratory. In this case, the test was done by an outside laboratory (i.e. 85025-90), the physician will bill the patient for the service, and the laboratory in turn will bill the physician.
Correct coding: 85025-90
91-Repeat clinical diagnostic laboratory test
A patient presents with diabetes and he undergoes a glucometer test (82962) in the physicians’ office. The results of this test reveal an extraordinary blood sugar confirms the suspicion of uncontrolled diabetes. Hence, he again undergoes the glucometer after ingestion of 1000 mg Glucophage in the office and he is observed for some time. The repeat test revealed that there is a decline in blood sugar. In this case, a repeat laboratory test was performed. Hence the second test would be added with modifier 91.
Correct coding: 82962, 82962-91
Other Modifiers are:-
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 an operation.
P6 - A declared brain-dead patient whose organs are being removed for donor purposes.
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 an operation.
P6 - A declared brain-dead patient whose organs are being removed for donor purposes.
LT - Left side (used to identify procedures performed on the left side of the body)
RT - Right side (used to identify procedures performed on the right side of the body)
E1 - Upper left, Eyelid
E2 - Lower left, Eyelid
E3 - Upper right, Eyelid
E4 - Lower right, Eyelid
FA - Left hand, Thumb
TA - Left foot, Great toe
F1 - Left hand, Second digit
T1 - Left foot, Second digit
F2 - Left hand, Third digit
T2 - Left foot, Third digit
F3 - Left hand, Fourth digit
T3 - Left foot, Fourth digit
F4 - Left hand, Fifth digit
T4 - Left foot, Fifth digit
F5 - Right hand, Thumb
T5 - Right foot, Great toe
F6 - Right hand, Second digit
T6 - Right foot, Second digit
F7 - Right hand, Third digit
T7 - Right foot, Third digit
F8 - Right hand, Fourth digit
T8 - Right foot, Fourth digit
F9 - Right hand, Fifth digit
T9 - Right foot, Fifth digit
E2 - Lower left, Eyelid
E3 - Upper right, Eyelid
E4 - Lower right, Eyelid
FA - Left hand, Thumb
TA - Left foot, Great toe
F1 - Left hand, Second digit
T1 - Left foot, Second digit
F2 - Left hand, Third digit
T2 - Left foot, Third digit
F3 - Left hand, Fourth digit
T3 - Left foot, Fourth digit
F4 - Left hand, Fifth digit
T4 - Left foot, Fifth digit
F5 - Right hand, Thumb
T5 - Right foot, Great toe
F6 - Right hand, Second digit
T6 - Right foot, Second digit
F7 - Right hand, Third digit
T7 - Right foot, Third digit
F8 - Right hand, Fourth digit
T8 - Right foot, Fourth digit
F9 - Right hand, Fifth digit
T9 - Right foot, Fifth digit
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