UNDERSTANDING & CODING WITH MODIFIERS -21 Prolonged Evaluation and Management When the service provided is prolonged or otherwise greater than that usually required for the highest level of service in a given category. An office visit that usually requires 45 minutes to 70 minutes to complete. (This modifier may only be used with the highest levels of service for E&M codes.) Correct coding: 99215-21 (Established patient office visit) -22 Unusual Procedural Services When the service provided is greater than the time or service usually required for the procedure. A surgical procedure that usually takes 1 hour took 3 hours. A report or summary should accompany the claim to explain the reason for the increase in charges. Correct coding: 58180-22 (Supracervical abdominal hysterectomy) -23 Usual Anesthesia Occasionally, a procedure that usually requires either no anesthesia or local anesthesia must be done under general anesthesia because of unusual circumstances. This situation is reported by adding modifier -23 to the procedure codes of the basic service. During a sigmoidoscopy, the patient required general anesthesia. Correct coding: 45330 Sigmoidoscopy, flexible 45330-23 General anesthesia applied -24 Unrelated Evaluation and Management Service by the Same Physician during a Postoperative Period Use this modifier when the physician needs to indicate that an E&M service was performed during a post-operative period for a reason unrelated to the original procedure. A patient had gall bladder surgery but came to the office because of a cold 3 weeks following that procedure (same physician). By using this modifier, the coder alerts the carrier that the office visit was not related to the surgical procedure. The physician will then be paid for the visit pertaining to the cold. -25 Significant, Separately Identifiable E&M Service by the Same Physician on the Day of a Procedure This modifier indicates that on the day a procedure or other service was performed, the patient's condition required a significant, separately identifiable E&M service in addition to the usual preoperative and postoperative care associated with the procedure. 1
Patient was seen for a sore throat and removal of a wart. Both services (the office visit and the procedure) could be coded because the office visit (sore throat) was unrelated to the reason for the surgery. -26 Professional Component Certain procedures are a combination of a physician component and a technical component. To report only the physician component, add this modifier to the CPT code number. The patient has had a chest x-ray. and the physician is only interpreting the film. -32 Mandated Services This modifier applies to mandated consultation and services related to mandated consultations. -47 Anesthesia by Surgeon Use this modifier to code regional or general anesthesia provided by the surgeon. Do not use it to code for local anesthesia. The surgeon who drains this patient's cyst also administered the regional anesthesia. -50 Bilateral Procedure When the same procedure is performed on both sides of the body use this modifier to indicate that service. The modifier is appended to the second procedure. This patient has two hernias. one in the right groin and one in the left -51 Multiple Procedures When multiple procedures other than E&M services are performed on the same day or at the same session by the same provider, the primary procedure or service may be reported as listed and the additional procedure reported 2
with the multiple procedures modifier. The surgeon removed the patient's uterus and also cut an opening into the bladder and drained it. -52 Reduced Services Under certain circumstances, a service or procedure is partially completed. This modifier alerts the carrier that a reason exists for a lower-than-usual charge. The reduced services modifier will protect the charge data for the practice. Noninvasive physiologic studies of upper or lower extremity arteries, multiple levels or with provocative functional maneuvers, complete bilateral study (e.g., segmental blood). The study was performed on a patient who has a history of amputation of the extremity. -53 Discontinued Procedure The physician may need to terminate a procedure due to extenuating circumstances or terminate those that threaten the well-being of the patient. Note: This modifier is not used to report the elective cancellation of a procedure before patient's anesthesia induction and/or surgical preparation in the operating suite. Physician began a colonoscopy but had to discontinue the procedure because the patient had not been properly prepped -54 Surgical Care Only This modifier indicates that one physician performed a surgical procedure and another physician provided preoperative and/or postoperative management. The physician performed only the laminectomy. -55 Postoperative Management Only This modifier indicates that a physician other than the surgeon provided the postoperative care. The physician provided the postoperative management for a laminectomy performed by another physician 3
-56 Preoperative Management Only This modifier indicates that a physician other than the surgeon provided the preoperative evaluation of the patient. The physician provided the preoperative evaluation for a laminectomy performed by another physician. -57 Decision for Surgery Use this modifier for an evaluation and management service that resulted in the initial decision to perform surgery. It applies only to major procedures (those with a 90 day global period) when surgery is performed within 24 hours of the decision for the surgery. The patient saw the surgeon, and the decision was made for surgery the next day. -58 Staged or Related Procedure or Service by the Same Physician during the Postoperative Period This modifier is used when the physician needs to indicate that a procedure or service performed during the postoperative period was planned prospectively at the time of the original procedure (staged), was more extensive than the original procedure, or was performed for therapy following a diagnostic surgical procedure. Patient had breast biopsy. Results indicated a need for a partial mastectomy. The service was scheduled within the 10-day global period of the biopsy. -59 Distinct Procedural Service This modifier indicates that a procedure or service was distinct or independent from other services performed on the same day. It is used to identify procedures or services that are not normally reported together but are appropriate under the circumstances. It may represent a different patient encounter, different site or organ system, separate lesion, or separate injury not ordinarily encountered or performed on the same day by the same physician. Removal of a lesion from the arm and another lesion from the back. -62 Two Surgeons Under certain circumstances two surgeons (usually with different skills) may be required to manage a surgical procedure. Laminectomy performed by a neurosurgeon and an orthopedic surgeon. Each bills the same CPT code with 4
modifier 62. -63 Procedure Performed on an Infant Weighing Less than 4 kg In some cases, the small size of an infant significantly increases the complexity and physician work components required for a procedure. This modifier is only used for procedures on patients in this circumstance. The patient is a 3-kg infant who requires an enterectomy, resection of small intestine. -66 Surgical Team Used when highly complex procedures (requiring the concomitant services of several physicians, often of different specialties, plus other highly skilled, specially trained personnel, various types of complex equipment) are carried out under the. surgical team concept A heart transplant involves the skills of a highly trained cardiovascular team -76 Repeat Procedure by Same Physician Use this modifier when a physician needs to indicate that a procedure or service was repeated subsequent to the original service on the same day. Patient had an EKG in the morning with a repeat EKG in the afternoon. -77 Repeat Procedure by Another Physician This modifier indicates that a procedure had been performed by another physician on the same day and was repeated by a different physician. Patient had an EKG at the primary care physician's office and was sent to a cardiologist that same day who repeated the EKG on the same day. -78 Return to the Operating Room for a Related Procedure This modifier indicates that another procedure, related to the first procedure, was performed during the initial procedure's postoperative period and required a return to the operating room. 5
The patient had abdominal surgery. Three days after surgery an infection occurs in the wound site, requiring the patient to be returned to the operating room for debridement of the wound site. -79 Unrelated Procedure or Service in a Postoperative Period When a patient is seen by the same physician for an unrelated problem or condition in a postoperative period, use this modifier. A patient has a Maze procedure for treatment of atrial fibrillation. The patient goes home; the wound site is healing well. Two weeks later, the patient is seen by the same physician for pericardiotomy for removal of foreign body. Since the second procedure is within the global period for the original surgery, attach modifier -79 to the second procedure. -80 Surgical Assistant This modifier identifies the services of another physician, who acts as a second pair of hands during a surgical procedure. A patient is treated for an intestinal fistula closure, which required the assistance of another physician to complete the procedure. The primary surgeon reports the service. To report the services of the assistant you would add modifier -80 to the code. -81 Minimum Assistant Surgeon Use this modifier for a procedure that does not normally require a surgical assistant but because of extenuating circumstances, requires the services of another physician for a short time. Note: Many commercial insurance companies allow this modifier to be used when assistance is provided by personnel other than an MD or DO. For Medicare carriers, you must use modifier -AS to report services provided by an assistant who is not an MD or DO. A patient is treated for gingivitis requiring Gingivectomy, excision gingiva, each quadrant. The assistance of another physician was required for a short period of time to complete the procedure. Using the same example, if the physician had used a nurse practitioner or physician assistant for help with this service you could apply modifier -81 with some commercial carriers. 6
-82 Assistant Surgeon Use this modifier when a qualified resident surgeon is not available. This modifier is typically reserved for teaching hospitals and teaching physician services A teaching physician required assistance for the closure of an intestinal fistula. At the time of the procedure, a resident was not available to provide assistance. Another teaching physician was called to provide surgical assisting. -90 Reference (Outside) Laboratory This modifier is used when laboratory procedures are performed by a party other than the treating or reporting physician. Only use this modifier with the 80000 code series. A patient with Conn's disease is scheduled for aldosterone studies in the morning and in the afternoon to compare results of electrolyte excretion by the kidneys. -91 Repeat Clinical Diagnostic Laboratory Test Used to indicate a repeat of the same laboratory test on the same day to obtain subsequent (multiple) test results. Note: This modifier may not be used when tests are rerun to confirm initial results; when testing problems with specimens or equipment occur; or for any other reason when a normal, one-time, reportable is all that is required. This modifier may not be used when other code{s) describe a series of test results (e.g., glucose tolerance tests, evocative/suppression testing) Patient's test results for aldosterone are inconclusive, so the lab runs the test again. 7