Lesson 5 – CPT Modifiers

FUNCTIONAL VS. INFORMATIONAL MODIFIERS

CPT MODIFIERS When a simple CPT code isn’t enough, we turn to CPT modifiers. These import­ant additions to CPT codes give extra information about how, where, and why a procedure was performed. Since medical procedures and services are often complex, we sometimes need to supply additional information when we’re coding. CPT Modifiers, like mod­ifiers in the English language, provide additional information about the proce­dure. In English, a modifier may describe the who, what, how, why, or where of a situation. Similarly, a CPT modifier may describe whether multiple procedures were performed, why that procedure was necessary, where the procedure was performed on the body, how many surgeons worked on the patient, and lots of other information that may be critical to a claim’s status with the insurance payer. Certain modifiers may allow a healthcare provider to ask for more money from a payer. Modifiers -22 is one such modifier: If a surgeon performs a procedure that requires significantly more time to complete, due to a complication during the surgery, that procedure may be coded with a -22 at the end, for increased procedural services. Essentially, this modifier lets the payer know that the healthcare provider did more work than the basic CPT code would imply, and should be compensated for that work. CPT Modifiers are always two characters and maybe numeric or alphanumeric. Most of the CPT modifiers you’ll see are numeric, but there are a few alphanu­meric Anesthesia modifiers that we’ll toward the end of this course. CPT modifiers are added to the end of a CPT code with a hyphen. In the case of more than one modifier, you code the “functional” modifier first, and the “in­formational” modifier second. The distinction between the two is simple: you always want to list the modifiers that most directly affect the reimbursement process first. There’s a straightforward reason for this, too. While CMS-1500 and UB-04 forms, the two most common claim forms, have space for four modifiers, payers don’t always look at modifiers after the first two. Because of this, you always want the most important modifiers to be visible. We’ll return to this point in a few exam­ples after we examine the CPT modifiers. Bear in mind that each of the CPT modifiers you’ll find in this course are A) copyrighted by the American Medical Association (AMA) and B) contingent on a number of factors and guidelines. In other words, there are rules for their use. You can’t simply add a modifier to the end of a procedure code if you think it makes sense. There are, for example, a number of modifiers that state they are not compatible with Evaluation and Management (E&M) codes. (medicalbillingandcoding.org.,2021)

Let’s look now at the CPT modifiers that have been approved for the 2013 CPT manual. The following list has all of the CPT modifiers and a brief description of what they mean when it is not already clear.

2013 APPROVED CPT MODIFIERS

• – Increased procedural services

We talked about this example earlier in this course. This modifier lets the payer know that the procedure required substantially more work than would normally be expected. This code is not compatible with E&M.

• – Unusual anesthesia

This modifier will alert the payer to the fact that a procedure that would normally not require general anesthesia does, in fact, require general anesthesia.

• – Unrelated evaluation and management service by the same physician or other qualified healthcare professional during a postoperative period

If a healthcare provider needs to perform an evaluation during a post­operative period, but that procedure is not related to the operation just performed, this modifier is appropriate. This is used with E&M code.

This modifier will alleviate appeals for denied E&M claims during a global surgical period.

• – Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service

If a patient’s condition requires a separate examination on the same day as a surgical operation, and this examination exceeds the usual pre- or postoperative evaluation required with the procedure, this modifier may be added to the CPT code that describes this additional evaluation.

• – Professional component

A professional component is the element of a procedure performed by by a licensed medical professional. This might mean the interpretation of a diagnostic test, rather than the administration of it.

This is reported separately from the technical component of the procedure code.

• – Mandated services

This modifier describes services, consultations, or evaluations that are required by a third party, such as an examination that an insurance company requires of a patient in order to determine medical necessity.

• – Preventive services

Medical services performed in order to prevent or detect future illness or injury, including immunizations, screenings, etc.

47 – Anesthesia by surgeon

This modifier includes general or regional anesthesia administered by the surgeon, but does not include local anesthetic. This modifier would not be used with CPT codes for anesthesia, either.

• – Bilateral procedure

This modifier describes medical procedures performed on both sides of the body. This only applies to parts of the body that are, in fact, bilateral (eg, the kidneys). This code also typically requires that the bilateral procedure be performed in the same operating session.

• – Multiple procedures

One of the most common modifiers, this indicates that the healthcare provider performed more than one procedure in one session. This modifier is added to the secondary (or tertiary, etc) procedure performed after the initial one.

Most payers can pay 100% for the first procedure but reduce reimbursement on subsequent procedures to 50%, sometimes lower depending on the payer.

• – Reduced services

In the case of a procedure being reduced in scope or intensity, or in the case of a physician being unable to complete the procedure, you may use this modifier. Note that this is different from a discontinued procedure (which is modifier -53), but may be used to describe a discontinued procedure or one that is either aborted.

• – Discontinued procedure

If extenuating circumstances demand it, a healthcare provider or surgeon may elect to stop a procedure in the middle of performing it. In cases like this, use -53 at the end of the CPT code to show that the healthcare provider prepared for and initiated the service, only to stop mid-way through.

• – Surgical care only

If a surgeon is performing the surgery, but is not responsible for the pre- or postoperative evaluation or care, you may use this modifier.

• – Postoperative management only

If different healthcare providers perform the surgery and the postoperative care, this modifier may be added to the postoperative care.

• – Preoperative management only

This is identical to -55, but relates to preoperative care instead of postoperative care.

• – Decision for surgery

If, during an evaluation and management procedure, the physician decides surgery is necessary, you may add this modifier to the evaluation and management procedure code.

• – Staged or related procedure or service by the same physician or other qualified healthcare professional during the postoperative period

2013 APPROVED CPT MODIFIERS

This modifier applies to two different circumstances related to an operation on a patient. If, during the initial surgical procedure, the healthcare provider anticipates (or stages) a postoperative procedure, you may use this modifier. Similarly, if the healthcare provider anticipates a postoperative procedure, and this procedure ends up being more exten­sive or time-intensive than initially expected, this modifier lets the payer know that more work was required during this procedure.

• – Distinct procedural service

If two or more distinct services are performed on a patient on on the same date, this modifier can be used to explain why two procedure codes are being reported.

This modifier indicates a procedure or service is independent from other procedures performed on the same day.

• – Two surgeons

In the case of two surgeons operating on a patient at the same time, you may use this modifier to explain to the payer why two separate healthcare professionals are billing for the same procedure performed on the same patient.

• – Procedure performed on infants less than 4kg 66 – Surgical team

This modifier alerts the payer to the fact that a team of more than two surgeons operated on the patient during the procedure.

• – Repeat procedure or service by same physician or other qualified healthcare professional

This modifier may be used when a physician performs the same procedure twice on a patient on the same date. It may also describe multiple diagnostic procedures, like x-rays, that are performed on the same date. This modifier helps prevent claim denials based on duplicate procedures.

This is added to the procedure code with the number of units specified and payment is made for each unit billed.

• – Repeat procedure by another physician or other qualified healthcare professional

This modifier is identical to -76, but applies when a different physician or healthcare professional performs the second procedure or diagnostic test.

• – Unplanned return to the operating/procedure room by the same physician or other qualified healthcare professional following initial procedure for a related procedure during the postoperative period

This modifier indicates that a second operation is performed during what would normally be the postoperative period, usually due to complications with the initial operation.

• – Unrelated procedure or service by the same physician or other qualified healthcare professional during the postoperative period

This modifier describes a secondary operation or procedure that is performed during the postoperative procedure but is not tied to the initial operation.

• – Assistant surgeon

This is a personnel code, which describes a situation in which an assistant surgeon helped with the procedure.

• – Minimum assistant surgeon

This code describes a procedure in which the assistant surgeon was only active for part of the procedure.

• – Assistant surgeon (when qualified resident surgeon not available)

This code is used exclusively in teaching hospitals

• – Reference (outside) laboratory

If a test is performed by a third party other than the treating physician or that physician’s office, you may append this modifier to the end of that procedure code.

• – Repeat clinical diagnostic laboratory test

If diagnostic tests are performed more than once in the same day, this modifier should be added to the procedure code for that test.

Note that this modifier may be used when clinical tests are done twice in order to confirm a diagnosis.

• – Alternative laboratory platform testing

This modifier describes a laboratory test performed with a portable kit that consists, either wholly or in part, of a single­use, disposable element.

99 – Multiple modifiers

Most payers only pay attention to the first two modifiers listed with a procedure code. However, there may be instances where it’s important for the healthcare provider’s reimbursement that the payer acknowledge several modifiers. When this happens, use the -99 modifier to show that there is more than two modifiers.

Let’s take a quick look at an example of CPT modifiers in action.

CPT MODIFIERS EXAMPLE

A surgeon performs a procedure to remove a bone cyst in the upper arm of a pa­tient. The procedure also includes obtaining a graft from elsewhere in the body. Due to minor complications, the surgeon is unable to fully excise the bone cyst.

For the procedure, we’d code 24115, for “excision or curretage of bone cyst or benign tumor, humerus; with autograft (includes obtaining the graft).” Since the procedure was completed but not fully successful, we’d add the -52 modifier, for reduced services, to the code, and we’d end up with 24115-52.

Now let’s say that a team of surgeons is performing a closed, or percutaneous,

angioplasty in a patients renal system. For this procedure, we’d code 35471 for “transluminal balloon angioplasty, percutaneous; renal or other visceral artery,” and we’d add the modifier -66 for “surgical team.” So we’d end up with 35471-66.

• MODIFIERS APPROVED FOR AMBULATORY SURGERY CENTERS (ASC) HOSPITAL OUTPATIENT USE
• PHYSICAL STATUS MODIFIER EXAMPLE
• PHYSICAL STATUS MODIFIER (FOR ANESTHESIA)

Anesthesia procedures have their own special set of modifiers, which are simple and correspond to the condition of the patient as the anesthesia is administered. These codes are:

• Pi – a normal, healthy patient
• P2 – a patient with mild systemic disease
• P3 – a patient with severe systemic disease
• P4 – a patient with severe systemic disease that is a constant threat to life P5 – a moribund patient who is not expected to survive without the operation P6 – a declared brain-dead patient whose organs are being removed for donor purposes

As we said, these are relatively straightforward, but let’s look at an example that will also use some of the CPT modifiers we learned just a minute ago. (medicalbillingandcoding.org.,2021)

Let’s return to that angioplasty example. The patient needs to be anesthetized before undergoing this procedure, so we turn to the Anesthesia section of the CPT codebook and find the code 00216 for “vascular procedures.” Now, kidney problems notwithstanding, our patient is in good health, so we’d add the -P1 modifier to this anesthesia code, and end up with 00216-P1.

CPT modifiers are also used in ambulatory surgery centers (ASC). These hospital outpatient facilities specialize in procedures where the patient leaves the same day. The following CPT modifiers are also approved for use in an ASC hospital outpatient use: -25, -27, -50, -52, -58, -59, -73, -74, -76, -77, -78, -79, and -91.

Most of these modifiers were covered in the section above on general CPT modifiers except for -27, -73, and -74. Modifier -27 describes multiple outpatient hospital E&M encounters on the same date and is relatively self-explanatory. -73 describes the discontinuation of an outpatient surgical procedure before the administration of anesthesia, while -74 describes the same thing except after the administration of anesthesia.

Note that there may be some overlap or contradiction with the set of HCPCS modifiers, which we’ll cover more in depth in its own course later in Section 2.

For example, HCPCS codes, which are used to report procedures to Medicare and Medicaid, have modifiers that describe which side of the body a procedure is performed on. Naturally, these modifiers would contradict the CPT modifier -50, which is used to describe a bilateral procedure.

We won’t dive much deeper than that for now, but just know that HCPCS, another important code set that shares a lot with CPT, has its own set of modifiers, and that it’s important to note which format you need to use for a particular claim.

We’re jumping ahead a little bit here, but know that there are also a number of important modifiers in the Healthcare Common Procedure Coding System, or HCPCS. These modifiers describe things like which side of the body or which body part the procedure is performed on. Since we’ll have to discuss HCPCS in depth before we talk about HCPCS modifiers, you’ll have to wait until the course on HCPCS Codes before you get a full breakdown of these additional bits of code. Just know that there is significant crossover between CPT modifiers and HCPCS modifiers. The HCPCS modifier -LT, for example, often shows up to tell the payer that a typically bilateral procedure was only performed on the left side of the body. Modifiers like this are often of the “informational” variety, rather than the “functional” one, and so should be added after modifiers that directly affect reimbursement (cms.gov.,2021)

SUPPLEMENTAL REPORTS

HCPCS MODIFIERS

Many CPT modifiers require supplemental reports to the health insurance payer. If, for instance, a payer wants to know why a surgery to repair lesions on the liver of a patient was discontinued (let’s say there was a complication with one of the proximal organs), the coder would want to file a supplementary report stating this. We both want to code to the highest level of specificity and provide as much documentation as possible. If a modifier that requires justification of medical necessity is left without a supplemental report, the claim that procedure is on may very well be rejected.