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Resolved CPT Modifiers

CCO Video Modifiers Made Easy:



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22- Increased Procedural Services
23- Unusual Anesthesia
24- Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period
25- Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service
26- Professional Component
27-Multiple Outpatient Hospital E/M Encounters on the Same Date
32- Mandated Services
33- Preventative Services
47- Anesthesia by Surgeon
50- Bilateral Procedures
51- Multiple Procedures (some multiple surgical procedures must be reported WITHOUT modifier 51 identified as add on codes (appendix I)
52- Reduced Services
53- Discontinued Procedure
54- Surgical Care Only
55- Postoperative Management Only
56- Preoperative Management Only
57- Decision for Surgery
58- Staged or Related Procedure or Service by the Same Physician During the Postoperative Period
59- Distinct Procedural Service
62 -Two Surgeons
63- Procedure Performed on Infants less than 4 kg.
66- Surgical Team
73- Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedure Prior to the Administration of Anesthesia
74- Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedure After the Administration of Anesthesia
76 -Repeat Procedure by Same Physician or Other Qualified Health Care Professional
77- Repeat Procedure by Another Physician or Other Qualified Health Care Professional
78- Unplanned Return to the Operating Room by Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period
79- Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period
80- Assistant Surgeon
81- Minimum Assistant Surgeon
82- Assistant Surgeon (when qualified surgeon no available)
90- Reference (Outside) Laboratory
91- Repeat Clinical Diagnostic Laboratory Test
92-Alternative Laboratory Platform Testing
95- Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunication System
96-Habilitative Services
97-Rehabilitative Services
99- Multiple Modifiers

Review the proper use of each modifier.
Understand when each modifier should be applied.
  • The procedure has both a professional and technical component
  • Service is performed by more than 1 physician and/or in more than 1 location
  • Service has been increased or reduced
  • Only part of a service was performed
  • An adjunctive service was performed
  • Service or procedure was provided more than once
  • Unusual events occurred
  • Service was provided during a global period but is NOT included as part of the global reimbursement
 

Lori

Moderator
Staff member
Modifier #22 - Increased Procedural Services


CPT Modifier #22 (1).png

Modifier 22 examples:

  • Trauma that significantly complicates the particular procedure and cannot be reported with any other procedure.
  • Significant scarring that requires extra time and work.
  • Morbid obesity causes extra work for the physician.
  • Services that are significantly more complex than described by the CPT code.
 

Lori

Moderator
Staff member
f CPT Modifier #23.png
Coding Tidbit #12.png
CCO Anesthesia Times (1).png

AA – Anesthesia services performed personally by an anesthesiologist.

QK – Medical direction by a physician of two, three, or four concurrent anesthesia procedures involving qualified individuals.

AD – Medical Supervision by a physician, more than four concurrent anesthesia procedures.

QY – Medical direction of one CRNA/AA (Anesthesiologist's Assistant) by an anesthesiologist.

QX – CRNA/AA (Anesthesiologist's Assistant) service with medical direction by a physician.

QZ – CRNA service without medical direction by a physician.

This modifier is informational only and does not affect reimbursement
 

MelissaS_64806

New member
Free COC Exam
If coding an anesthesia claim with P3 or P4 -- should there also be a diagnosis code that supports that indicator? Or does confirmation of that status solely rely on documentation and a single dx is enough (like pain in left hip)?
 

Lori

Moderator
Staff member
I consulted with
Judy A Wilson from AAPC & she stated "The anesthesiologists pick the PS and yes there should and would be a dx code to support the PS code. Medicare doesn't pay for these codes but other carriers do and they must be on all anesthesia records. It is base on the health of the patient.
Yes, you need supporting documentation."

Providers should submit the pre-anesthesia evaluation and the anesthesia report with their claim which documents the rationale for the use of general anesthesia in high risk patients or clinical history which supports a high risk condition.



 

MelissaS_64806

New member
Free COC Exam
I consulted with
Judy A Wilson from AAPC & she stated "The anesthesiologists pick the PS and yes there should and would be a dx code to support the PS code. Medicare doesn't pay for these codes but other carriers do and they must be on all anesthesia records. It is base on the health of the patient.
Yes, you need supporting documentation."

Providers should submit the pre-anesthesia evaluation and the anesthesia report with their claim which documents the rationale for the use of general anesthesia in high risk patients or clinical history which supports a high risk condition.




thank you!!!
 

Lori

Moderator
Staff member
Modifier 24

Use CPT modifier 24 for unrelated evaluation and management service during a postoperative (global) period. A major surgery's global period is the day before, the day of, and 90 days after the surgery.

Medicare defines the same physician as physicians in the same group practice who are of the same specialty. In this instance, they must bill and be paid as though they were a single physician.

Modifier 24 is applied to:
Evaluation and management (E/M) services (99202-99499).
General ophthalmological services (92002-92014) (eye examination codes).

Use when:

An unrelated E/M service is performed beginning the day after the procedure, by the same physician, during the 10 or 90-day postoperative period.
Documentation indicates the service was exclusively for the treatment of the underlying condition and not for post-operative care.
The same physician is managing immunosuppressant therapy during the post-operative period of a transplant.
The same physician is managing chemotherapy during the postoperative period of a procedure.
The same diagnosis as the original procedure could be used for the new E/M if the problem occurs at a different anatomical site.



 

Lori

Moderator
Staff member
Modifier 25

Defined as a significant, separately identifiable evaluation and management (E/M) service by the same physician or other qualified health care professional on the same day of the procedure or other service.

 

Lori

Moderator
Staff member
Modifier 26 & Modifier TC

26-Is appended to billed codes to indicate that only the professional component of a service/procedure has been provided. It is generally billed by a physician. Services with a value of “1” or “6” in the PC/TC Indicator field of the National Physician Fee Schedule may be billed with modifier 26.

Defined as the professional component (PC).

The PC is outlined as a physician's service, which may include technician supervision, interpretation of results and a written report.
Use modifier 26 when a physician interprets but does not perform the test.
Most radiology codes, including ultrasounds, x-rays, CT scans, magnetic resonance angiography, and magnetic resonance imaging, may be billed with modifier 26 or TC, or with no modifier at all, indicating that the provider performed both the professional and technical services.
This modifier must be reported in the first modifier field.

Procedures falling into the following types of service:
1 - Medical Care/Injections
2 - Surgery
4 - Radiology
5 - Lab
6 - Radiation Therapy
8 - Assistant Surgeon


  • To bill for only the technical component of a test
  • When billing both the professional and technical component of a procedure when the technical component was purchased from an outside entity; the provider would bill the professional on one line of service and the technical on a separate line.
A global service includes both professional and technical components of a single service. It is identified by reporting the eligible code without modifier 26 or TC. In such cases, the provider is reimbursed for the equipment, supplies, and technical support, as well as the interpretation of the results and the report. When reporting a global service, no modifiers are necessary to receive payment for both components of the service.

Do not append modifier 26 if there is a dedicated code to describe only the professional/physician component of a given service.


TC-Used when only the technical component (TC) of a procedure is being billed when certain services combine both the professional and technical portions in one procedure code. Use modifier TC when the physician performs the test but does not do the interpretation.

Screen Shot 2022-10-25 at 12.47.32 PM.png


 

Lori

Moderator
Staff member
Modifier 27

Multiple outpatient hospital evaluation and management (E/M) services on the same date.

Exclusively for hospital outpatient departments (ex. hospital emergency department, clinic, and critical care).

Note: Physician practices may not use this modifier.

This modifier should only be reported on the UB-04 Part A claim form.

Hospitals may append modifier 27 to the second and subsequent E/M code to indicate that the E/M service is a “separate and distinct E/M encounter” from the service previously provided that same day in the same or different hospital setting.

Hospitals can use modifier 27 to the range of E/M service codes listed below.

92002-92014 (Ophthalmological E/M services)
99281-99285 (Hospital type A emergency department visits)
99291-99292 (Critical care)
G0175 (Interdisciplinary team conference)
G0380-G0384 (Hospital type B emergency department visits)
G0402 (Initial preventive physical examination)
G0463 (Hospital outpatient clinic visit for assessment and management)
Report condition code G0 (zero) with modifier 27 when multiple medical visits occur on the same day in the same revenue centers.

 

Lori

Moderator
Staff member
Modifier 32

Is used only whenever a service has to be extended to a third-party entity or in the case of Worker's Compensation or some other such official entity.

 

Lori

Moderator
Staff member
Modifier 33

Helps the insurance company to quickly identify the service as preventive and apply the proper benefit and payment to the claim but without it, the claim can be processed incorrectly causing the patient to incur costs for a service that should be paid in full by the insurance company.

Preventive services that are approved by the U.S. Preventive Services Task Force (USPSTF) it is applied to indicate that the preventive service is one that waives a patient's co-pay, deductible, and coinsurance. An exception is that modifier 33 does not have to be appended to those services that are inherently preventive (for instance, screening mammography).

USPSTF has provided a list 4 of preventive services they recommend and have assigned them either an A or B grade. The 'A' grade meaning it is recommended as highly beneficial and 'B' grade that it is moderately to substantially beneficial.


Some preventive services are inherently preventive in nature and have been performed regularly for years, insurance companies already consider them to be preventive services and do not need modifier 33 appended to them to help them recognize them as preventive. Some well-known, preventive services include immunizations, annual pelvic exams and PAP smears, and screening mammograms.

Do not apply modifier 33 to inherently preventive services.

If the patient is seen for an EM service in which the preventive service is performed but is NOT the primary reason for the EM service, the EM service will be billed with whichever diagnoses are applicable, according to the findings of the exam. This type of EM service will be processed as usual and cost-sharing may be applicable to the patient.


 

Lori

Moderator
Staff member
Modifier 47

Anesthesia by surgeon.

Guidelines and Instructions:

This modifier may be submitted when the operating surgeon performs the anesthesia service (does not include local anesthesia).
Add CPT modifier 47 to the basic service for regional or general anesthesia provided by the surgeon.
 

Lori

Moderator
Staff member
Modifier 50- Bilateral Procedures defined as a bilateral procedure performed on both sides of the body.

It is recommended that an anatomical modifier be included in addition to modifier 50 to show the additional services are not duplicates.

Inappropriate to apply to a "bilateral description" code.

Do not append to procedures for midline organs such as the bladder, uterus, esophagus, or nasal septum.

Inappropriate to report when performed on different areas of same side of body.

 

Lori

Moderator
Staff member
51- Multiple Procedures (some multiple surgical procedures must be reported WITHOUT modifier 51 identified as add-on codes (check appendixes or your CPT table of contents for the correct appendix in your manual)

Modifier 51 Multiple Procedures indicates that multiple procedures were performed in the same session. It applies to Different procedures performed in the same session. A single procedure is performed multiple times at different sites.

Diagnostic Imaging Services subject to the Multiple Procedure Payment Reduction that are provided on the same day, during the same session by the same provider.

Note: Medicare doesn’t recommend reporting Modifier 51 on your claim; our processing system will append the modifier to the correct procedure code as appropriate.
Medicare pays for multiple surgeries by ranking from the highest physician fee schedule amount to the lowest physician fee schedule amount.
100% of the highest physician fee schedule amount
50% of the physician fee schedule amount for each of the other codes
Medicare will forward the claim information showing Modifier 51 to the secondary insurance.
Multiple surgery pricing also applies to assistant at surgery services.
Multiple surgery pricing applies to bilateral services (modifier 50) performed on the same day with other procedures.

Modifier is appended when:
The same physician performs more than one surgical service at the same session (Indicator 2).
The technical component of multiple diagnostic procedures, Multiple Procedure Payment Reduction (MPPR) rule applies (Indicator 4).
The multiple surgical procedures are done on same day but billed on two separate claims.
The surgical procedure code is the lower physician fee schedule amount.
The diagnostic imaging procedure with the lower technical component fee schedule amount.

Do not append to add-on codes (See Appendix D of the CPT manual)
Do not report on all lines of service
Do not append when two or more physicians each perform distinctly, different, unrelated surgeries on the same day to the same patient.

 

Lori

Moderator
Staff member
52- Reduced Services

Used to indicate a partial reduction, cancellation, or discontinuation of services for which anesthesia is not planned. The modifier provides a means for reporting reduced services without disturbing the identification of the basic service. It also identifies a situation where a physician reduces or eliminates a portion of a service or procedure.

Modifier 52 should be applied to CPTs which represent diagnostic or surgical services that were reduced by the provider by choice.

Circumstances for applying modifier 52 would not include a change to the procedure that was unexpected by the provider, so in order to append modifier 52 appropriately, you need to know why the services were reduced by the provider.

WHEN NOT TO USE MODIFIER 52​

  • The code description includes unilateral or bilateral.
  • An existing CPT or HCPCS code properly identifies the reduced service.
  • Anesthesia administration and/or the patient’s well-being at risk were factors in ending the procedure.


Hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers -73 and -74.

Coding tips or abbreviated description for anatomically compatible CPT codes

If modifier -52 is reported, payment may be reduced. Therefore, use the code that explains the extent of the procedure. If no code exists for what was performed, report the intended code with modifier -52.

Essentially, CPT instructs that when performing a diagnostic or screening endoscopic procedure on a patient who is scheduled and prepared for a total colonoscopy, if the physician is unable to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances, report 45378 (colonoscopy) or 44388 (colonoscopy through stoma) with modifier -53 and provide appropriate documentation. On the other hand, if the colonoscopy is therapeutic and the scope does not reach the cecum, report the colonoscopy code with modifier -52.

Note that there is a difference in using modifiers -52 and -53 for upper versus lower endoscopic procedures. For upper endoscopies in which the duodenum is deliberately not examined, append modifier -52, if a repeat examination is not planned, or modifier -53, if a repeat examination is planned.

Examples:

  • EGD is performed with scope going into the stomach. The duodenum is not examined, and there is no plan to perform repeat EGD to examine the duodenum. Report the procedure code with modifier -52.
  • EGD is performed to check on a gastrointestinal bleed, but the duodenum could not be examined as the stomach is full of blood. The current procedure performs a control of the bleeding, but the provider does want to complete the full examination at a later date. Report the procedure code with modifier -53

 

Lori

Moderator
Staff member
53- Discontinued Procedure

Appropriate usage​

Unusual (discontinued) circumstances.
A discontinued procedure after induction of anesthesia.
Append modifier to the discontinued procedure’s Current Procedural Terminology code.

Inappropriate usage​

To report the elective cancellation of a procedure.
Procedure discontinued prior to the anesthesia being induced.
Note: Consult Modifier 73
When used on E/M services.
For outpatient hospital/ ambulatory surgical center.

Supporting documentation should:
State when the procedure was started.
Explain why the procedure was discontinued.
Notate the percentage of the procedure that was performed.

Unexpected or Due to Risk Calls for Modifier 53

If a provider discontinues a procedure due to risk to the patient, look to modifier 53.

CPT® Appendix A tells us, “Under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. This circumstance may be reported by adding the modifier ‘53’ to the code reported by the individual for the discontinued procedure.”

Modifier 53 might also apply if the provider must stop a procedure due to equipment failure or other extenuating circumstances (for example, the provider injures themselves while performing a procedure).

 

Lori

Moderator
Staff member
54- Surgical Care Only

Use​

  • Surgeon performs surgery only
    • Bill surgical date of service
    • Append to surgical code

Do not Use​

  • Do not append modifier 54 if patient is under surgeon's care for the full 10 or 90 days of postoperative care
  • Do not append on ASC facility or assistant surgeons services
 

Lori

Moderator
Staff member
55- Postoperative Management Only

When one physician or other qualified healthcare professional manages the post-op care and another performs the surgical procedure. The surgeon fully transfers all or a portion of the post-op care.

Use​

  • Use with surgical codes only to indicate that only the postoperative care was performed.
  • The surgeon performs part of postoperative care
    • Submit the claim with two lines using the same date of service and procedure code; append the modifier to line 2
    • Include the date span in Item 19 narrative of the CMS-1500 claim form or the electronic equivalent
    • Submit the claim with the number of units as 1
  • Physician rendering additional postoperative care
    • Submit a claim with the surgery date and procedure code
    • Include the date span of assumed care in Item 19 narrative of the CMS-1500 claim form or the electronic equivalent
    • Submit the claim with the number of units as 1

Do Not Use​

  • Do not append when a surgeon performs surgery only: no postoperative care
  • Do not append if the patient is under surgeon's care for full 10 or 90 days of postoperative care
  • Do not append on ASC facility or assistant surgeons' claims
  • Do not submit modifier 55 on CPT codes that has 0 days global period
  • Do not submit modifier 55 on E/M service
  • Do not submit modifier 55 along with other Global Surgical split billing modifiers 54 & 56
  • Do not submit modifier 55 along with modifiers 80, 81, 82, AS
  • Do not report modifier 55 along with CPT 99024 (Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure)
When billing out-of-hospital medical care associated with a given surgical procedure for postoperative care only, report the original date of surgery as your date of service.
If postoperative care is split between physicians, each physician must also indicate the period of their responsibility for the patient’s postoperative care by reporting the appropriate range of dates.
If a transfer of postoperative care occurs, the receiving physician cannot bill for any part of the global services until he/she has provided at least one service.
Physicians who share postoperative management must coordinate their billing.
Physicians who share postoperative management must submit information on their claims showing when they assumed or relinquished responsibility for the postoperative care.
When more than one physician bills for postoperative care, apportion the postoperative percentage according to the number of days each physician was responsible for the patient’s care.
Payment is limited to the allotted amount of postoperative services only.
Medicare has split global surgery package relative values into preoperative, intraoperative, and postoperative percentages with a physician fee schedule database containing the percentage for the post-operative portion of the global package that shows the amount that would be reimbursed for the physician who performs only the post-operative care.
Reimbursement from commercial insurance differs and depends upon its Split Surgical Package.


 

Lori

Moderator
Staff member
56- Preoperative Management Only

Modifier 56 indicates that a physician or qualified health care professional other than the surgeon performed the preoperative care and evaluation prior to surgery.

When one physician performed the preoperative care and evaluation and another physician performed the surgical procedure, the preoperative component may be identified by adding the modifier- 56 to the usual procedure number.

Medicare does not recognize modifier 56. Only the E/M code should be reported to indicate preop care and evaluation on claims submitted to Medicare. Payers may differ with respect to the rules on the use of modifier 56.
 
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