Modifiers
Modifiers is to report specific circumstances or alterations to
a procedure, service, or medical equipments without
changing the definition of the code.
It is a 2 digit numerical codes eg 50.
They are appended to CPT and HCPCS level II codes.
gives additional information which is not present in the
procedure codes
22 modifier ; 12345-22
INCREASED PROCEDURAL SERVICES
Eg A patient has a colonoscopy and a polyp is removed. The
removal of the polyp causes excessive bleeding and an extra 30
minutes is spent controlling the bleeding.
Modifier 22 would be added to the surgical code and the
operative report and/or letter would be sent with the claim to
the payer.
colonoscopy eg 45379-22
Key words : extended time, took longer than normal.
Dr. Regis performed an appendectomy on Wilfred Maxell.
However, the operation took twice as long as usual because
Wilfred weighs 432 pounds. Which modifier should be
appended to the code for the surgical procedure?
Appendenctomy-22
23 Modifier : unusual Anesthesia.
Used by anestheologist or CRNA with anesthesia codes.
• E.g. Alexander, an 11-year-old boy, had a superficial cut, about 3.3 cm,
on his left cheek, after being in a car accident. Dr. Chandra is ready to
perform a simple repair of the wound, but she is very concerned.
Alexander has Tourette’s syndrome that causes him to jerk or move
abruptly. Although anesthesia is not typically used for a simple repair of
a superficial wound, Dr. administers general anesthesia.
00300-23
Keyword: unable to tolerate without general anesthesia etc.
inappropriate – when given for convenience.
24 modifiers------(24,25,57-----E and M chapter)
Unrelated E/M by the same physician during a postoperative
period.
Eg append mod 24 to an E/M code if a physician treats a
patient or migraines during a postoperative periods and they
are unrelated to the surgical procedure.
Keywords- unrelated, outside of, not related to.
Eg The patient is two weeks status post neuroplasty for
carpal tunnel of the right hand and presents to his surgeon
today for a new complaint of right knee swelling and pain.
The appropriate coding on E/M code is 24 modifier.
25
Significant, separately identifiable evaluation
and management service by the same
physician on the same day of the procedure
or other service
Eg When an established male pt is treated for
hypertension and then ask the physician to
biopsy a soft tissue lump located on his back;
99213-25, 21920
A patient presents to the office for scheduled lesion removal.
When the patient arrives, she has a cough, sore throat, and
fever, which are evaluated and treated in addition to the
scheduled procedure.
E/M code-25, Lesion removal code
26 modifier( 70000 moslty)
a procedure containing both a technical and a
professional component.
Modifier 26 – The professional component of
a diagnostic procedure is provided by the
physician, and include supervision,
interpretation, and a written report.
Modifier TC – The technical component of
a diagnostic procedure accounts for
equipment, supplies.
Mod-26
4. The physician removed a foreign body during a flexible
esophagoscopy under fluroscopic radiological supervision and
interpretation (the same physician provided both the surgical
and radiological services). The procedure was performed in a
hospital. How would the physician report these services?
a. 43200, 74235-26
b. 43215, radiological S&I is bundled
c. 43216
d. 43215, 74235-26
32 Mandated service
eg if the insurance company request a physician to receive a
second opinion before the additional service or procedure is
authorized.
Keyword: second opinion, required by the insurance.
33 Preventive service
This modifier is used to identify the preventive services .
When physician provide preventive medical services(routine
immunization, preventive screening for women, newborn
testing)on the same patient on the same day, use modifier 33
to the codes describing preventive services for that day.
47 Anesthesia by Surgeon
Eg pt in a remote area required exploration of deep penetrating
wound of thigh. The surgeon gave epidural anesthesia and
then explored the leg; 20103-47.
Keywords: surgeon administered anesthesia, anesthesiologist
not available etc.
50- bilateral procedures:
Eg 1 : when the pt undergoes surgery for a
bilateral laparoscopic inguinal hernia repair :
cpt – 49650-50.
Some codes specify ‘unilateral’ and include
a parenthetical statement.
Example: 50592 ,63045.
22526
Keywords: bilateral, both side, left and right.
A 68-year-old female undergoes stereotactic needle biopsy of
an area of suspicious micro calcifications in the left and right
breasts that reveals ductal carcinoma in situ. A bilateral
mastectomy is planned.
19303–50, Mastectomy, simple, complete
Mod-50
. A patient has nasal polyps removed from both sides of her
nose. A total of 3 polyps were removed. How should the
physician’s done services in the hospital ?
a. 30110 x 3
b. 30115-50
c. 30110 x 2
d. 30110-50
51 – Multiple procedure.
More than one procedure performed at the same session by the
same provider.
Not used on E/M services, vaccines or codes designated as ‘add-
on’ codes.
Example: An orthopedic surgeon performs a closed treatment of
a femoral shaft fracture on the left leg and a closed treatment of a
right knee dislocation during the same operative session. It would
be coded as
27500-LT and 27552-51-RT.
Key words: separate from etc.
52- Reduced service.
Procedure partially reduced.
Service not completed in its entirety.
Example: "For an incomplete colonoscopy, with full
preparation for a colonoscopy, use a colonoscopy code
with the modifier 52.
Keywords: partially, to be reduced, part of the procedure not
completed.
53- discontinued procedure.
Procedure terminated by the physician due to:
Circumstances threatening the well-being of
the patient
Example: A patient who is having a surgical
procedure and after the administration of
general anesthetic exhibits unstable vital
signs. At the recommendation of the
anesthesiologist the surgeon decides to
terminate the procedure.
Keywords – procedure stoped before
completion, aborted the procedure.
54- surgical care only
When the physician is giving only surgical care and not pre
and post operative care. Then he will append mod 54.
Key word; only performed the surgical procedure no
preop/postop management.
Pre
(surgical)
post
the surgery only
Example
Dr. Ross performed a bilateral osteotomy on the shaft of
Jack’s femur. Another surgeon performed the same procedure
on Jack two weeks ago but was unsuccessful, so Dr. Ross
repeated the procedure. As an expert in this procedure, he
was brought in to perform the surgery only and will not be
involved in any preoperative or postoperative care of the
patient.
27448-50-54
55- postoperative management only.
Physician only taking care of the post operative management
and not surgery or pre-operative management.
Keywords- post-op follow –up only, postoperative care turned
over to, transfer of care etc.
Pre
surgical
post
56- preoperative management only.
Physician taking care of only pre-operative management and
not surgery or post-op management.
Keywords- pre-op evaluation only, covering for surgeon etc.
57- decision for surgery
E/M service which is given on the day before or on the day of
the surgery which results in decision to perform surgery.
eg; physician exams the pt in the ER and makes the decision
to admit the patient and performs appendectomy the same
day :
99221-57, 44950.
Keywords; decision to perform surgery, will need to go to OR
etc
58- staged or related procedures.
The performance of a procedure in the post operative period
was :
- planned at the time of original procedure.
- more extensive than original procedure.
- for therapy following a diagnostic surgical procedure.
Example 2 : – March 2 – Breast Biopsy – March 6 – Modified
radical mastectomy – Add modifier 58 to the modified radical
mastectomy
Keywords: return to OR, will proceed with additional service
with next procedure.
Modifier 58 to indicate an expected return to the operating
room to complete a procedure in stages
59- distinct procedural service
Two different procedure which usually are not reported
together.separate procedure, with separate techniques under
certain circumstances had to be reported together done by same
physician on the same day.
Eg twins 59514-c sec,59409-vaginal-59
Procedures not normally reported together
Different Procedure or Surgery
Different Site or Organ System
Separate Incision/Excision
Separate Lesion
Different procedure done by the same physician on the same day.
Example: Colonoscopy with removal of polyps in the
transverse colon by snare/cautery and rectal polyps removed
by biopsy forceps.
You may code each "technique" done in different areas of the
colon
45385 (for the snare)
45380-59 (biopsy forceps)
Mod- 62
2. Two surgeons working together perform a partial
esophagectomy with cervical esophagostomy, without
reconstruction. How would these services be reported?
a. 43124, 43124-51
b. 43124
c. 43124-62 for one surgeon, 43124-62 for the second
surgeon
d. 43122-62 for one surgeon, 43122-62 for the second
surgeon
63 modifier.
63- procedure performed on infant less than 4 kg.
Earl Hillier, a 5-week-old male, was born prematurely and
weighs 3.8 kg.Dr. Daniel performs a cardiac catheterization
on Earl. Which modifier should be appended to the procedure
code?
Keywords: weight, incubator, neonate, newborn etc.
Modifier 76 - Repeat Procedure or Service by Same
Physician
Example: A patient who goes to the Emergency Room with a
trauma to the chest. A two-view chest x-ray is taken that
shows a pneumothorax.
After a chest tube is placed a repeat two view chest x-ray is
taken to verify the placement of the chest tube.
71020 and 71020-76. DR A DrA
Modifier 77 - Repeat Procedure or Service by Another
Physician
Example: A patient who sees the family practitioner for chest
pain and the physician does an EKG and then refers the
patient to a cardiologist. The patient is able to see the
cardiologist on the same day and the cardiologist performs a
repeat EKG.
The second EKG would be reported with modifier 77.
Keyword- repeated by another physician etc.
drA DrB
78- unplanned return to the operating room.
Pt taken back the operating room to take care of the
complications during the postoperative period of initial
procedure.
Eg 1 - A CABG was performed and later in the day pt was
taken back to ER to take care of postoperative hemorrhage.,
35820-78.
Example 2: January – Gastric bypass (90 day global period)
March – Incisional hernia on the bypass incision, taken back to
the operating room for incisional hernia repair.
Add modifier 78 to the hernia repair
Keywords- complications, had to return to the OR.
79- unrelated procedure or service by the same physician.
The procedure or service is given by the same physician
during the post-operative period which was unrelated to the
original procedure.
Eg : – January – Amputated DIP (distal interphalangeal joints)
joint (finger) surgery
March – Below the knee amputation post operative
Add modifier 79 to the below the knee amputation
Keyword- not related to the previous care, etc.
80, 81 & 82modifier
80- assistant surgeon
Key words- assisted, surgeon called in to help etc.
81- minimum assistant surgeon
Another surgeon is called to assist for limited time etc.
Keywords- Assisted partially, helped with the part of the
procedure etc.
80, 81 & 82modifier
82- assistant surgeon (when the qualified resident surgeon
not available).
Keywords; surgical resident not available etc.
Eg: Dr. Rita is preparing to perform open-heart surgery on
Frank. Dr. Fortner is asked to assist because a surgical
resident is not available.
90- modifier
90- reference outside laboratory
To identify the laboratory procedures performed by a party
other than the treating or reporting physician.
Used to bill for lab services purchased from an outside lab
Keywords- independent lab, separate from physician etc.
91- modifier
Repeat Clinical Diagnostic Lab Test –
Repeat the same laboratory test on the same day to obtain
the subsequent test results.
Not used to repeat a test due to equipment malfunction or
lost results.
Glucose tolerance test not
Confirm not.
Keywords- subsequent lab test, repeat lab after 4 hrs etc.
92- modifier
Alternative Lab Platform Testing –
Testing is performed using a kit or transportable instruments
wholly or in parts consist of single use, disposable analytical
chamber.
eg– HIV testing.
Keywords- portable, kit, disposable etc.
95
Telecommunication
96
Habilitative services
97
Rehabilitative services
99- multiple modifier
When 2 more modifier is need to completely describe the
service append mod-99 to the basic procedure and other
modifier may be listed as a part of service description.
. If three modifier are required to report the service then
append 99 to the basic procedure.
Dr. Ross performed a bilateral osteotomy on the shaft of
Jack’s femur. Another surgeon performed the same procedure
on Jack two weeks ago but was unsuccessful, so Dr. Ross
repeated the procedure. As an expert in this procedure, he
was brought in to perform the surgery only and will not be
involved in any preoperative or postoperative care of the
patient.
27448-50-54
Laboratory Modifiers
90 – Reference (Outside) Laboratory – Used
to bill for lab services purchased from an
outside lab
91 – Repeat Clinical Diagnostic Lab Test –
Not used to confirm results – Not used to
repeat a test due to equipment malfunction
92 – Alternative Lab Platform Testing –
Single use – HIV testing
IF THE PHYSICIAN HAD TO STOP IN THE MIDDLE OF A
PROCEDURE BECAUSE THE PATIENTS BLOOD PRESSURE
WAS DROPPING AND THEY COULD NOT STABILIZE IT ,
WHICH MODIFIER WOULD YOU USE ?
