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. CPT Modifiers are always two characters, and may be numeric or alphanumeric. The distinction between the two is simple: you always want to list the modifiers that most directly affect the reimbursement process first.
Because of this, you always want the most important modifiers to be visible. Modifiers 59, 25 and A Guide for Coders. Learn about the pros and cons of in-house billing vs. Click here. Free e-book: Pros and Cons of In-house vs. Outsourced Medical Billing. Proper use of modifiers is important both for accurate coding and because some modifiers affect reimbursement for the provider.
Omitting modifiers or using the wrong modifiers may cause claim denials that lead to rework, payment delays, and potential reimbursement loss. Two important categories are pricing modifiers also called payment-impacting modifiers or reimbursement modifiers and informational modifiers. A pricing modifier is a medical coding modifier that causes a pricing change for the code reported. The Multi-Carrier System MCS that Medicare uses for claims processing requires pricing modifiers to be in the first modifier position, before any informational modifiers.
On the CMS claim form, the appropriate field is 24D shown below. You enter the pricing modifier directly to the right of the procedure code on the claim. Most providers use the electronic equivalent of this form to bill Medicare for professional pro-fee services.
Claims that do not have the pricing modifier in the first position may encounter processing delays. To assist with proper reporting and modifier placement, individual payers may provide lists that distinguish pricing modifiers from informational modifiers for their claims.
An informational modifier is a medical coding modifier not classified as a payment modifier. Another name for informational modifiers is statistical modifiers. These modifiers belong after pricing modifiers on the claim. Although you would not receive payment for the Column 2 code of the edit without modifier 59 on one of the codes from the edit pair, you may find modifier 59 classified as an informational modifier rather than a payment modifier.
Bypassing or overriding an edit is also called unbundling. Modifier 59, referenced in the previous section, is just one of the modifiers that can bypass an NCCI edit. Below is an overview of these modifiers.
You should report different diagnosis codes, however, only if the documentation supports them. Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. If more than one evaluation and management face-to-face service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems.
Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level. Medicare also includes the decision to perform a minor surgical procedure in the procedure code, the NCCI manual states.
Here is an example of when to use modifier 25 based on a scenario in Medicare Claims Processing Manual , Chapter 12, Section Suppose the physician sees a patient with head trauma and decides the patient needs sutures.
After checking allergy and immunization status, the physician performs the procedure. Appending modifier 59 signifies the code represents a procedure or service independent from other codes reported and deserves separate payment. Like modifier 25, modifier 59 is difficult to master because it requires determining whether the code is truly distinct and separately reportable from other codes.
For instance, you may be able to use anatomic modifiers to demonstrate that procedures occurred at separate sites on the body. As an example, the first-quarter Medicare NCCI PTP edits include the edit pair Arthroscopy, shoulder, surgical; with rotator cuff repair and Arthroscopy, shoulder, surgical; synovectomy, partial.
This specificity gives auditors, payers, and providers more information to help them determine which type of reporting is prone to errors. Medicare still accepts modifier 59, but check with individual payers to see which modifiers they prefer for a distinct procedural service.
The policy applies to work performed by same-specialty members of the same group. This article has already explained that global period indicators are relevant to modifier 25 and 57 use. Suppose, for example, that a biopsy reveals a malignant tumor. Another important global package modifier is modifier 58 Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period.
You should append modifier 58 to the code for the staged or related procedure. It is also useful to periodically audit your claims to confirm you are using the appropriate codes.
Click here for best practices to employ when auditing your billing. The correct modifier to use is determined by payor preference. Before assigning a modifier to establish where a procedure took place, it is essential to check if an ICD diagnosis code is able to provide the information. For example, pain in the right lower leg would be M Diagnosis coding always requires the most specific code possible. It may not be necessary to include a modifier if the description is contained in the ICD coding.
Like all billing scenarios, the use of a modifier can vary in reference to ICD coding, so if you have any questions, it is best to check with the payor. Modifier 22 is used to describe an increased workload associated with a procedure.
This modifier should be used in exceptional cases only, and payors will frequently require documentation of the service before they make payment. For example, 22 can be used when there is unusual or excessive hemorrhaging during a procedure. The correct use of a 25 modifier is usually indicated when there is two distinct diagnoses made during the visit. However, under the right circumstances, only one diagnosis may be required.
For more detailed information, visit our fact sheet about using this modifier. Modifier 26 indicates the professional service of a CPT that has a global professional and technical definition. For example, an orthopedist receives an x-ray and determines a diagnosis from the x-ray.
The correct code CPT would be because the x-ray was taken elsewhere. The CPT without the modifier would indicate that both the x-ray and its interpretation were done by the same provider group. Modifier 50 indicates that a procedure took place on both sides of the body. Before applying this modifier, it is important to check the definition of the CPT to confirm bilaterally is not already mentioned in the code definition.
Modifier 51 indicates that multiple procedures were performed by the same physician in the same session. The procedure with the highest reimbursement should be listed first without the modifier and additional procedures listed in order of reimbursement value with the modifier.
For example, if a patient were to come in for multiple x-rays, the first x-ray with the highest reimbursement would be coded with the CPT, and all subsequent X-rays would be amended with modifier Modifier52 indicates that the physician has elected to discontinue a service or procedure.
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