CPT code modifiers can be two digit numbers, two character modifiers, or alpha-numeric indicators. Modifiers are a tool to provide more detail to the performance of a medical procedure or service. By using modifiers correctly and communicating specific information to the insurance carriers, medical coding companies ensure that physicians get paid appropriately for services rendered.
CPT modifiers are placed at the end of a CPT code with a hyphen and may indicate the following:
- Whether a service or procedure has a professional component or a technical component
- If multiple procedures were performed or only part of a service was performed
- Why a procedure was necessary
- The location on the body where the procedure was performed
- Whether the service or procedure was performed by more than one physician
- Whether a service or procedure was provided more than once
- Unusual events occurred
- An add-on or additional service was performed
- Other information that may be vital to a claim’s specific reimbursement status
Correct Use of Modifiers – Points to Note
- Modifiers are used to provide additional information about complex medical procedures. When a procedure is complex, a simple CPT code is not enough. A modifier should be used to inform the payer that a CPT-defined service or procedure was altered in some manner and can no longer be described by the billing code.
- While up to 4 modifiers may be stated on a claim, payers only look at the first two, that is, the primary and secondary modifiers. Therefore the best practice is to code the important “functional” modifier first and the “informational” modifier second.
- There are specific rules and guidelines for the use of modifiers. The documentation within the medical record to support the use of each modifier should be clear.
- While some modifiers can be used only with Evaluation and Management (E&M) codes, there are several modifiers that are not compatible with E&M codes.
- Repeated misuse of modifiers will attract scrutiny and trigger audits.
Commonly Used CPT and HCPCS Modifiers
- 22 Unusual procedural services
- 23 Unusual anesthesia
- 24 Unrelated evaluation and management service by the same physician during a postoperative period
- 25 Significant, separately identifiable E&M service by the same physician on the same day of the procedure or service
- 26 Professional component
- 27 Multiple outpatient hospital E&M encounters on the same date
- 32 Mandated services
- 47 Anesthesia by surgeons
- 50 Bilateral procedure
- 51 Multiple procedures Indicates that multiple procedures (other than E/M services)
- 52 Reduced services
- 53 Discontinued procedure
- 54 Surgical care only
- 57 Decision for Surgery – Indicates an E/M service that resulted in the initial decision to perform a surgery
- 58 Staged or related procedure or service by the same physician during the postoperative period
- 59 Distinct Procedural Service – Indicates that a non-E/M procedure or service was distinct or independent from other non-E/M services performed on the same day:
- XE-Separate Encounter
- XP-Separate Practitioner
- XS-Separate Organ/Structure
- XU-Unusual Non-overlapping Service
- 76 Repeat procedure or service by same physician or other qualified healthcare professional
- 77 Repeat procedure by another physician or other qualified healthcare professional
- 95 Synchronous telemedicine service rendered via real-time interactive audio and video telecommunications system
Modifiers for Anesthesia Claims
- AA Anesthesia services performed personally by anesthesiologist
- AD Medical supervision by a physician; more than four concurrent anesthesia procedures
- GC Services performed in part by a resident under the direction of a teaching physician; services are not reimbursable to a resident
- QZ CRNA service: without medical direction by a physician
- QY Medical direction of one certified registered nurse Anesthetist by an anesthesiologist
- QK Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals
- QX CRNA service: with medical direction by a physician
- QS Monitored anesthesia care (MAC) provided by an anesthesiologist
- P1-P6 Anesthesia Physical Status Modifiers
Anatomical Modifiers: Anatomical modifiers indicate the area or part of the body on which the procedure is performed on different sites during the same session. Examples:
- E1-E4 Eyelids
- FA-F9 Fingers
- TA-T9 Toes
- RT Right
- LT Left
- LC Left circumflex, coronary artery
- LD Left anterior descending coronary artery
- LM Left main coronary artery
- RI Ramus intermedius
- RC Right coronary artery
Other types of modifiers include: DME Modifiers, Early Intervention Modifiers, Ambulance Modifiers, Modifiers used in Ambulatory Surgery Centers (ASCs), Physical and Occupational Therapy Modifiers, and Miscellaneous Modifiers.
Examples of Modifier Use and Issues Involved
Here are some examples provided by the American Academy of Professional Coders on the use of modifiers:
- Patient had blepharoplasty done on the right and left upper eyelid during the same operative episode. The procedure should be reported as two separate items – one with E1 modifier (Upper left, eyelid) and the other with E3 modifier (Upper right, eyelid). Reimbursement would face multiple procedure reduction rules. Failure to use a modifier could result in a denial of the second procedure as can appear to be a duplicate.
- Patient had a lumpectomy and after pathology, it was determined that mastectomy is required to be performed. Mastectomy is more extensive and related to the initial surgery. In this case, use of Modifier 58, Staged or related procedure in the post-op period by the same physician, identifies that it is staged/related in the post-op period.
According to an article in RAC Monitor, modifiers 22, 24, 25, and 59 are those that come in for the most claim scrutiny. Proper documentation is critical to addressing the concerns with these modifiers. For example, take Modifier –22, Increased procedural service.
According to the CPT descriptor, when the service provided exceeds the normal ranges of complexity, length, risk, and difficulty (more complicated, complex, difficult, or requiring significantly more time than usual), modifier 22 should be added to the procedure code. Valid reasons to support the use of modifier 22 include excess BMI of the patient or copious scar tissue or co-morbidities that cause complications during the surgery, all of which lead to extra work. When this modifier is used, the medical record will be scrutinized for documentation of the “extra” work or service involved. In this case, simply indicating that the patient had a BMI of 62 or that the patient had copious scar tissue is not sufficient. The surgeon should ensure that documentation within the operative report reflects the unusual circumstances of the procedure.
CPT code modifiers impact both reimbursement and work relative value unit productivity. Without modifiers, many procedures will not be properly reimbursed and will leave revenue on the table. On the other hand, inappropriate use of modifiers will attract increased scrutiny by insurers and regulators. Outsourcing medical billing and coding to an experienced service provider could avoid such issues.