PRESENTED BY BARBARA PARKER, CMA, CPCSLIDES PREPARED BY LORI DAFOE, CPC

CODING WITH MODIFIERS

MODIFIER OBJECTIVES

At the conclusion of this session, you should be able to:

• Explain what CPT modifiers are and their importance to receiving correct reimbursement

• Identify when and how to use CPT modifiers.

MODIFIERS

• In today’s regulatory environment, it can be a real challenge to obtain reimbursement for procedures and services rendered

• Accurate coding is the most crucial step in the reimbursement process

MASTERING MODIFIERS

• Coders need to use all the “tools” at their disposal to facilitate the reimbursement process

• Modifiers are overlooked tools

WHAT IS A MODIFIER?

• A Modifier provides the means by which the rendering physician may indicate that a service or procedure has been performed, or has been altered by some specific circumstances, but not changed in its definition of code

• They are essential ingredients to effective communication between providers and payors

WHAT IS A MODIFIER?

• Just as “modifiers” in the English language provide additional information, CPT modifiers also answer questions such as:

• which one• how many• what kind• when • what

WHAT IS A MODIFIER?

•Modifiers are essential tools in the coding process• They are used to enhance a code narrative to describe1.) the circumstances of each procedure or service2.) how it individually applies to the patient

PRIMARY FUNCTIONS

• Show that a service has been modified but not changed in its identification or definition• Explain special circumstances or conditions of

patient care• Indicate repeat or multiple procedures• Method to show cause for higher or lower costs

while protecting charge history data

MODIFIERS

• A complete listing of CPT modifier is found in Appendix A of CPT

• Two or more modifiers may be used with one code to give the most accurate description possible for the service rendered

MODIFIERS

• Not all modifiers can be used in every section of CPT

• Consult with carriers regarding the use of two-digit modifier

STEP BY STEP GUIDANCE

• Review CPT (AMA) Guidelines• Review individual carrier guidelines• Reference the practitioner’s or facilities patient

medial record and/or visit note prior to appending modifiers• Use only 2 digits when appending modifiers

(unless instructed otherwise by an individual carrier)

STEP BY STEP GUIDANCE

• Provide training for physicians, staff, clinicians, etc. and update training regularly• Take a proactive approach and find the errors in

modifier application before the claim is submitted to the insurance carrier• Understand that the insurance carrier

interpretations are not always the same as CMS or CPT• Review the National Correct Coding Initiative

(NCCI) each quarter for correct usage for each CPT code that your organization uses

MODIFIER TIPS

• Always have the most recent edition of the CPT book on hand• Have your billing staff regularly attend coding

workshops• Remember that modifiers are often used

differently for physician services and hospital outpatient services• Learn as much as you can about using coding

modifiers so you can help your billing staff with coding questions

MODIFIER 21 – PROLONGED EVALUATION AND MANAGEMENT (E/M) SERVICE

• Only use with E&M codes.• Use when the service exceeds the highest level

within a given category• Recommend sending a written report to the

carrier

MODIFIER 22 – UNUSUAL PROCEDURAL SERVICES

• Do not use this modifier on E&M codes• Use this modifier when the service provided is

greater than that described by the procedure code• Specific examples of unusual circumstances include:• Increased risk• Severe respiratory distress• Excessive bleeding (more than 500 cc)• Friable tissue

APPROPRIATE USE OF MODIFIER -22

• Extensive trauma that requires additional work

• Significant scaring requiring extra time and work

• Extra work due to morbid obesity

• Increased time due to extra work by the physician

INVALID USE

• Modifier 22 is not valid when there is also a “re-operation” code used with the primary code. • Modifier 22 is not valid if the purpose of the

complication is based on the surgeon’s choice of approach (e.g., open vs. laparoscopic)• Modifier 22 is not valid to describe an average

amount of lysis or division of adhesions between organs and adjacent structures.

CONSIDERATIONS FOR MODIFIER 22

• The additional time and work must be significant.• The surgeon’s documentation should be

thorough!• The documentation should be submitted with the

claim. • Any additional fees should be charged up front to

payers, which are unlikely to raise fees on their own just because modifier 22 is appended.

MODIFIER 24 – UNRELATED E/M SERVICE BY THE SAME PHYSICIAN DURING A

POSTOPERATIVE PERIOD• Only use with E&M codes.• To use this modifier, the E&M service must be unrelated to

the surgery, but provided within the global care postoperative period.

• Use when patient care is by the same physician for surgery.• Medicare Carrier Manual (MCM 4822 and 4824) indicate

that an evaluation and management service(s) submitted with modifier 24 must be sufficiently documented to establish that the visit was unrelated to the surgery.

• In order for critical care services (CPT 99291 and/or 9292) to be paid for services furnished during the preoperative or postoperative period, with modifier -24, the documentation submitted must support that the critical care was unrelated to the specific anatomic injury or general surgical procedure performed.

MODIFIER 25 – SIGNIFICANT SEPARATELY IDENTIFIABLE E/M SERVICE BY THE SAME PHYSICIAN ON THE SAME

DAY OF THE PROCEDURE OR OTHER SERVICE

• Only use with E&M codes.• Patient care is by the same physician for

procedure and E&M service• Documentation should indicate that the patient’s

condition required a significant separately identifiable E&M service on the day a procedure or service identified by a CPT code was performed above and beyond the other service provided• This modifier is not used to report E&M service

that resulted in a decision to perform major surgery

MODIFIER 25: CMS POLICY

• Modifier 25 should be used only when a significant, separately identifiable E&M visit is rendered on the same day as a minor surgical procedure. Payment for preoperative and postoperative visits is included in the payment for the procedure. For minor procedures, where the decision to perform the minor procedure is typically made immediately before the service (e.g., whether sutures are needed to close a wound, whether to remove a mole or wart, etc.), the E/M visit is considered to be a routine preoperative service and should not be billed in addition to the minor procedure.• The policy applies only to minor surgeries and endoscopies

for which a global period of 0-10 day applies.

MODIFIER 25: CMS POLICY GUIDANCE

• If the patient’s clinical record documents that extra pre-op and/or post-op work beyond what is usually performed with the service was performed, then it is proper to use the 25 modifier to indicate that extra work.• The clinical record should clearly document the

extra or unusual work performed.• The provider should determine if the E&M service

for which he/she is billing is distinct from the procedure.

MODIFIER 25?

• Medicare patient presents with complaints of left knee pain. The physician evaluated the knee and determines the patient would benefit from arthrocentesis. The patient declines the injection at this time, but calls back two days complaining of continued pain.• At the follow-up visit, the physician performs a

cursory exam of the knee and proceeds to perform the large joint injection that was recommended at the previous visit.• 25 or not?

NOT!

• In this example, it would not be appropriate to bill the E&M service.

• Correct coding: CPT 20610 – Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, knee joint, subacromial bursa)

MODIFIER 25?

• An established Medicare patient visited her internist for a follow up for hypertension and diabetes. The patient also complains of several skin tags along her bra area that are painful, itching, and bleeding due to the location. The physician performs a problem-focused history and examination, evaluates the patient’s hypertension, and determines the blood pressure is higher than it should be and adjusts medications. The patient’s blood sugar is doing well and the diabetes is well controlled with the current insulin regimen. During the encounter, the physician also evaluates the 6 skin tags and determines the patient would benefit from removal. This is performed in the office suite.

• 25 or not?

YES!

• Correct coding: CPT 99212-25 – Office visit for an established patient level two, and CPT 11200 – Removal of skin tags, any area; up to and including 15 lesions.

MODIFIER 26 – PROFESSIONAL COMPONENT

• Some procedures can be divided into a professional only component (performed by a physician) and a technical only component (technician’s portion). Modifier -26 is used to describe the portion of the service that is performed by a physician.

• The technical component includes:providing the equipmentsuppliestechnical personnelcosts attendant to the performance of the procedure, other

than the professional services• The professional component includes:

the physician’s work in providing the services (e.g., reading films, interpreting diagnostic tests, etc)

interpretation and written report provided by the physician performing the service

MODIFIER 26 – PROFESSIONAL COMPONENT

• Some CPT codes are indicated to be the professional component only, or the technical component only. No modifiers would be appended to these codes.

• A facility performs a 12 lead ELG and has an independent physician read the strip93005 Tracing only (facility)93010 Interpretation and report only (physician)

MODIFIER 26: EXAMPLE

• If the physician owns the x-ray machine, buys the supplies, and pays the personnel in addition to reading the x-ray, the modifier -26 would not be used.

• A physician has x-ray equipment in his office and performs a PA and lateral chest x-ray. The physician also reviews the x-ray and dictates a report.

• Correct Coding: CPT 71020

MODIFIER 32: MANDATED SERVICES

• Many third party payors and professional review organizations require an independent evaluation of a patient prior to procedures being performed. This modifier describes the visit required by the payor or review organization.• This modifier is not for a consultation with

another physician for patient comfort or reassurance.• This modifier is also not used when another

physician evaluates a patient for medical clearance prior to a procedure.

MODIFIER 47: ANESTHESIA BY SURGEON

• This modifier is to be used when the surgeon performs and administers regional or general anesthesia in addition to the surgical procedure.• Do not use this modifier for local anesthesia.• Do not use this modifier with anesthesia

procedures 00100-01999.• Do not use this modifier if the surgeon is

monitoring general anesthesia performed by an anesthesiologist, CRNA, resident or intern.

MODIFIER 50: BILATERAL PROCEDURES

• Most of the bilateral procedures listed in the Surgery section have been deleted.• This modifier is to be used when surgeries are

performed bilaterally during the same operative session.• Some carriers prefer a “two code listing”, (i.e.

64721, 64721-50). Others prefer it listed on one line, while others want –LT & -RT. • The bilateral surgery may be performed

Through the same incisionSeparate body parts

MODIFIER 51: MULTIPLE PROCEDURES

• This modifier is used to identify the secondary procedure or when multiple procedures are performed on the same date or during the same operative session by the same physician.• The procedures may be in the same operative

incision or at a different anatomical site.• Always list the major procedure (highest dollar

value) first and append the modifier to the subsequent procedures.

MODIFIER 51: MULTIPLE PROCEDURES

• Some of the listed procedures in CPT are commonly carried out in “addition to” the primary procedure performed.• All add-on codes found in CPT are exempt from

the multiple procedure concept.

MODIFIER 52: REDUCED SERVICES

• Used to identify when a service or procedure is less extensive than the description given in CPT would indicate it to be.

• To develop a reduced fee, try calculating the reduced service by time.

• Calculate the amount (cost) per minute of the complete procedure; times the amount per minute by the time it took to do the reduces procedure.

• Many carriers reduce the amount automatically, so the preferred method is to bill the carrier the full amount and let the insurance carrier determine the value of the service.

MODIFIER 53: DISCONTINUED PROCEDURE

• This modifier describes procedures that have been discontinued due to extenuating circumstances.

• Usually the patient’s well-being is threatened, thereby precipitating the physician’s decision to terminate the procedure.

• This modifier should not be used if a surgical procedure is canceled prior to t the patient’s anesthesia induction and /or surgical preparation in the operating room.

MODIFIERS 54, 55, 56 CPT GLOBAL SURGICAL PACKAGE

MODIFIER 54: SURGICAL CARE ONLY

• Used when the surgeon provides the surgical care only without pre- or postoperative services.• Fees and reimbursement should be reduced to represent the surgical portion of the global service.

MODIFIER 56: PREOPERATIVE MANAGEMENT ONLY

• To be used when the physician provides only the preoperative care.• May be used when the physician prepares the

patient for surgery performed by another physician.• Fees and reimbursement should be adjusted accordingly.

MODIFIER 55: POSTOPERATIVE MANAGEMENT ONLY

• Used when the physician provides only the follow-up care during the global period.• Surgery was performed by a different physician• The physician providing the follow- up care does not perform, nor assist with the surgical procedure.• Fees and reimbursement should be reduced to represent “postop- erative” management only.

GLOBAL SPLIT

MODIFIER 57: DECISION FOR SURGERY

• This modifier is appended to the appropriate E&M service to denote the visit where the decision to perform major surgery (90 global days) was made.• Modifier is used when the decision for major

surgery is made the day of or the day prior to performing the procedure.• Assists in recouping payment for this visit

because many payors will reimburse the visit where surgery is decided, but will not pay for other preoperative visits.

MODIFIER 57: DECISION FOR SURGERY

• Modifier indicates to the payor that additional time and effort was necessary and all necessary counseling, including risks and outcomes were discussed with the patient.• There is no increase in fee for use of this modifer.

MODIFIER 58: STAGED OR RELATED

• Physician may need to indicate that the performance of a procedure or service during a post-operative period was:Planned prospectively at the same time as the original

procedure (staged)More extensive than the original procedureFor therapy following a diagnostic surgical procedure

MODIFIER 59: DISTINCT PROCEDURAL SERVICE

• Under certain conditions the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day:A different session or patient encounterDifferent procedure or surgeryDifferent site or organ systemSeparate incision/excisionSeparate lesionSeparate injury (or area of injury in extensive injuries)

not ordinarily encountered or performed on the same day by the same physician

CCI GUIDANCE

• The 59 modifier is often misused. The two codes in a code pair edit often by definition represent different procedures. The provider cannot use the 59 modifier for such an edit based on the two codes being different procedures.

• However, if the two procedures are performed at separate sites or at separate patient encounters on the same date of service, the 59 modifier may be appended.

• The 59 modifier cannot be used with E&M services (CPT codes 99201-99499) or radiation treatment management code 77427).

MODIFIER 62: TWO SURGEONS

• Used when skill of two surgeons (usually of different skills) may be required in the management of a specific surgical procedure.• Surgeon each performs a separate portion of one

procedure.• Each physician would bill same CPT code with 62

modifier.• If a co-surgeon acts as an assistant in the

performance of 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, as appropriate.

MODIFIER 63: PROCEDURES PERFORMED ON INFANTS LESS THAN

4KG• Procedures performed on neonates and infants up

to a present body weight of 4 kg may involve significantly increased complexity and physician work commonly associated with these patients.

• This circumstance may be reported by adding the modifier 63 to the procedure number.

• Unless otherwise designated, this modifier may only be appended to procedures/services listed in the 20000-69999 series. Modifier 63 should not be appended to any CPT codes listed in the Evaluation and Management Services, Anesthesia, Radiology, Pathology/Laboratory, or Medicine Sections.

MODIFIER 63: PROCEDURES PERFORMED ON INFANTS LESS THAN

4KG• Modifier 63 is appended only to invasive surgical

procedures and reported only for neonates/infants up to a present body weight of 4kg, cut off. With this group of neonates/infants, there is a significant increase in work intensity specifically related to temperature control, obtaining IV access (which may be required upward of 45 minutes), and the operation itself, which is technically more difficult with regard to maintenance of homeostasis.

MODIFIER 66: SURGICAL TEAM

• More than two surgeons.• Used for highly complex or intricate procedures,

which require multiple concomitantly operating physicians.• Usually of different specialties.• May require assistance of specially trained

ancillary personnel or specialized equipment.• Approved procedures for modifier 66 include

most of your transplant codes (heart, lung, kidneys, including live donor procedures)

MODIFIER 76: REPEAT PROCEDURE BY SAME PHYSICIAN

• Modifier 76 is used when a physician repeats a procedure on the same day.• May be used for multiple diagnostic testing

performed on the same day.• Modifier assists in prevention of denials or

duplicate claims messages from carriers.• Modifier used for radiology, lab, and minor

surgical procedures (repeat blood sugars).

CMS EXAMPLES OF REPEAT PROCEDURES:

• Follow up x-rays after chest tube placement, central venous line placement, s/p setting of fracture.• Repeat electrocardiograms for evaluation or

treatment of arrhythmia or ischemia• Repeat coronary angiogram or coronary artery

bypass following abrupt closure of previously treated vessel.

MODIFIER 77: REPEAT PROCEDURE BY DIFFERENT PHYSICIAN

• Identical to modifier 76 except the repeat procedure is performed by another physician.• Used when physician repeats a procedure that

another physician performed on the same day.• Multiple diagnostic testing performed on same

day by more than one physician.

MODIFIER 78: RETURN TO THE OR FOR RELATED PROCEDURE DURING POST-OP

PERIOD

• Indicates second operative session is used and occurs during the postoperative period.Second procedure is related to the first procedure usually

due to complication or other problems related to initial surgery

MODIFIER 79: UNRELATED PROCEDURE OR SERVICE BY SAME PHYSICIAN DURING THE

POSTOP PERIOD

• Used to report unrelated procedure performed during postoperative period that is unrelated and not a result of the first surgery.Second surgery should be submitted with 79 modifier to

explain surgery/procedure.Carrier may deny service without 79 modifier.

ASSISTANT SURGEON MODIFIERS

Modifier Definition

80 Assistant Surgeon

81 Minimum Assistant Surgeon

82 Assistant Surgeon (when qualified resident surgeon is not available)

AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistance at surgery

MODIFIER 80: ASSISTANT SURGEON

• Modifier 80 attached to surgical procedures when:Surgical procedures are performed by an assistant at

surgery.Assistant is usually paid a small portion of the surgical

fee by the carrier.Generally private payors pay 20-25% of the surgical fee

to the assistant.

(not allowed when two surgeons or team surgeons are indicated)

An assistant at surgery serves as an additional pair of hands for the operating surgeon.

MPFSDB INDICATOR TABLE FOR ASSISTANT SURGERY

Indicator

Definition

0 Assistant surgeon may be paid with documentation. Use 80 modifier.

1 Assistant surgeon cannot be paid.

2 Assistant surgeon can be paid. Use 80 modifier.

9 Assistant surgeon concept does not apply.

MODIFIER 81: MINIMAL ASSISTANT SURGEON

• Used when the assisting surgeon participated only for a portion of the procedure.Can be used when a second or third assistant surgeon is

required during a procedure.Medicare, Medicaid and commercial payors have lists of

procedures codes that they do not allow minimal assistant surgeons.

CMS rarely recognizes modifier 81 except in extreme cases, and does not appear on the Medicare Physician Fees Schedule Date Base (MPFSDB).

When modifier 81 is used with a procedure code that has a maximum allowable payment, the payment for the procedure shall be no more than 13% of the maximum allowable listed or the billed charge, whichever is less.

MODIFIER 82: ASSISTANT SURGEON WHEN QUALIFIED RESIDENT NOT

AVAILABLE• Modifier -82 used in teaching facility when a

qualified resident or fellow is not available to assist.• Use this modifier:

In a teaching facility.When an appropriate training program for the medical

specialty is not available.The unavailability of a qualified resident surgeon is a

prerequisite for use of modifier 82 appended to the usual procedure code number(s)

EXCEPTIONAL CIRCUMSTANCES

• Payment is made for the services of assistants at surgery in teaching hospitals despite the availability of a qualified resident to furnish the services in the following circumstances:In emergency or life-threatening situations where

multiple traumatic injuries require immediate treatment.If the primary surgeon has an across-the-board policy of

never involving residents in the preoperative, operative or post-operative care of his or her patients.

MODIFIER 90: OUTSIDE LAB

• This modifier is used to indicate that although the physician is reporting the performance of a laboratory test, the actual testing component was a service from a laboratory.• When the physician bills the patient for lab work

that was performed by an outside or (reference) lab, add the 90 modifier to the lab procedure codes. Physicians use this modifier when laboratory procedures are performed by a party other than the treating or reporting physician.

CMS GUIDELINES

• Physicians should NEVER bill Medicare or Medicaid patients for lab work done outside their office.• The laboratory performing the service will bill for

the laboratory procedure. CMS does not recognize the use of modifier 90. (We will not address billing purchased services in this session)

MODIFIER 91: REPEAT LABORATORY PROCEDURE

• In the course of treatment of the patient, it may be necessary to repeat the same laboratory test on the same day to obtain subsequent (multiple) test results. Under these circumstances, the laboratory test performed can be identified by its usual procedure number and the addition of the modifier 91.

MODIFIER 91: REPEAT LABORATORY PROCEDURE

• This modifier may not be used when other code(s) describe a series of test results (eg, glucose tolerance tests, evocative/supression testing). This modifier may only be used for laboratory test(s) performed more than once on the same day on the same patient.

MODIFIER 91: REPEAT LABORATORY PROCEDURE

• Modifier 91 is not intended to be used when:Laboratory tests are rerun to confirm initial resultsDue to testing problems encountered with specimens or

equipmentFor any other reason when a normal, one-time,

reportable result is all that is required

MODIFIER 99: MULTIPLE MODIFIERS

• Used when 2 or more modifiers are necessary to correctly report a procedure