Coding with Modifiers

Presented by Deborah Grider CMA, CPC, CPC-H, CPC-P, CCS-P, EMS, RMC Medical Professionals, Inc

Disclaimer
This material, or parts thereof, may not be reproduced, stored in a retrieval system or transmitted in any form by any means (electronic, mechanical, photocopying, recording, or otherwise) without the express prior written consent of the publisher. Pursuant to the protection of proprietary documentation under established copyright laws, the attendee may not distribute and/or sell all or any portion of this material. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. The information herein is accurate as of the publication date and is subject to change in interpretation. Failure to abide fully with all the terms and conditions contained in this material may result in possible civil and criminal penalties including liquidating damages. This material is the property of Deborah Grider, CMA, CPC, CPC-H, CPC-P, CCS-P, EMS Copyright 1995-2006. All Rights Reserved. All CPT codes, descriptions, and two-digit modifiers, only. Copyright 1996-2006, American Medical Association (AMA). All Rights Reserved. Though all of the information has been carefully researched and checked for accuracy and completeness, Deborah Grider does not accept responsibility or liability with regard to errors, omissions, misuse and misinterpretation. Please keep in mind that every insurance company has processing and reimbursing procedures that are individual to each particular company. Instructions and recommendations given in this booklet should not be interpreted as applying specifically to every insurance carrier. Please confirm with your carriers coding practices that are applicable to each carrier.

MODIFIER OBJECTIVES
At the conclusion of this session, you should be able to: explain what CPT modifiers are and their importance to receiving correct reimbursement identify when and how to use CPT modifiers

MODIFIERS
In todays regulatory environment, it can be a real challenge to obtain reimbursement for procedures and services rendered Accurate coding is the most crucial step in the reimbursement process

MASTERING MODIFIERS
Coders need to use all the tools at their disposal to facilitate the reimbursement process Modifiers are overlooked tools

-22, -24, -32, -25 -52, -80, -56, -57 -78, -76, -90, -21

WHAT IS A MODIFIER?
A modifier provides the means by which the rendering physician may indicate that a service or procedure has been performed, or has been altered by some specific circumstances, but not changed in its definition or code They are essential ingredients to effective communication between providers and payors

WHAT IS A MODIFIER?
Just as modifiers in the English language provide additional information, CPT modifiers also answer such questions as which one how many what kind when what

WHAT IS A MODIFIER?
Modifiers are essential tools in the coding process They are used to enhance a code narrative to describe the circumstances of each procedure or service how it individually applies to the patient

WHAT IS A MODIFIER?
Primary functions show that a service has been modified but not changed in its identification or definition explain special circumstances or conditions of patient care indicate repeat or multiple procedures method to show cause for higher or lower costs while protecting charge history data

MODIFIERS
A complete listing of CPT modifiers is found in Appendix A of CPT Two or more modifiers may be used with one code to give the most accurate description possible for that service

MODIFIERS
Not all modifiers can be used in every section of CPT Consult with carriers regarding the use of twodigit modifier

Step By Step Guidance

Review CPT (AMA) Guidelines Review individual carrier guidelines Reference the practitioners or facilities patient medical record and/or visit note prior to appending modifiers Use only 2 digits when appending modifiers (unless instructed otherwise by an individual carrier) With implementation of standard code sets with HIPAA (Healthcare Insurance Portability and Accountability Act), five digit modifiers are no longer accepted.

Step By Step Guidance

Provide training for physicians, staff, clinicians, etc and update training regularly Take a proactive approach and find the errors in modifier application before the claim is submitted to the insurance carrier. Understand that insurance carrier interpretations are not always the same interpretation as CPT. Review the National Correct Coding initiative (NCCI) each quarter for correct modifier usage for each CPT code that your organization uses

Modifier Tips
Always have the most recent edition of the CPT book on hand. Have your billing staff regularly attend coding workshops. Remember that modifiers are often used differently for physician services and hospital outpatient services. Learn as much as you can about using coding modifiers so you can help your billing staff with coding questions.

MODIFIER 21 Prolonged Evaluation and Management (E/M) Service

This modifier is used only with E/M codes and is used when the service exceeds the highest level within a given category A report must be submitted to the carrier

MODIFIER 21 Prolonged Evaluation and Management (E/M) Service

Initial office evaluation of a 65-year-old woman with exertional chest pain, intermittent claudication, syncope and a murmur of aortic stenosis. The physician performs a comprehensive history and comprehensive physical examination including supine and upright blood pressures, vascular system in neck and extremities, heart, neurological system. Medical decision making is of high complexity and involves ordering appropriate diagnostic procedures electrocardiogram, 2-D and Doppler echocardiography for estimated degree of stenosis and function of ventricle, chest x-ray to check for cardiac hypertrophy and valvular and/or aortic root calcification) and decision regarding hospitalization for cardiac catheterization and coronary angiography and possible head-up tilt table testing. Alternative approaches to diagnosis and therapy are explained to the patient. The physician spent an additional 30 minutes with the patient discussing alternative treatment and therapy with the patient. CPT Code: 99205-21

MODIFIER 22 Unusual Procedural Services

Use this modifier when the service provided is greater than that described by the procedure code Specific examples of unusual circumstances include: Increased risk Severe respiratory distress excessive bleeding (more than 500 cc) friable tissue

Appropriate Use Modifier 22

Trauma extensive that requires additional work enough to complicate the particular procedure and cannot be billed with additional procedures Significant scaring requiring extra time and work Extra work due to morbid obesity Increased time due to extra work by the physician

Invalid Use
Modifier 22 is not valid when there is also a "re-operation" code used with the primary procedure code. For example, if the patient has had previous coronary artery bypass surgery (CABG) and is now undergoing a new CABG, code 33530 is billed in addition to the primary procedure. Modifier 22 is not valid if the purpose of the complication is based on the surgeons choice of approach (e.g., open, laparoscopic). Modifier 22 is not valid to describe an average amount of lysis or division of adhesions between organs and adjacent structures. Routine lysis of adhesions is considered an integral and inclusive part of the procedure

Considerations for Modifier 22

The surgeon's documentation should be thorough. If it does not indicate the nature of the difficulty or the extra work performed, you should not expect carriers to automatically bump up the fee. The documentation should be submitted with the claim because modifier 22 claims may spur an automatic manual review. The additional time and work must be significant. Many coding specialists say that unless 25 percent more work was performed, modifier 22 should not be appended. For CMS, and many other third party payers, the physician's operative time is increased by 50 percent or more, modifier 22 should be appended. A second diagnosis code may be required to warrant the unusual circumstances. Any additional fees should be charged up front to payers, which are unlikely to raise fees on their own just because modifier 22 is appended.

MODIFIER 22 Unusual Procedural Services

A physician performed a laminotomy with decompression of the nerve root with a partial facetectomy, foraminotomy, and excision of a herniated disk. During the surgery the physician encountered excessive bleeding (hemorrhage) which was difficult to control. This required an additional 60 minutes of time to complete the surgery. 63020-22-Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk; one interspace, cervical

MODIFIER 24 Unrelated E/M Service by the Same Physician During a Postoperative Period
To use this modifier, the E/M service must be unrelated to the surgery, but provided within the global care postoperative period. Use when patient care is by the same physician for surgery and E/M service. Medicare Carrier Manual (MCM 4822 and 4824) indicates that an evaluation and management service(s) submitted with modifier 24 must be sufficiently documented to establish that the visit was unrelated to the surgery. The diagnosis must support that the claim is unrelated to the initial procedure. In order for 99291 or 99292 (critical care) to be paid for services furnished during the preoperative or postoperative period, with modifier24, the documentation must support that the critical care was unrelated to the specific anatomic injury or general surgical procedure performed must be submitted.
An ICD-9-CM code in the range 800.0 through 959.9 (except 930-939) which clearly indicates that the critical care was unrelated to the surgery is acceptable documentation.

MODIFIER 24 Unrelated E/M Service by the Same Physician During a Postoperative Period
To use this modifier, the E/M service must be unrelated to the surgery, but provided within the global care postoperative period. Use when patient care is by the same physician for surgery and E/M service. Medicare Carrier Manual (MCM 4822 and 4824) indicates that an evaluation and management service(s) submitted with modifier 24 must be sufficiently documented to establish that the visit was unrelated to the surgery. The diagnosis must support that the claim is unrelated to the initial procedure. In order for 99291 or 99292 (critical care) to be paid for services furnished during the preoperative or postoperative period, with modifier24, the documentation must support that the critical care was unrelated to the specific anatomic injury or general surgical procedure performed must be submitted.
An ICD-9-CM code in the range 800.0 through 959.9 (except 930-939) which clearly indicates that the critical care was unrelated to the surgery is acceptable documentation.

MODIFIER 24
A 65-year-old diabetic man who is pacemaker dependent is noted to have episodic failure to pace. Non-invasive telemetry has been performed and a low impedance detected. The patient is taken to the catheterization laboratory after receiving mild sedation. A temporary transvenous pacemaker is inserted through the contralateral internal jugular vein and its pacing parameters tested. The original pacer site is prepped and under local anesthesia the pacer and lead are carefully dissected free of scar tissue. The lead is disconnected from the pacer and visually inspected. Its electrical integrity is evaluated with a pacing system analyzer. A focal defect in external insulation is noted and repaired using a piece of tubular insulation, adhesive, and suture material. The electrical integrity is confirmed using the pacing system analyzer. The temporary lead is withdrawn and the pacemaker and repaired lead carefully re-inserted into the pocket which is closed in layers. The entire procedure is performed with automated cuff blood pressure, pulse oximeter, and ECG monitoring. The patient returned four weeks later for routine follow up with complaints of lethargy, and weakness. His blood sugars have been ranging between 280 and 350 for the past week.. The physician performed an expanded problem focused examination and determined the patients insulin needed to be adjusted in addition to counseling on diet and exercises. Routine follow up for the pacemaker was also performed. 99213-24-Office or other outpatient visit for the evaluation and management of an established patient, which requires at least two of these three key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity.

MODIFIER 25 Significant Separately Identifiable E/M Service by the Same Physician Physician on the Same Day of the Procedure or Other Service Patient care is by the same physician for procedure and E/M service May need to indicate that the patients condition required a significant, separately identifiable E/M service on the day a procedure or service identified by a CPT code was performed above and beyond the other service provided This modifier is not used to report E/M service that resulted in a decision to perform major surgery

MODIFIER 25 CMS Policy

Modifier 25 should be used only when a significant, Separately Identifiable E/M visit is rendered on the same day as a minor surgical procedure. Payment for preoperative and postoperative visits is included in the payment for the procedure. For minor procedures, where the decision to perform the minor procedure is typically made immediately before the service (e.g., whether sutures are needed to close a wound, whether to remove a mole or wart, etc.), the E/M visit is considered to be a routine preoperative service and should not be billed in addition to the minor procedure.
The policy applies only to minor surgeries and endoscopies for which a global period of 0-10 day applies.

MODIFIER 25 CMS Policy Guidance

A good standard for determining whether the 25 modifier should be used is this: If documentation of the patients clinical record, that extra pre-op and/or post-op work beyond what is usually performed with that service was performed, then it is proper to use the 25 modifier to indicate that extra work. To document the extra work performed, the clinical record should clearly indicate that extra or unusual work. The physician must determine if the E/M service for which he/she is billing is distinct from the surgical service.

MODIFIER 25 Example
An established patient presented with a 2.0 cm laceration of the right index finger. While there the patient asked the physician to evaluate swelling of the left leg and ankle and an expanded problem focused history and physical examination with low medical decision-making was performed for this problem. CPT Codes billed: 12001 with diagnosis code 883.0-Open wound of finger(s) without mention of complication and 99213-25 Diagnosis Code(s): 719.0-Effusion of joint 883.0-Open wound of finger(s) without mention of complication

MODIFIER 25 Example
Medicare patient presents with complaints of left knee pain. The physician evaluates the knee and determines the patient would benefit from Arthrocentesis. The physician gives the patient an injection and schedules a follow up visit for one month. In this example it would not be appropriate to bill the Evaluation and Management Service because the focus of the visit is related to the knee pain, which precipitated the Arthrocentesis. Correct Coding: 20610 20610 Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, knee joint, subacromial bursa)

MODIFIER 25 Example
An established Medicare patient visited her internist in follow up for hypertension and diabetes. The patient also complains of left knee pain, which started to bother her while working in the garden. The physician performs a problem-focused history and examination, evaluates the patients hypertension, and determines the blood pressure is higher than it should be and adjusts medications. The patients blood sugar is doing well and the diabetes is well controlled with the current insulin regimen. During the encounter, the physician also evaluates the knee and determines the patient would benefit from Arthrocentesis. The physician gives the patient an injection and schedules a follow up visit for one month. Correct coding: 99212-25, 20610

MODIFIER 26 Professional Component

Some procedures can be divided into a professional only component (performed by the physician) and a technical only component (technicians portion). Modifier -26 is used to describe the portion of the service that is performed by a physician. The technical component includes: providing the equipment supplies technical personnel costs attendant to the performance of the procedure other than the professional services The professional component includes: the physician's work in providing the services (e.g., reading films, interpreting diagnostic tests, etc) interpretation and written report provided by the physician performing the service.

MODIFIER 26 Professional Component

If the physician owns the x-ray machine, buys the supplies, and pays the personnel in addition to reading the x-ray, the modifier -26 would not be used A physician has x-ray equipment in his office and performs a PA and lateral chest x-ray. The physician also reviews the x-ray and dictates a report 71020

MODIFIER 26 Professional Component

Some CPT codes are indicated to be the professional component only, or the technical component only. No modifiers would be appended to these codes A facility performs a 12 lead EKG and has an independent physician read the strip 93005 Tracing only (facility) 93010 Interpretation and report only (physician)

MODIFIER 26 Professional Component

A 5-year-old boy with an implanted programmable CSF valve and shunt system, is referred by a pediatrician for recent onset of constant complaints of headache. His history includes implantation of the shunt 3 years prior for hydrocephalus. After reviewing the patient chart and previous films, and evaluating the patient in the office, the surgeon decides to decrease the shunt pressure. The surgeon orders a radiograph to determine the current setting of the shunt valve. After reviewing the results of the radiograph, the physician reprograms the shunt from 120 mm H2O to 80 mmH2O. This is done in the radiology department. After confirming the pressure setting, the patient is released from radiology department. The surgeon dictates a written interpretation report and a follow-up phone call to the boy's family several days later finds that a headache has not occurred since the reprogramming. The written report is sent to the referring pediatrician.

CPT Code billed by the Surgeon: 62252-26 CPT Code billed by Radiology Department: 62252-TC

MODIFIER 26 Professional Component

A pathologist performs a level II gross and microscopic examination of an appendix. The pathologist is independent, is contracted by an independent laboratory and he is providing only the professional component of the procedure. CPT Code billed: 88302-26-Level II - Surgical pathology, gross and microscopic examination.

MODIFIER 32 Mandated Services

Many third party payors and professional review organizations require an independent evaluation of a patient prior to procedures being performed. This modifier describes the visit required by the payor or review organization This modifier is not for a consultation with another physician for patient comfort or reassurance This modifier is also not used when another physician evaluates a patient for medical clearance prior to a procedure

MODIFIER 32 Mandated Services

A patient is seen by a consulting physician in the office prior to a hysterectomy to verify medical necessity at the insurance carriers request. 99243-32

MODIFIER 32 Mandated Services

A 40-year-old male presents who sustained a work-related back injury without subsequent surgical repair/reconstruction, who has participated in an acute therapy program and who continues to exhibit pain, weakness, fatigue, stiffness, and possible psychosocial limitations. Return to work potential is undetermined. The workers compensation carrier requests an evaluation of the patients current condition and prognosis from an orthopedic surgeon for a second opinion. The physician performs a comprehensive history and examination with moderate complexity decision making CPT Code billed: 99274-32-Confirmatory consultation for a new or established patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity.

MODIFIER 47 Anesthesia By Surgeon

This modifier is to be used when the surgeon performs and administers regional or general anesthesia in addition to the surgical procedure Do not use this modifier for local anesthesia Do not use this modifier with anesthesia procedures 00100 - 01999 Do not use this modifier if the surgeon is monitoring general anesthesia performed by an anesthesiologist, CRNA, resident, or intern

MODIFIER -47 -47 Anesthesia By Surgeon

The surgeon initiates a regional Bier block. The physician monitors the patient and block while performing a flexor tendon repair of the forearm 25260-47

MODIFIER 50 Bilateral Procedures

Most of the bilateral procedures listed in the Surgery section have been deleted This modifier is to be used when surgeries are performed bilaterally during the same operative session The bilateral surgery may be performed through the same incision separate body parts

MODIFIER -50 -50 Bilateral Procedures

The surgeon performed a carpal tunnel on the right and left during the same operative session CPT requires listing the procedure code once and the modifier once 64721-50 Some carriers prefer a two code listing 64721, 64721-50

MODIFIER 50 Bilateral Procedures

The surgeon performed a carpal tunnel on the right and left wrist during the same operative session for a 40 year old female with carpal tunnel syndrome CPT code billed: 64721-50-Neuroplasty and/or transposition; median nerve at carpal tunnel Diagnosis code: 354.0 carpal tunnel syndrome

MODIFIER 51 Multiple Procedures

This modifier is used to identify the secondary procedure or when multiple procedures are performed on the same date or during the same operative session by the same physician The procedures may be in the same operative incision or at a different anatomical site Always list the major procedure (highest dollar value) first and append the modifier to subsequent procedures

MODIFIER 51 Guidance
51 modifier is only appended to secondary procedure codes when multiple procedures are performed on the same date When multiple procedures, other than Evaluation and Management Services, are performed on the same day or at the same session by the same provider, the major primary procedure or service may be reported as listed. The secondary additional, or lesser procedure(s) or service(s) may be identified by adding appending the modifier 51 to the secondary additional procedure or service code(s) This modifier may be used to report multiple medical procedures performed at the same session, as well as a combination of medical and surgical procedures, or several surgical procedures performed at the same operative session

MODIFIER 51 Multiple Procedures

A middle-aged patient presents with progressive, painful restriction of the hallux metatarsophalangeal joint. The patient has been treated conservatively without success. The patient is treated surgically with a distal first metatarsal cheilectomy. This includes removal of bone at the distal first metatarsal, proximal phalanx, debridement of the MTP joint, and capsular. During the same operative session the surgeon corrects a hammertoe on the third toe.

MODIFIER 51 Multiple Procedures

CPT Codes billed: 28289 (primary procedure) and 28285-51 (secondary procedure. 28289 Hallux rigidus correction with cheilectomy, debridement and capsular release of the first metatarsophalangeal joint 28285-51 Correction, hammertoe (eg, interphalangeal fusion, partial or total phalangectomy)

MODIFIER -51 -51 Multiple Procedures

Some of the listed procedures in CPT are commonly carried out in addition to the primary procedure performed All add-on codes found in CPT are exempt from the multiple procedure concept

MODIFIER 52 Reduced Services

Used to identify when a service or procedure is less extensive than the description given in CPT would indicate it to be This may be used to identify an aborted procedure Use this modifier to identify an attempted procedure that cannot be completed It should not be used to identify gift reductions or discounts such as waiving fees or family/friend/professional discounts.

MODIFIER 52 Reduced Services

To develop a reduced fee, try calculating the reduced service by time. Calculate the amount (cost) per minute of the complete procedure; times the amount per minute by the time it took to do the reduced procedure The preferred method is to bill the carrier the full amount and let the insurance carrier determine the value of the service

MODIFIER 52 Reduced Services

A 28-year-old woman, established patient, presents to the office for a health evaluation and physical examination. Her interval past medical, family and social history is reviewed. A complete review of systems is documented. A detailed physical is performed. The patient refused a pelvic examination. Pap smear and breast exam. Counseling is provided regarding diet and exercise, substance use, sexual activity and dental health. Risk factors are identified and interventions discussed. Medically appropriate lab tests are ordered. CPT Code billed: 99395-52 with the diagnosis of V70.0

MODIFIER 52 Reduced Services

A male, who is blind, presents with bilateral upper extremity amputation at the wrist, requiring tendon transfer and interosseous release to allow abduction and adduction of the radius from the ulna (Krukenberg procedure). At operation, tendons are transferred, but due vascular malformation, the surgeon was unable to release the interosseous membrane. The skin flaps are rotated as needed, and the arm is placed in a bulky dressing. CPT Code billed: 25915-52 Krukenberg procedure

MODIFIER 52 Reduced Services

A 27-year-old woman is at 42-weeks gestation, 2 weeks past her due date. She needs evaluation of fetal well being in order to facilitate a decision of whether to induce labor or not. A fetal biophysical profile with non-stress testing is obtained. The health of a term or near-term fetus is assessed using ultrasound to monitor the fetus' movements, tone, and breathing. The amniotic fluid volume could not be checked. The fetal heart rate was monitored electronically in a biophysical profile. A nonstress test was conducted to monitor the baby's heart rate over a period of 20 minutes to look for accelerations with the baby's movement. CPT code billed: 76818-52 and 76818 Fetal biophysical profile; with non-stress testing

MODIFIER -52 -52 Reduced Services

Attempted to excise vascular malformation of the hand, deep. Unable to completely excise secondary to entrapment of other structures 26116-52

MODIFIER 53 Discontinued Procedure

This modifier describes procedures that have been discontinued due to extenuating circumstances Usually the patients well-being is threatened, thereby precipitating the physicians decision to terminate the procedure This modifier should not be used if a surgical procedure is canceled prior to the patients anesthesia induction and/or surgical preparation in the operating room

MODIFIER 53 Discontinued Procedure

A 68 year-old patient scheduled for a duodenal intubation and aspiration was taken into the laboratory where the procedure was to be performed. The patient was given a local anesthetic by the physician and a tube was inserted nasally and positioned in the duodenum. Prior to obtaining the specimen, the patient experienced severe nausea with vomited. The physician elected to discontinue the procedure prior to obtaining the specimen. CPT code billed: 89100-53 89100-53 Duodenal intubation and aspiration; single specimen (eg, simple bile study or afferent loop culture) plus appropriate test procedure

MODIFIER 53 Discontinued Procedure

A patient presented to the operating room for a diagnostic arthroscopy of the knee. The physician inserted the arthroscope and the patient suddenly went into respiratory distress. The arthroscope was withdrawn and the procedure was terminated 29870-53

MODIFIERS 54, 55,56 CPT Global Surgical Package

CPT MAJOR SURGRY PRE-OP LOCAL INFILTRATE TOPICAL ANESTHESIA SURGERY POST-OP

CPT MODIFIER 56

CPT MODIFIER 54

CPT MODIFIER 55

MODIFIER 54 Surgical Care Only

Used when the surgeon provides the surgical care only without pre- or postoperative services Fees and reimbursement should be reduced to represent the surgical portion of the global service

MODIFIER 56 Preoperative Management Only

To be used when the physician provides only the preoperative care May be used when the physician prepares the patient for surgery performed by another physician Fees and reimbursement should be adjusted accordingly

MODIFIER 56 Preoperative Management Only

A patient in a rural area sees her general surgeon regarding abdominal pain. The patient has a prior history of abdominal surgery and x-rays and laboratory testing is performed. The physician assesses the patient and determines the patient needs surgery. Since the physician does not perform this surgery, the patient is sent to a gastroenterologist. The general surgeon contacts a gastroenterologist, provides all supporting data and testing and surgery is scheduled. The general surgeon sends a letter to the surgeon requesting he provide only the surgical portion of the surgery and he will provide the postoperative care. The general surgeon bills: 44120-56 44120-56, 55 Enterectomy, resection of small intestine; single resection and anastomosis

MODIFIER 54 Surgical Care Only

This 67-year-old female presents to the surgeon with a prior history of abdominal surgery and a strictured segment of small bowel evident on small bowel follow-though radiographs. Prior to the surgery. the surgeon reviews laboratory and x-ray/imaging studies to plan the operative approach; discusses the procedure with the patient, and obtains informed consent. At operation, dissection of the small bowel is performed. The strictured segment is mobilized and resected, and bowel continuity is reestablished. The patient is released from the hospital the next morning in good condition and a transfer of care occurs back to the general surgeon in her home town.

The surgeon bills: 44120-54 44120-54 Enterectomy, resection of small intestine; single resection and anastomosis

MODIFIER 54 Surgical Care Only

MODIFIER 55 Postoperative Management Only

Used when the physician provides only the follow-up care during the global period Surgery was performed by a different physician The physician providing the follow-up care does not perform, nor assist with the surgical procedure Fees and reimbursement should be reduced to represent postoperative management only

MODIFIER 55 Postoperative Management Only

If complications are encountered, they should be billed using the appropriate CPT codes The patient was seen and evaluated by a general surgeon 100 miles away at the nearest hospital. The surgeon performed the surgery. The patient returned home and all follow-up care was rendered by the primary care physician 49505-55

Global Split

MODIFIER 57 Decision for Surgery

This modifier is appended to the appropriate E/M service to denote the visit where the decision to perform surgery was made Modifier is used when the decision for major surgery is made the day of or the day prior to performing the procedure Assists in recouping payment for this visit because many payors will reimburse the visit where surgery is decided, but will not pay for other preoperative visits

MODIFIER 57 Decision for Surgery

Modifier indicates to the payor that additional time and effort was necessary and all necessary counseling, including risks and outcomes were discussed with the patient There is no increase in fee for use of this modifier

MODIFIER 57 Decision for Surgery

A physician is consulted to determine if surgery is necessary for a 72-year old Medicare patient with severe abdominal pain. The physician services meet the criteria necessary to report a consultation, including documented findings and he/she communicates with the requesting physician. The physician documents a 99244 consultation. The requesting physician agrees with the consultant's findings and requests that the consultant take over the case and discuss his findings with the patient.

MODIFIER 57 Decision for Surgery

The patient consents to undergo surgery to repair a perforated ulcer; the operation is performed later that same day. The procedure planned based on findings is 44602-Suture of small intestine (enterorrhaphy) for perforated ulcer, diverticulum, wound, injury or rupture; single perforation. The global days based on CMS guidelines is 90 days for this planned procedure CPT code billed: 99244-57

MODIFIER 57 Decision for Surgery

A patient well known to the cardiologist with CAD was seen for the patients annual visit. The patient had not seen the cardiologist for the past year. After performing a comprehensive history and detailed examination, the cardiologist determined the patient would benefit from a valve replacement and scheduled surgery the following day. The patient is counseled for 15 minutes regarding treatment options, risks, and projected outcomes. The procedure that was planned was a Valvuloplasty, mitral valve, with cardiopulmonary bypass (33425) CPT code billed: 99214-57

MODIFIER 58
Physician may need to indicate that the performance of a procedure or service during a post-operative period was:
planned prospectively at the same time as the original procedure (staged) more extensive than the original procedure for therapy following a diagnostic surgical procedure

Example
The graft is performed 10 days following an allograft application of pigskin to allow underlying tissues time to heal. The surgeon knows at the time of the allograft that grafting will be performed at a later date. The procedure was planned at time of original surgery

Correct Coding
Code 15760-- graft composite, including primary closure Code 15760-58 graft composite, including primary closure-staged or related procedure or service by same physician during postoperative period Using modifier 58 lets the carrier know this additional procedure was planned during the postoperative period

Example
A surgeon performs a radical mastectomy (19200) on a 56 year-old female patient. The patient indicated she preferred a permanent prosthesis after the surgical wound healed. The surgeon took the patient back to the operating room on during the postoperative global period and inserted a permanent prosthesis. CPT Code billed: 11970-58 (second procedure for the permanent prosthesis) 11970-58 Replacement of tissue expander with permanent prosthesis

Example
A diabetic patient with advanced circulatory problems has three gangrenous toes removed from her left foot (28820, 28820-51, 28820-51). During the postoperative period it becomes necessary to amputate the patient's left foot CPT code billed: 28805-58 28805-58-Amputation, foot; transmetatarsal

Example
A surgeon performed a choroidal neovascularization (G0186) on a Medicare patient using a photocoagulation technique. Due to the size and location of the lesions the physician accomplished the procedure in three operative sessions on three separate days. A modifier is not appended because the code descriptor indicates more than one session might be necessary to complete the procedure. CPT code billed: G0186 G0186-Destruction of localized lesion choroids (for example, choroidal neovascularization), photocoagulation, feeder vessel technique (one or more sessions)

MODIFIER 59 Distinct Procedural Service

under certain conditions the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. a different session or patient encounter different procedure or surgery different site or organ system separate incision/excision separate lesion separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician

Example
Excision of a benign lesion of the chest and Irrigation and Drainage of an abscess on the neck Code 11400--Excision benign lesion, except skin tag, trunk, arm, or legs; lesion diameter 0.5 cm or less Code 10060-59-- I & D of abscess
distinct procedure

Example
A patient underwent placement of a flow directed pulmonary artery catheter for hemodynamic monitoring via the subclavian vein (93503). Later in the day, the catheter must be removed and a central venous catheter is inserted through the femoral vein CPT code(s) billed: 93503-Swan-Ganz catheter and 36010 93503 Insertion and placement of flow directed catheter (eg, Swan-Ganz) for monitoring purposes 36010-59 Introduction of catheter, superior or inferior vena cava

Rationale
Because the pulmonary artery (PA) catheter requires passage through the vena cava, it may appear that the service for the PA catheter was being "unbundled" if both services were reported on the same day. The central venous catheter code should be reported with the 59 modifier (CPT code 36010-59) indicating that this catheter was placed in a different site as a different service on the same day.

Example
A pressure sore of the right ankle and right hip were debrided in the morning; but due to the patients condition, the selective debridement of the sacral pressure sore was performed at a separate session in the afternoon on that same date by the same provider. CPT code(s) billed: 97601 and 97601-59
97601 Removal of devitalized tissue from wound(s); selective debridement, without anesthesia (eg, high pressure waterjet, sharp selective debridement with scissors, scalpel and tweezers), including topical application(s), wound assessment, and instruction(s) for ongoing care, per session

CCI Guidance
The 59 modifier is often misused. The two codes in a code pair edit often by definition represent different procedures. The provider cannot use the 59 modifier for such an edit based on the two codes being different procedures. However, if the two procedures are performed at separate sites or at separate patient encounters on the same date of service, the 59 modifier may be appended. The 59 modifier cannot be used with E & M services (CPT codes 99201-99499) or radiation treatment management (CPT code 77427).

MODIFIER 62 Two Surgeons

Used when skill of two surgeons (usually of different skills) may be required in the management of a specific surgical procedure. Surgeon each performs a separate portion of one procedure Each physician would bill same CPT code with 62

MODIFIER 62 Two Surgeons

If a co-surgeon acts as an assistant in the performance of additional procedure(s) during the same surgical session, those services may be reported using separate procedure code(s) with the modifier 80 or modifier 82 added, as appropriate.

Example
A neurological surgeon and an otolaryngologist are working as co-surgeons in performing transspenoidal excision of a pituitary neoplasm
Code 22820-62--Excision of pituitary tumor, transnasal or transeptal approach. Two surgeons separate skills--same procedure

Example
A 67-year-old male Medicare patient presents with COPD and CAD s/p MI has a 5.8 cm aortic aneurysm. Imaging studies indicate that the aneurysm is infrarenal with an adequate neck to allow successful deployment of an endovascular prosthesis. There is also adequate normal aorta below the aneurysm to allow use of a tube graft. The iliac artery anatomy should accommodate passage of the device. This procedure was performed by two surgeons acting as co-surgeons. Surgeon A:34800-62 Surgeon B:34800-62 Each surgeons bills with CPT code 34800-62 34800 Endovascular repair of infrarenal abdominal aortic aneurysm or dissection; using aorto-aortic tube prosthesis

Modifier 63-Procedures Performed 63-Procedures on Infants less than 4kg

Procedures performed on neonates and infants up to a present body weight of 4kg may involve significantly increased complexity and physician work commonly associated with these patients. This circumstance may be reported by adding the modifier 63 to the procedure number. Unless otherwise designated, this modifier may only be appended to procedures/services listed in the 20000-69999 code series. Modifier 63 should not be appended to any CPT codes listed in the Evaluation and Management Services, Anesthesia, Radiology, Pathology/Laboratory, or Medicine sections.

Modifier 63-Procedures Performed 63-Procedures on Infants less than 4kg

Modifier 63 is appended only to invasive surgical procedures and reported only for neonates/infants up to a present body weight of 4kg, cut off. With this group of neonates/infants, there is a significant increase in work intensity specifically related to temperature control, obtaining IV access (which may be required upward of 45 minutes), and the operation itself, which is technically more difficult with regard to maintenance of homeostasis.

Examples of CPT codes Where Modifier 63 would be appropriate

44120-63 Enterectomy, resection of small intestine; single resection and anastomosis 44140-63 Colectomy, partial; with anastomosis 33820-63 Repair of patent ductus arteriosus; by ligation 43220-63 Esophagoscopy, rigid or flexible; with balloon dilation (less than 30mm diameter) 43246-63 Upper gastrointestinal endoscopy including esophagus, stomach, and either the duodenum and/or jejunum as appropriate; with directed placement of percutaneous gastrostomy tube 47000-63 Biopsy of liver, needle; percutaneous

Examples of CPT codes Where Modifier 63 would be not be appropriate

30540 Repair choanal atresia; intranasal 30545 Repair choanal atresia; transpalatine 31515 Laryngoscopy direct, with or without tracheoscopy; for aspiration 36420 Venipuncture, cutdown; under age 1 year 43313 Esophagoplasty for congenital defect (plastic repair or reconstruction), thoracic approach; without repair of congenital tracheoesophageal fistula 44055 Correction of malrotation by lysis of duodenal bands and/or reduction of midgut volvulus (eg, Ladd procedure) 46070 Incision, anal septum (infant)

Example
A three week old, not 1500 gram premature infant develops abdominal distention, intolerance of feeding and clinical signs of sepsis. The baby requires intubation and the start of vasopressors for blood pressure control and peripheral and renal perfusion. Plain radiographs reveal necrotizing enterocolitis. Surgical consultation is obtained. The premature infants status continues to decline. Eight hours after presentation repeat radiographs reveal pneumoperitoneum and surgery is recommended. At laparotomy, NEC is seen throughout the small bowel terminal ileum and right colon. The dead bowel is resected, the remaining bowel irrigated and a stoma with Hartman pouch is fashioned. The neonate has a difficult postoperative course but is tolerating enteral formula with supplemental hyperalimentation by the second postoperative week.

Example
CPT code billed: 44120-63 44120-63 Enterectomy, resection of small intestine; single resection and anastomosis The patient who is 3 weeks old is approximately 1500 grams which puts the patient at higher risk, so modifier 63 is appropriate.

MODIFIER 66 Surgical Team

more than two surgeons Used for highly complex or intricate procedures which require multiple concomitantly operating physicians. Usually of different specialties may require assistance of specially trained ancillary personnel or specialized equipment

Approved Procedures for Modifier 66

33945-Heart transplant, with or without recipient cardiectomy 32851-Lung transplant, single; without cardiopulmonary bypass 32852-Lung transplant, single; with cardiopulmonary bypass 32853-Lung transplant, double (bilateral sequential or en bloc) without cardiopulmonary bypass 32854-Lung transplant, double (bilateral sequential or en bloc); with cardiopulmonary bypass 50320-Donor nephrectomy, open from living donor (excluding preparation and maintenance of allograft) 50360-Renal allotransplantation, implantation of graft; excluding donor and recipient nephrectomy 50365-Renal allotransplantation, implantation of graft; with recipient nephrectomy

Example
A 44-year-old woman dyspneic at rest from severe chronic obstructive lung disease and required home oxygen. The physician decided a lung transplant was necessary. At thoracotomy, the left lung is removed by dividing the left mainstem bronchus at the level of the left upper lobe. The two pulmonary veins and single pulmonary artery are divided distally. An allograft left lung is inserted. The recipient left mainstem bronchus and pulmonary artery are re-resected to accommodate the transplant. The recipient pulmonary veins are opened into the left atrium. An endto-end anastomosis of the recipient's respective structures (pulmonary artery, mainstem bronchus and left atrial cuffs) is made to the similar donor structures. Two chest tubes are inserted. Bronchoscopy is performed in the operating room.
CPT Code billed: 32851-66 Lung transplant, single; without cardiopulmonary bypass

MODIFIER 76 Repeat Procedure by

same Physician
Modifier 76--used when physician repeats a procedure on same day May be used for multiple diagnostic testing performed on same day Modifier assists in prevention of denials or duplicate claims messages from carriers Modifier used for radiology, lab, and minor surgical procedures (repeat blood sugars)

MODIFIER 76 Repeat Procedure by

same Physician
CMS examples of repeat procedures are: follow-up x-rays (after chest tube place, central venous line placement, new onset of distress, s/p setting of fracture, etc.) repeat electrocardiograms for evaluation or treatment of arrhythmia or ischemia repeat coronary angiogram or coronary artery bypass following abrupt closure of previously treated vessel

Example
A pulmonologist inserts a chest tube in the emergency room. A chest x-ray is performed prior to placement of the chest tube before and after placement to verify the position of the chest tube at the same operative session. CPT code(s) billed: First procedure: 32020 and 71020-26-Radiologic examination, chest, two views, frontal and lateral; Second procedure: 71020-76-26-Radiologic examination, chest, two views, frontal and lateral; repeat procedure by same physician

Example
A physician performs a femoral-popliteal bypass graft in the morning. Later that day, the graft clots and the entire procedure is repeated by the same physician. The initial procedure is reported with 35556, Bypass graft, with vein; femoral-popliteal. The repeat procedure is reported as 35556-76. This alerts the third-party payor that you have not accidentally reported 35556 twice. First procedure: 35556-Bypass graft, with vein; femoralpopliteal Second procedure: 35556-76-Bypass graft, with vein; femoral-popliteal, repeat procedure by same physician

MODIFIER 77 Repeat procedure by Different physician

Identical to modifier 76 except the repeat procedure is performed by another physician Used when physician repeats a procedure that another physician performed on the same day Multiple diagnostic testing performed on same day by more than one physician

Example
A physician performs a femoral-popliteal bypass graft in the morning. Later that day, the graft clots and the entire procedure is repeated However, the surgeon (Doctor A) who performed the surgery in the morning, is not available to perform the repeat operation later that day. A second surgeon (Doctor B) performs the same procedure later that night. Doctor A reports 35556-Bypass graft, with vein; femoral-popliteal Doctor B reports 35556-77-Bypass graft, with vein; femoral-popliteal, repeat procedure by different physician

Example
Doctor B is not affected by Doctor A's global service. Doctor B's performance of a surgical service (35556) will begin a global package related to the repeat surgical procedure. Again, documentation should be provided to the thirdparty payor to clarify that a repeat procedure was performed by another surgeon.

Example
A primary care physician performs a chest x-ray in the physicians office and observes a suspicious mass. He sends the patient to a pulmonologist who, on the same day, repeats the chest x-ray. The pulmonogist also provides the total procedure for the x-ray (technical and professional). The rationale for repeating the chest x-ray is that the film does not give the pulmonologist a good picture and he wants to repeat the x-ray to confirm the diagnosis.

Example
First physician would code
71020--Radiologic examination chest, two views, frontal and lateral repeat procedure different physician

Second physician would code:

71020-77--Radiologic examination chest, two views, frontal and lateral repeat procedure different physician

MODIFIER 78 Return to the Operating Room for a related Procedure during the Postoperative period
Indicates second operative session is used and occurs during the postoperative period
Second procedure is related to the first procedure usually due to complication or other problems related to initial surgery

Example
A patient had a cholecystectomy 3-5 days prior and had increasing abdominal pain over the incisional site. The patient is returned to the operating room and a diagnostic laparoscopy is performed where significant scarring and adhesions are found. The surgeon performs a lysis of adhesions
procedure is directly related to first procedure

Example
56304-78 Laparoscopy, surgical; with lysis of adhesions Modifiers -78 indicates that the procedure what not the same initial procedure is related Note: complication diagnosis code should be matched to this procedure to alleviate insurer questions about second procedure

Example
Initial Procedure
A 66-year-old male complains of pain and weakness in his left lower extremity after walking 50 feet. Femoral, popliteal and ankle pulses are not palpable on the affected extremity. Doppler studies identify a systolic blood pressure of only 60 mm Hg at the left ankle. An arteriogram demonstrates complete occlusion of the left external iliac artery with reconstitution of the common femoral artery. At operation an ilio-femoral bypass is performed using a synthetic conduit. CPT code billed: 35665-Bypass graft, with other than vein; iliofemoral

Example
Second Procedure
On day two, the patients wound site was hemorrhaging and the patient was taken back to the emergency room. Through an incision in the extremity over the affected area, the physician isolates the vessel and explores it for postoperative complications such as hemorrhage, thrombosis, or infection. The physician found the hemorrhage, dissected the adjacent critical structures as necessary to access the vessel. The complication was identified and corrected. The hemorrhage is controlled by suture repair of the artery. The physician sutured the skin incision with a layered closure and the patient was returned to the recovery room in good condition. CPT Code billed: 35251-78 Repair blood vessel with vein graft; intra-abdominal

MODIFIER 79 Unrelated Procedure or Service by Same Physician during the Postoperative Period Used to report unrelated procedure performed during postoperative period that is unrelated and not a result of the first surgery
second surgery should be submitted with 79 to explain surgery/procedure Carrier may deny service without 79

Example
The patient had a diskectomy with fusion of the L4L5 vertebrae 70 days ago. The patient tripped over a toy at home, fell and fractured the right radial shaft. The orthopedic surgeon who performed the first procedure is contacted. The surgeon performs a closed manipulation of the radial shaft and applies a cast. The second procedure is unrelated to the first procedure.

Example
25505
Closed treatment of radial shaft fracture; without manipulation

25505-79
Closed treatment of radial shaft fracture; without manipulation unrelated procedure by same physician during postoperative period. Note: if this was a Medicare patient the global period on the diskectomy is 90 days.

Example
The patient had a repeat femoral-popliteal graft (35556) on June 1st. The patient goes home and the incision and graft heal well. However, the patient develops acute renal failure a week after being home on June 9th, and is hospitalized. The patient does not respond to medical treatment of the renal failure. Hemodialysis is indicated and the same physician inserts a cannula for hemodialysis (36810 Insertion of cannula for hemodialysis, other purpose; (separate procedure) arteriovenous, external [Scribner type] on June 10th.

Example
The physicians services for the insertion of the cannula for hemodialysis are reported as 36810-79, because this service (36810) is unrelated to the femoral-popliteal bypass graft (35556) performed during the previous hospitalization. First procedure: 35556-Bypass graft, with vein; femoral-popliteal (typical global days 90) Second Procedure: 36810-79-Insertion of cannula for hemodialysis, other purpose (separate procedure); arteriovenous, external (Scribner type)

Assistant Surgeon Modifiers

Modifier 80 81 82 AS Definition Assistant Surgeon Minimum Assistant Surgeon Assistant surgeon (when qualified resident surgeon is not available) Physician assistant, nurse practitioner, physician assistant or clinical nurse specialist. Services for assistant at surgery

MODIFIER 80 ASSISTANT SURGEON

Modifier 80 attached to surgical procedures when:
surgical procedures are performed by an assistant at surgery. assistant normally required assistant is usually paid a small portion of the surgical fee by by the carrier Generally private payors pay 20-25% of the surgical fee to the assistant
not allowed when two surgeons or team surgeons are indicated

MODIFIER 80 ASSISTANT SURGEON

An assistant at surgery serves as an additional pair of hands for the operating surgeon.
Assistants at surgery do not carry primary responsibility for or "perform distinct parts" of the surgical procedure. Co-surgeons share responsibility for a surgical procedure, each serving as a primary surgeon during some portion of the surgery. Both must be surgeons, and are frequently of different specialties. Co-surgeons may also have pre-operative responsibility, are always responsible for dictating the operative report for the portion of the surgery that is their primary responsibility and always has the responsibility for some of the post-operative care.

MPFSDB Indicator Table for Assistant Surgery

Indicator 0 Definition Assistant surgeon may be paid with documentation. Use 80 modifier Assistant surgeon cannot be paid. Assistant surgeon can be paid. Use -80 modifier. Assistant surgeon concept does not apply.

1 2

Example
Example: A physician may assist a surgeon drilling burr holes for exacerbation of an extradural hematoma Primary surgeon codes 61154 61154-Burr holes with evacuation and/or drainage of hematoma; extradural or subdural 61154-80 Burr holes with evacuation and/or drainage of hematoma; extradural or subdural; assistant surgeon (assistant would code)

Example
An assistant surgeon is frequently used in arthrodesis surgery. The assistant will help hold the vertebrae in place and assist in harvesting and placing the bone graft.

Answer
Primary Surgeon
22610--Arthrodesis, posterior or posterolateral technique, single level, thoracic (with or without transverse technique)

Assistant Surgeon
22610-80 --Arthrodesis, posterior or posterolateral technique, single level, thoracic (with or without transverse technique), assistant surgeon

MODIFIER 81 MINIMAL ASSISTANT SURGEON

Used when the assisting surgeon participated only for a portion of the procedure
can be used when a second or third assistant surgeon is required during a procedure Medicare, Medicaid and commercial payors have lists of procedure codes they do not allow minimal assistant surgeons.

CMS Guidelines
CMS rarely recognizes modifier 81 except in extreme cases. Modifier 81 does not appear on the Medicare Physician Fees Schedule Data Base (MPFSDB). When modifier 81 is used with a procedure code that has a maximum allowable payment, the maximum allowable payment for the procedure shall be no more than 13% of the maximum allowable payment listed in these rules or the billed charge, whichever is less. When modifier 81 is with a By Report (BR) procedure, the maximum allowable payment for the procedure is no more than 13% of the reasonable amount paid for the primary procedure.

Example
A second surgeon assists for a small portion of the rotator cuff tear and helps to position the arm and perform a partial suture of the cuff for a total rotator cuff tear

Answer
Primary Surgeon
23420--Repair of complete shoulder (rotator) cuff avulsion, chronic

Second Surgeon
23420-81 --Repair of complete shoulder (rotator) cuff avulsion, chronic

MODIFIER 82 Assistant Surgeon when Qualified Resident not Available

Modifier -82 used in teaching facility when a qualified resident or fellow is not available to assist.
use this modifier in a teaching facility when an appropriate training program for the medical specialty is not available The unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s)

Example
A lung hernia through the chest wall needs immediate repair in a teaching hospital setting. The residents on call are assisting in another procedure. A second thoracic surgeon assists the primary surgeon

Example
Primary Surgeon bills
32800 Repair lung hernia through chest wall

Assistant Surgeon bills

32800-82 Repair lung hernia through chest wall, assistant surgeon; resident not available

Exceptional Circumstances
Payment is made for the services of assistants at surgery in teaching hospitals despite the availability of a qualified resident to furnish the services in the following circumstances:
in emergency or life-threatening situations where multiple traumatic injuries require immediate treatment. if the primary surgeon has an across-the-board policy of never involving residents in the preoperative, operative or post-operative care of his or her patients.

MODIFIER 90 Outside Lab

This modifier is used to indicate that although the physician is reporting the performance of a laboratory test, the actual testing component was a service from a laboratory. When the physician bills the patient for lab work that was performed by an outside or (reference) lab, add the 90 modifier to the lab procedure codes. Physicians use this modifier when laboratory procedures are performed by a party other than the treating or reporting physician.

MODIFIER 90 Outside Lab

CMS Guidelines Physicians should never bill Medicare or Medicaid patients for lab work done outside their office. The laboratory performing the service will bill for the laboratory procedures. CMS does not recognize the use of modifier 90. The physician may only bill the insurance carrier for the actual laboratory testing performed in the office.

Example
Dr Jones, an internist performs an examination of a non-Medicare patient and, as part of the exam, orders a complete blood count. He does not perform in-office lab testing. He has an arrangement with a laboratory to bill him for the testing procedure, and, in turn, he bills the patient. The physicians staff performs the venipuncture. The physician reports the appropriate E/M code, the venipuncture (36415), and 85025-90 for the CBC performed by the outside lab.

Example
The physician bills: 36415-Collection of venous blood by venipuncture 85025-90-Blood count; complete (CBC), automated (Hgb, Hct, RBC, WBC and platelet count) and automated differential WBC count

Modifier 91 Repeat Laboratory Procedure

In the course of treatment of the patient, it may be necessary to repeat the same laboratory test on the same day to obtain subsequent (multiple) test results. Under these circumstances, the laboratory test performed can be identified by its usual procedure number and the addition of the modifier 91. This modifier may not be used when tests are rerun to confirm initial results; due to testing problems with specimens or equipment; or for any other reason when a normal, one-time, reportable result is all that is required.

Modifier 91-Repeat Laboratory Procedure

This modifier may not be used when other code(s) describe a series of test results (eg, glucose tolerance tests, evocative/suppression testing). This modifier may only be used for laboratory test(s) performed more than once on the same day on the same patient.

Modifier 91-Repeat Laboratory Procedure

Modifier 91 is not intended to be used when:
laboratory tests are rerun to confirm initial results due to testing problems encountered with specimens or equipment for any other reason when a normal, one-time, reportable result is all that is required

Example
A 14-year-old male presents as an outpatient to the laboratory for aerobic and anaerobic culture of two sites of a single vertical wound to the anterior left foreleg incurred, which is a result of a scooter mishap. The laboratory technologist obtains independent specimens; one from the proximal wound site and one from the distal wound site for aerobic culture of the drainage material for testing, using the appropriate type aerobic culturettes. The laboratory technologist also obtains independent specimens using anaerobic culturettes; one from the proximal wound site and one from the distal wound site for anaerobic culture of the drainage material for testing.

Example
The following codes are billed:
87071-Culture, bacterial; quantitative, aerobic with isolation and presumptive identification of isolates, any source except urine, blood or stool 87071-59 Culture, bacterial; quantitative, aerobic with isolation and presumptive identification of isolates, any source except urine, blood or stool 87073 Culture, bacterial; quantitative, anaerobic with isolation and presumptive identification of isolates, any source except urine, blood or stool 87073-59 Culture, bacterial; quantitative, anaerobic with isolation and presumptive identification of isolates, any source except urine, blood or stool

Reason for Using 59

Rationale for Using Modifier 59 versus 91 Both cultures were from two separate wound sites and two separate cultures (aerobic and anaerobic). Since there was no indication that the labs were repeated on the same day, modifier 91 would not be appropriate. However, since two separate cultures were identified at two separate sites, modifier 59 would be appropriate (distinct and separate)

Example
A 65-year-old male patient with diabetic ketoacidosis had multiple blood tests performed to check the potassium level following subsequent potassium replacement and low-dose insulin therapy. After the initial potassium value, three subsequent blood tests were ordered and performed on the same date following the administration of potassium to correct the patients hypokalemic state.
CPT code(s) billed: 84132 Potassium; serum 84132-91 Potassium; serum 84132-91 Potassium; serum 84132-91 Potassium; serum

MODIFIER 99 Multiple Modifiers

Used when 2 or more modifiers are necessary to correctly report a procedure List with highest number first

Example
A orthopedic surgeon assisted with multiple procedures performed on a patient involved in a multi-trauma. The patient underwent a craniotomy with debridement for an extradural hematoma, cranial decompression of the posterior fossa and treatment of a rib fracture with external fixation following a motorcycle crash. The patient tolerated the procedures well. CPT code(s) billed:
61312 Craniectomy or craniotomy for evacuation of hematoma, supratentorial; extradural or subdural 61345-51 Other cranial decompression, posterior fossa 21810-59 Treatment of rib fracture requiring external fixation (flail chest) The claim should be submitted as follows: 61312 61312-80 61345-99-80-51 21810-99-80-59

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