Modifiers are codes that provide additional information about a procedure. They are added to CPT or HCPCS codes to communicate certain circumstances regarding the performance of a procedure or service. Appending the correct modifier to provide more specificity to payers about the service or procedure rendered will facilitate appropriate reimbursement. Likewise, an incorrectly used a medical billing modifier on a claim will lead to denials. Experienced providers of medical billing and medical coding services can help practices file clean claims by assigning the correct codes and modifiers to support the services rendered.
Types of Medical Coding Modifiers
As we know, CPT codes are five-digit numbers and primarily used in office and outpatient settings to report medical procedures and services in claims submitted to insurance companies. These codes are assigned based on the physician’s documentation in the medical record. Modifiers provide a way to convey specific circumstances related to the performance of a procedure or service.
The two broad types of modifiers used in medical billing are:
- Level I Modifiers – Level I CPT modifiers consist of two digits and are maintained by the American Medical Association (AMA).
- Level II Modifiers – Level II modifiers or HCPCS modifiers are alphanumeric or have two letters and maintained by the Centre for Medicare & Medicaid Services (CMS)
Specifically, a modifier provides the mechanism to:
- Report or indicate that a service or procedure has been performed and altered by some specific circumstance without changing the meaning of the CPT code.
- Provide additional information about the service that has been performed more than one time or services that have occurred unusually.
- Provide details not included in the code descriptor
- To report codes in connection with specific payer programs
CPT lists additional situations when a modifier may be appropriate:
- The service or procedure has both professional and technical components
- More than one provider performed the service or procedure
- More than one location was involved
- A service or procedure was increased or reduced in comparison to what the code typically requires
- The procedure was bilateral
- The service or procedure was provided to the patient more than once
Commonly Used CPT Code Modifiers
- CPT Modifier 22Increased Procedural Service – This modifier describes an increased workload associated with a procedure. Modifier 22 is used in unusual circumstances such as surgeries that took significantly more time than usually required to complete, which includes increased intensity, time, technical difficulty of procedure, severity of patient’s condition (such as unusual or excessive bleeding during a procedure).
- CPT Modifier 25 Significant, Separately Identifiable Service – Modifier 25 is applied when there is a significant, separately identifiable evaluation and management (E/M) service done by the same physician or other qualified health care professional on the same day of the procedure or other service. It is used to report surgical procedures, labs, X-rays, and supply codes that are documented as a separately identified E&M service performed on the same day as another procedure. If the patient presents to the office and a procedure was not anticipated, modifier 25 can be reported with the E&M service.
- Modifier 26 Professional Service – Modifier 26 indicates the professional component when a service has both professional & technical components. For e.g., in radiology services, the physician’s note on the scans is considered as the professional component while the machinery used is counted as a technical component. The professional component may include technician supervision, interpretation of results, and a written report. Append modifier 26 for the following:
- To bill only the professional component portion of a test when the provider utilizes equipment owned by a hospital/facility.
- To report the physician’s interpretation of a test, which is separate, distinct, written, and signed.
- Modifier 50 Bilateral Procedure – Modifier 50 indicates that bilateral procedures were performed in the same session. For e.g., when billing for a bilateral mastectomy, CPT code 19303 (Mastectomy, simple, complete) would be reported with this modifier. Before applying this modifier, it is important to check the CPT code definition to confirm that bilateral is not included in its descriptor.
- Modifier 51 Multiple Procedures-Modifier 51 is used to denote multiple procedures (other than E/M services) performed by the same physician during the same session. Modifier 59 is used to indicate:
- Additional or different procedures performed at same session
- Same procedure performed multiple times at same site
- Same procedure performed multiple times at different sites
The primary procedure may be reported first without the modifier. Additional procedure(s) may be identified by attaching modifier 51 to the code(s).
- Modifier 52 Reduced Services – Modifier 52 indicates that the physician has elected to partially reduce or eliminate the service or procedure. The basic service described by the CPT code has been performed, but not all aspects of the service have been completed. When a physician performs a bilateral procedure on one side only, append modifier -52. For e.g., if a physician performs a unilateral tonsillectomy on a six-year old child, report CPT code 42820) and append modifier 52.However, if the CPT code description includes “unilateral or bilateral,” (e.g. unilateral nasal endoscopy CPT code 31231) do not append modifier 52.
- Modifier 59 Distinct Procedural Service – This modifier indicates that a procedure is separate and distinct from another procedure on the same date of service. It identifies procedures or services that are not usually reported together. Indications for the use of modifier 59 are:
- Different session or encounter on the same date of service
- Different procedure distinct from the first procedure
- Different anatomic site
- Separate incision, excision, injury or body part
Both modifier 52 and 59 should not be applied to an E/M service.
- Modifier 76 – Modifier 76 is used to report repeat procedure performed on the same day by the same physician and is also consequent to the original procedure. For instance, CPT code 94640 signifies treatment of acute airway obstruction with inhaled medication and/or the use of an inhalation treatment to induce sputum for diagnostic purposes. If more than one inhalation treatment is performed on the same date of service, code 94640 should be reported by appending modifier 76.
Ensure Accurate Medical Billing and Coding with Professional Support
The AMA publishes CPT coding guidelines each year on coding specific procedures and services. Proper use of modifiers is crucial for accurate coding and also because many modifiers impact providers’ reimbursement. Not using a modifier or using the wrong modifier can result in claim denials and lead to rework, payment delays, and potential reimbursement loss. Incorrect use of a modifier can also result in excess of the amount payable for a service rendered or receiving payment when payment is not due, which if not reported by the practice, can lead to heavy fines and penalties.
Getting professional support can go a long way in ensuring that the billing and coding cycle runs smoothly. Top medical billing companies have expert coders who are knowledgeable about CPT codes and modifiers and can help physicians report their services with the utmost specificity. They will ensure that modifier codes are reported only when they are relevant and supported by specific documentation in the patient’s medical record.
Rajeev Rajagopal, the President of OSI, has a wealth of experience as a healthcare business consultant in the United States. He has a keen understanding of current medical billing and coding standards.