CH 14 Modifiers
Step By Step Medical Coding 2012 Carl Buck
These modifiers are alphanumeric, and also called National Level modifiers
HCPCS modifiers or Level II modifiers
In what two places in the CPT manual can I find a list of modifiers?
Inside cover and Appendix A
These modifiers are two digits and are also called Level I HCPCS modifiers
Increased Procedural Services modifier
What must accompany use of modifier -22?
Which global period indicator renders a modifier -22 invalid? 0, 10, 90, or XXX?
XXX (eg. E/M, radiology, laboratory, pathology, most medicine codes, etc.)
Unusual Anesthesia modifier
-23. Use when general anesthesia is used for a procedure that would not normally require it.
To what section of codes is modifier -23 appended?
Unrelated Evaluation and Management Service by Same Physician During Post-op Period modifier
What section of codes is the only section used with modifier -24?
E/M codes. (Can also use with Ophthalmology codes)
Significant Separately Identifiable E/M Service by Same Physician on Same Day of Procedure modifier
Can Modifier -25 be added to an E/M code when a decision for surgery is made on the same day as a procedure?
Yes, if procedure has global of 0-10 days or XXX global indicator and if E/M service is not associated with decision to perform the minor surgical procedure.
What modifier is added to an E/M code when the service resulted in a decision for surgery on the day before or day of a procedure with a 90 day global?
-57 (Decision for Surgery)
Professional Component Modifier
Mandated Services Modifier
What are some examples of situations in which to use modifier -32
police mandate, workers compensation, or 3rd party payer mandating physical exam.
Preventive Service Modifier
This mandate requires health insurance coverage of preventive services and immunizations without cost.
Patient Protection and Affordable Care Act (PPACA)
This organization grades preventive services.
US Preventive Services Task Force (USPSTF)
Anesthesia by Surgeon modifier
-47. Used when surgeon administers regional or general anesthesia
Is modifier -47 added to surgery codes or anesthesia codes, or both?
Only surgery codes.
Bilateral Procedures modifier
How does one maximize reimbursement with use of modifier -50?
Learn payer's rules. Some interpret -50 to pay code at 150%, some to pay at only 50%, necessitating two codes.
What is Medicare's rule regarding modifier -50?
Submit code on one line with quantity 1 and modifier -50. Medicare will reimburse at 150%.
Multiple Procedures Modifier
When more than one procedure is performed during an encounter, in what order are they listed?
List procedure with highest relative value unit first. Attach -51 to following procedure.
What are the 3 significant times when multiple procedures (-51) are reported?
1. Same operation, different site 2. Multiple operations, same operative session 3. Procedure performed multiple times
If a pt has a lesion excision on the neck and one on the forearm, what is this an example of and how is it coded?
Multiple Procedures (same operation, different site). List most expensive procedure first. Use Modifier -51 for following procedure.
If a pt has a two flexor tendons repaired on one leg during the same session, what is this an example of and how is it coded?
Multiple Procedures (procedure performed multiple times). Depending on payer, report code once with quantity 2 OR once w/o modifier, once with -51, or differentiate with HCPCS modifiers.
What is the difference between modifiers -51 and -59?
-51 = Multiple Procedures. -59 = Distinct Procedural Service. Some payers use them interchangeably; in general use -51 for 3 Significant Times.
Reduced Services modifier
What is an example of reduced service (-52)?
component of procedure not entirely completed, not due to pt risk, eg "excision of ischial pressure ucler with ostectomy" but ostectomy was not performed.
Discontinued Procedure modifier
What is an example of a discontinued procedure? (-53)?
Procedure stopped d/t pt risk (eg. surgical complication)
When do you NOT use modifier -53?
1. when pt cancels the procedure.
2. E/M services
3. Any code based on time.
What are the requirements for using modifier -53?
Pt must have been prepped and anesthetized. Attach cover note and state % of procedure completed and reason for discontinuation.
Surgical Care Only modifier
Postoperative Management Only modifier
Preoperative Management Only modifier
What documentation is required to bill with -54?
Signed transfer of care, kept in pt's medical record
Can you use modifier -56 on Medicare claims?
No, Medicare considers pre-op care part of the surgical package.
Decision for surgery modifier
What is the only type of code used with modifier -57?
E/M code (or ophthalmologic codes)
When is modifier -57 necessary?
When decision for surgery falls within global (including day before or day of major surgery).
Can I use modifier -57 to report decision for minor surgery?
No, use modifer -25 (although payers differ)
Staged or Related procedure or service by the same physician during the postop period modifier
When do I use modifier -58?
When subsequent surgery was planned or staged at the time of the first surgery.
What is an example of staged procedures?
multiple skin grafts, or if therapeutic procedure is performed d/t findings of diagnostic procedure (eg breast biopsy leading to mastectomy within global)
How does -58 affect the global period?
Resets the global.
Distinct Procedural Service modifier
When do I use modifier -59?
When performing procedures separately that are usually bundled.
Two Surgeons modifier
When do I use modifier -62?
Two co-surgeons of different specialties, both writing own report and submitting own claim.
How much are two co-surgeons reimbursed?
Procedure Performed on Infants less than 4kg modifier
Surgical Team modifier
When do I use modifier -66?
When 3 or more doctors of different specialties perform a surgery together (eg organ transplant).
Repeat Procedure/Service by Same Physician modifier
-76 (documentation must support medical necessity)
Repeat Procedure/Service by Another Physician modifier
-77 (documentation must support medical necessity)
What modifier is often combined with -77?
-52 (Reduced Service)
Unplanned Return to OR by Same Physician Following Initial Procedure for Related Procedure During Postop Period modifier
When do I use modifier -78?
Surgical treatment of surgical complication within global period
What happens to the global period when reporting modifier -78?
Nothing, keep original global period.
Unrelated Procedure/Service by Same Physician During Post-op Period modifier
When do I use modifier -79?
Unrelated surgery overlapping global period for 1st surgery (eg cataract surgery on other eye)
Assistant Surgeon modifier
When do I use modifier -80?
When a surgeon employs another as an "extra pair of hands" only. Append to assistant surgeon's claim.
Minimum Assistant Surgeon modifier
Assistant Surgeon (When Qualified Resident Surgeon Not Available) modifier
-82 (rare, must be accompanied by explanation)
Reference (Outside) Laboratory modifier
Repeat Clinical Diagnostic Laboratory Test modifier
-91 (use like Multiple Procedures, but on Lab codes)
Can modifier -91 be used to indicated malfunctioning lab equipment?
Alternative Laboratory Platform Testing modifier
-92 (eg HIV kit or transportable instrument)
Multiple Modifiers modifier