Modifiers
A medical coding modifier is two characters (letters or numbers)appended to a CPT or HCPCS level II code. The modifier provides additional information about the medical procedure, service, or supply involved without changing the meaning of the code. Medical coders use modifiers to clarify what occurred during an encounter.
A coder may use a modifier to indicate that a service did not occur exactly as described by a CPT or HCPCS Level II code descriptor. A modifier also may provide details not included in the code descriptor, such as anatomical location of the procedure. The CPT code book provides examples of when a modifier may be appropriate:
The service or procedure has both professional and technical components
More than one provider performed the service or procedure
More than one anatomical location was involved
A service or procedure was increased or reduced in comparison to what the code typically requires
The procedure was bilateral
The service or procedure was provided to the patient more than once
Proper use of modifier is important both for accurate billing and because modifies affect reimbursements. Omitting modifiers could affect reimbursements and could cause timely denials. Code it right the first time and avoid labor intensive work. One other note, modifiers are never to be used to provide reimbursement only. In my many years of experience I have seen providers use modifiers just to get reimbursed. Modifiers assist in getting reimbursed for services provided. Always code according to what has been documented.
CPT Modifiers
CPT modifiers are generally two digits. These are examples of the most commonly used CPT modifiers:
25 Significant, seperatel 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
59 Distinct procedural service
24 Unrelated E&M service by the same physician or other qualified healthcare professional during a postoperative period
79 Unrelated procedure or service by the same physician or other qualified healthcare professional during the postoperative period
HCPCS Level II Modifiers
HCPCS Level II modifiers are alphanumeric or have two letters. Below are some examples of HCPCS Level II Modifiers:
E1 Upper left, eyelid
TC Technical component
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
NCCI Modifiers
An NCCI modifier is a modifier that Medicare and Medicaid accept to bypass an NCCI edit under appropriate clinical circumstances. Bypassing or overriding an edit is also called unbundling.
Modifier 25 (Significant, separately identifiable E/M service by the same physician or other qualified health care professional on the same day of the procedure or service)
When a patient has a separate E/M service along with a procedure or other service on the same day by the same provider, you may report that E/M code separately for reimbursement by appending modifier 25 to the E/M code. Many coders find that determining whether an E/M code is significant and separately identifiable is the most problematic requirement for modifier 25 use. the documentation must clearly show that the provider performed extra E/M work beyond the usual work required for the other procedure or service on the same date. In other words, if you removed all the documentation for the procedure, would the documentation support an E/M code?
Example: Physician sees patient with head trauma and decides the patient needs sutures. After checking allergy and immunization status, the physician performs the procedure. An E/M is not separately reportable in the scenario. However, if the physician performs a medically necessary full neurological exam fo the head trauma, then reporting a separate E/M with modifier 25 appended would be appropriate.
Modifier 59 (Distinct procedural service)
Modifier 59 is a medical coding modifier that indicates documentation supports reporting non-E/M services or procedures together that you normally wouldn’t report on the same date. Appending modifier 59 signifies the code represents a procedure or service independent from other codes reported and deserves separate payment. The CPT definition of modifier 59 advises that the modifier may be appropriate for a code when documentation shows at least on of the following:
A separate patient encounter or session
A different procedure or surgery
A different anatomic site or organ system
A separate incision/excision
A separate lesion
A separate injury
A separate injury
Modifier 24 (Unrelated E/M by the same physician or other qualified health care professional during a postoperative period)
Modifier 24 is appropriate for use only on E/M codes during a postoperative period following a procedure that has global days associated with it.
Example: Patient has a biopsy and it is determined to be a malignant tumor. The patient returns during the biopsy’s global period for suture removal and on the same date has a discussion with physician about treatment options. The work and time discussing treatment options with patient can be reported with E/M code with a modifier 24 appended to indicate it not associated with the initial procedure. CPT surgery section guidelines provide wording “Care of the condition for which the diagnostic procedure was performed or of other concomitant conditions is not included and may be listed separately.”
Modifier 79 (Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period)
Example: Suppose a patient has a right eye cataract extraction reporting using 66984. The same patient then has a left eye cataract extraction (again 66984) by the same physician during the global period for the first procedure. You would append modifier 79 to the code for the second procedure. Although both procedures require the same code, they are unrelated because each surgery was on a different eye.
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