Modifier Descriptor

E1-E4 Eyelids
FA, F1-F9 Fingers
TA, T1-T9 Toes
RT Right side of body
LT Left side of body
LC, LD, LM, RC, RI Coronary artery modifiers

Modifier Descriptor Reimbursement Impact/Comments

• Affects reimbursement for surgical codes
only
• Additional reimbursement considered if
the additional work is documented in the
operative report submitted to support the
22 Increased Procedural Services use of modifier 22. Cover letters are not
considered part of the medical record and
cannot be used to support a case for
additional reimbursement
• 120% of fee schedule allowable after
medical record review
• 100% of contract allowable amount only when
the service and diagnosis are not related to the
Unrelated E/M service by surgical procedure
24 same physician during post- • May require medical record review
op period • Visits for complications of surgery that do not
require a return trip to the operating room are
not to be reported with Modifier 24
• Clinical notes must support a significant,
separately identifiable E/M service above and
Significant, separately beyond the services provided
identifiable E/M service by • For same day preventive and sick E/M, service
25 same physician on same day with lower valued resource consumption will be
of procedure or service reimbursed at 50% of allowable amount.
• All claims submitted with this modifier are
subject to pre and post-pay audit.
• Professional component of allowed amount
• Centers for Medicare and Medicaid designate
26 Professional Component
which procedure codes are valid for use with
modifier 26.
32 Mandated Services • Not reimbursed
• Modifier 33 should be appended to the listed
CPT/HCPCS codes contained in the U.S.
33 Preventive Service
Preventive Services Task Force List which have a
category A or category B rating.
• 150% of contract allowable
50 Bilateral procedure • Not for use with codes whose narrative indicates
bilateral
• 50% of the contract allowable, unless
51 Multiple procedure
otherwise specified.
52 Reduced Services • 50% of contract allowable
53 Discontinued Procedure • 25% of fee schedule allowable
54 Surgical care, only • 75% of fee schedule allowable
 • 25% of contract allowable
• Physician performing outpatient post-operative
care should report modifier 55
• Surgeon should not report modifier 55
55 Post-op management, only
• Dates of service should indicate the range from
first date of service to last. The number of units
reported should reflect the number of services
rendered.
56 Pre-op management, only • 25% of contract allowable
57 Decision for Surgery • No impact on reimbursement
Staged or Related Procedure
or Service by the Same
Physician or Other Qualified
58 • No impact on reimbursement
Health Care Professional
During the Postoperative
Period
• Append Modifier 59{X} to identify procedures
and/or services that are distinct and unrelated.
Medical record documentation must clearly
support the different session and/or procedure,
not normally performed on the same day by the
same physician and/or group.
59 Distinct procedural service
• Use modifier 59 only when modifier {XESPU}
is not appropriate
• Modifier 59 should be used only in absence of a
more descriptive modifier, and does not alter the
reimbursement impact when billed in conjunction
with another modifier
XE Separate encounter
XS Separate structure
XP Separate practitioner
Unusual non-overlapping
XU service
• 62.5% of contract allowable
• Use Modifier 62 only with qualified service
62 Two Surgeons
codes as allowed by the CMS National
Physician Fee Schedule Relative Value File
• 62.5% of contract allowable
• Medical documentation is required
66 Surgical Team • Use Modifier 66 only with qualified procedures
as allowed by the CMS national Physician Fee
Relative Value File
Discontinued Out-Patient
Hospital/Ambulatory Surgery
73 Center (ASC) Procedure Prior • 50% of contract allowable
to the Administration of
Anesthesia.
Discontinued Out-Patient
Hospital/Ambulatory Surgery
74 Center (ASC) Procedure • 50% of contract allowable
After Administration of
Anesthesia
• No impact on reimbursement
Repeat procedure by same
76 physician
• For repeat, same day laboratory services, use
modifier 91
 • No impact on reimbursement
Repeat procedure by another
77 physician
• For repeat, same day laboratory services, use
modifier 91
Unplanned return to OR for
78 related procedure during post- • 75% of contract allowable
op period
Unrelated procedure or
79 service by same physician • No impact on reimbursement
during postoperative period
• 16% of contract allowable
80 Assistant Surgeon • Valid for services designated in the CMS
National Relative Value File as qualifying
• 16% of contract allowable
81 Minimum Assistant Surgeon • Valid for services designated in the CMS
National Relative Value File as qualifying
Assistant Surgeon (when • 16% of contract allowable
82 qualified resident surgeon not • Valid for services designated in the CMS
available) National Relative Value File as qualifying
90 Reference laboratory • No impact on reimbursement
Repeat clinical diagnostic • No impact on reimbursement
91 laboratory test • Services must meet medical necessity criteria
92 Alternative laboratory testing • No impact on reimbursement
Synchronous telemedicine
• Reimbursement is calculated using 50% of the
Service rendered via a real-
95 time interactive audio and
Practice Expense Relative Value Unit (RVU) for
the service
video telecommunications
96 Habilitative Services • No impact on reimbursement
97 Rehabilitative Services • No impact on reimbursement
99 Multiple modifiers • No impact on reimbursement

Modifier - 24,58,78 & 79

Related Unrelated

Surgical
EM Services 24 Modifier 79 Modifier
Procedures

Non-Billable Surgical
58 Modifier 78 Modifier EM Services
Services 99024 Procedures

Postoperative
Staged/Planned
Complication

Required Return
To The
Operating Room
Anesthesia services Modifiers