What is Modifiers in Medical Coding :-

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.

INTRODUCTION :

 Modifiers are two- character suffixes (alpha and/or numeric) that

are attached to a procedure code.
 CPT modifiers are defined by the American Medical Association
(AMA).
 A modifier provides the means to report or indicate that a service
or procedure that has been performed has been altered by some
specific circumstances but not changed in its definition or code.
What is a CPT Code?

The Current Procedural Terminology (CPT) code is a standardized medical

code set designed to provide doctors, healthcare professionals, and
administrative entities with a unified language, improve reporting accuracy,
streamline processes, and increase efficiency. It is used for documenting and
reporting medical, surgical, radiological, laboratory, anesthesiological, genomic
sequencing, evaluation, and management (E/M).

CPT codes serve multiple roles:

 Clinical Reporting: They help healthcare providers accurately

report the various procedures, services, and interventions they
administer to patients.
 Administrative and Management: They are instrumental in
administrative tasks, such as medical claims processing and
creating guidelines for medical care review.
 Electronic Medical Billing: They are used alongside ICD-9-CM or
ICD-10-CM diagnostic codes during the electronic medical billing
process to communicate information to entities like physicians,
health insurance companies, and accreditation bodies.
Modifier 22 ( Increased procedural services) :

This modifier is used for increased procedural services). We use this modifier
whenever the doctor do extra things as compared to normal .

Note: This modifier should not be appended to the E&M service.

Example of Modifier 22:

A physician performs an induced abortion of the fetus, aged 21 weeks, by

dilation and evacuation. We should report the claim with a procedure code
along with modifier 22.

Modifier 23 (unusual Anesthesia):

Modifier 23 should be appended to the Anesthesia code to indicate a procedure

that is normally performed under local anesthesia or with regional block
required general anesthesia.

When the provider administers general anesthesia for a procedure that does not
normally require it or administers anesthesia due to unusual circumstances.

Example of Modifier 23 :

A cystoscopy does not usually require general anaesthesia, however, if

performed on a young child who can’t be controlled so for general anesthesia,
we need to append 23 modifier along with procedure code.

Modifier 24:

Unrelated evaluation and management services was performed during a

postoperative period.

The physician may need to indicate that an evaluation and management service
was performed during a postoperative period for a reasons unrelated to the
original procedure.
Example of Modifier 24 : A physician operated on the patients anus. Then , a
month later she sees the patient for a stomach problem. Bill modifier 24 in this
case.

Modifier 25:

Significant, separately identifical evaluation and management (E/M) service by

the same physician on the same day of a procedure.

A physician performs an E/M service on a patient on the same day that a

procedure is performed, and the E/M service is for unrelated to the procedure.

Example of Modifier 25 :

0-10 days global period are minor surgical procedures that include
complications related to the procedure and cannot be billed separately for 10
days after the procedure, such as the excision of a benign lesion on the trunk,
arms or legs; pressure Equalizer tubes inserted under local anesthesia, and
debridement.

When Not to Use the Modifier 25

 Do not use a 25 Modifier when billing for services performed

during a postoperative period if related to the previous surgery.
 Do not append Modifier 25 if there is only an E/M service
performed during the office visit (no procedure done).
 Do not use a Modifier 25 on any E/M on the day a “Major” (90 day
global) procedure is being performed.
 Do not append Modifier 25 to an E/M service when a minimal
procedure is performed on the same day unless the level of service
can be supported as significant, separately identifiable. All
procedures have an “inherent” E/M service included.
 Patient came in for a scheduled procedure only

Modifier 26 : Professional component

Certain procedures are a combination of a physician component and a technical

component. When the physician component is reported separately, add 26.

Example of Modifier 26 : A 72 year old woman comes to the emergency room

complaining of chest discomfort. The physician orders a complete 2D
echocardiography using hospital equipment. The physician provides the
written interpretation. Then append 26 modifier with CPT code.

Example of Modifier 26:

A sleep center performs polysomnography for a patient. A physician not

associated with the sleep center facility interprets the findings of the test. This
physician would append modifier 26 to 95811 to represent her interpretation of
the polysomnography.

Modifier 32: Mandated services:

When some services are done as a mandatory as part of their professions, such
services needs to be appended with modifier 32.

Modifier 33: Preventive Services:

Some tests are done as preventive measures for diseases so for those tests we
need to append modifier 33:

Modifier 47: Represents Anesthesia given by the surgeon.

This modifier is to be used when the surgeon performs and administers regional
or general anesthesia in addition to the surgical procedure.

Example of Modifier 47:

Patients in critical state and physician administers the Anesthesia and performs
the emergency surgery. In this case we can append 47 modifiers to the
procedure code.

50 Modifier: Bilateral Procedure

Bilateral procedure are typically performed on both sides of the body during
the same operative session by same physician in either separate operative areas
(e.g., hands, feet, legs, arms, ears) or In the same operative areas (e.g., nose,
eyes, breasts).

 Do not use modifier 50 with a procedure code that is described

as bilateral, or unilateral or bilateral, in its CPT description.

Example of Modifier 50:

Surgery done on both eyes is bilateral procedure whereas on only one eyes is a
unilateral procedure.

Modifier 51: Multiple procedure

This modifier indicates that multiple procedures were performed at the same
session.

 Do not append to add-on codes (See Appendix D of the CPT

manual)

When to use modifier 51

 When multiple procedures are performed by the same physician on the

same day
 When a single procedure is performed multiple times at different sites
 When a single procedure is performed multiple times at the same site

When not to use modifier 51

 When a procedure is performed along with an Evaluation and

Management (E/M) service
 When appending add-on codes

Example

For example, if a surgeon performs a laparoscopic cholecystectomy and a

laparoscopic appendectomy together, the surgeon would bill the laparoscopic
cholecystectomy as the primary procedure and append modifier 51 to the
laparoscopic appendectomy.

Example of Modifier 51 :

Colonoscopy was performed at same session as upper endoscopy. Both

procedure are performed on same day.

Use modifier 51 on upper endoscopy procedure.

Example of Modifier 51:

A surgeon performs a 24500 (Closed treatment of humeral shaft fracture;

without manipulation) and a 23500 (Closed treatment of clavicular fracture;
without manipulation). You would apply the multiple procedures reduction to
23500, which is the lower-paying code if your payer requires modifier 51.

Modifier 52 : Reduced services

Append modifier 52 to a procedure to show that the physician didn’t perform

the complete procedure in the code descriptor.

Example of Modifier 52 :

43770 - laproscopy, surgical, gastric restrictive procedure; placement of

adjustable gastric restrictive device.

For individual component placement, report 43770 with modifier 52.

Example of Modifier 52:

A provider performs a unilateral tonsillectomy for a ten-year-old patient (CPT

code 42820). In this case, apply modifier 52. This CPT assumes bilateral
surgery, so to show that it was only performed on one side, or electively
reduced, modifier 52 would be appropriate.
Modifier 53: Discontinued Procedure

Used to indicate that a surgical or diagnostic procedure was started but

discontinued due to exteruating circumstances that threatened the patients well
being.

This modifier is used to report services or procedures when disconnected after

anesthesia is administered to the patient.

Example of Modifier 53 :

A provider attempts to perform phenol injection to the superior hypogastric

plexus; following multiple needle positioning attempts at the right or left L5
region, the procedure is discontinued due to the patient increased heart rate and
suboptimal dye spread.

Example of Modifier 53:

A surgeon has a patient under anesthesia and fully prepared to proceed with
surgery. However, the physician cuts himself and therefore cannot carry out the
operation. Modifier 53 may apply to the surgical CPT to indicate an extenuating
circumstance that prevented the procedure from being performed. In this
scenario, the surgical prep and anesthesia indicate the procedure had already
begun but had to be discontinued.

Modifier 54 : Use for surgical Care Only

Indicates the surgeon has transferred postoperative care ( partial or total) to

another provider.

Example of Modifier 54 :

A neurosurgeon travel to a rural location to to perform a craniatomy for

drainage of an intracranial abscess. He assessed the patient the day before, and
performed the procedure. Follow up care was provided by a local surgeon.

Modifier 57: Decision for surgery

This modifier is appended to the appropriate E/M service to denote the visit
where the decision to perform major surgery (90 global days) was made.
Modifier is used when the decision for major surgery is made the day of or the
day prior to performing the procedure.

Uses of Modifier 57:

 Assign with E/M code only ( including opthalmolgical service)

 Used only for major Surgical procedure, a procedure with a 90
days global period.
 E/M service must be related to the procedure that follows
 Surgery should be performed on same day of E/M or next day.
Example of Modifier 57 :

A surgeon receives a request to evaluate the patient for acute upper quadrant
pain and tenderness.following full evaluation , the surgeon decide to remove
the gallbladder and schedule an immediate laproscopic cholecystectomy .

Example of Modifier 57:

A surgeon see a patient in the emergency department then perform repair of

laceration, comes and/or sclera, perforating and reposition or reaction of uveal
tissue on same day.

58, 78 and 79

All these modifiers are used for follow up visits.

58 – staged and related procedure.

78 – unplanned and related procedure

79 – unplanned and unrelated procedure.

Modifier 58:

Modifier 58 is a surgical – specific, used to indicate a staged or related

procedure or service by the same physician during the post operative period.
Example of Modifier 58 :

A surgeon performs a biopsy on a patient. The results indicate that the sample is
cancerous. The surgeon performs a second procedure to remove the cancer. Use
modifier 58 when billing for the second procedure.

Modifier 59: Distinct Procedural

Service indicate that a procedure is separate and distinct from another procedure
on the same date of service.

Indications for use of modifier 59:

 Different session or encounter on the same date of service

 Different procedure distinct from the first procedure
 Different anatomic site
 Separate incision, excision, injury or body part.
Example of Modifier 59:

A patient had a colonoscopy and a lesion is removed proximal to the splenic

flexure. During the same colonoscopy a biopsy is taken of a different lesion.
Both codes are reportable using modifier 59 on the second procedure.

Example of Modifier 59 :

A patient was planned appendectomy today. Today before the procedure he fell
down and got some laceration in right knee. Do physician now going to do both
appendectomy and laceration and simple laceration procedure on same day.

Modifier 62 : Two surgeon

When two surgeons work together as primary surgeons performing distinct parts
of a procedure, each surgeon should report the co-surgery once using the same
procedure code and report his/her distinct operative work by adding modifier 62
and any associated add-on codes for the procedure.


Example of Modifier 62 :

A neurological surgeon and an otolaryngologists are working as co-surgeons in

performing transphenoidal excision of a pituitary neoplasm.

Modifier 63: Procedure performed on infant less than 4 kg

Procedure performed on neonates and infants up to a present body weight of 4

kg may involve significantly increased complexity and physician work
commonly associated with these patients .

Modifier 66: Surgical Team

When a team of surgeons three or more works together to complete a procedure

reported using a single CPT code.

Use of modifier modifier 66 :-

 Highly complex procedure

 Require differently specialties
 Modifier 66 appended to procedure coded by surgical team.
 May require assistance of specially trained ancillary personal or
specialized equipment
 Approved procedure for modifier 66 include most of your
transplant codes(heart,lungs, kidneys, including live donor
procedure).
Example of Modifier 66 :

kidney transplant was performed by team of surgeons modifier 66 is append to

the procedure code.

Modifier 76 : Repeat procedure or service by same physician or other qualified

Healthcare professional.

It may be necessary to indicate procedure or service was repeated subsequent to

original procedure or service.
Modifier 76 used for :

Used to indicate that a procedure or service was repeated subsequent to the

original procedure or service by the same provider ID on for the same member
on the same date of service or within the post-operative period.

Inappropriate usage:

 It’s inappropriate to use modifier 76 with any lab codes for repeat
laboratory test within the same day- use modifier 91 instead of 76.
 It’s inappropriate to use modifier 76 with subsequent repeat
procedure due to technical fault or equipment issue.
 It’s inappropriate to use modifier 76 with subsequent repeat
procedure but at different anatomic site (Right and left or upper
and lower part) use 59 modifier 59.
Example

Whenen a physician (A) order 2 views of chest xray at 10 am

and due to medical necessity another physician (B) order for
another 2 views of chest xray at 11 am on the same day both the
physician belongs to same speciality.

A patient who goes to the emergency room with a trauma to the

chest. A two views chest xray is taken that shows a pneumothorax.
After a chest tube is placed a repeat two views chest xray is taken
to verify the placement of the chest tube.

Modifier 77 : Repeat procedure or service by another physician

Modifier 77 is used to indicate that another physician repeated a procedure or

service in a separate operative session on the same day.

Service originally performed by another physician. Documentation must include

for repeat procedure.

Can modifer 76 and 77 be used together??

You don’t report repeated procedures on one line with multiple units, So you
would never use both 76 and 77 on the same line.
Example of Modifier 77:

A patient who sees the family practitioner for chest pain and the physician does
an EKG and then refers the patient to a cardiologist. The patient is able to see
the cardiologist on the same day and the cardiologist performs a repeat EKG .
The second EKG would be reported with modifier 77.

Modifier 78: Unplanned return to the operating room or procedure room

during the global period of the initial procedure by the same physician.

Indicates second operative session is used and occurs during the post-operative
period.

Second procedure is related to the first procedure usually due to complications

or other problem related to initial surgery.

Example of Modifier 78 :

A physician performed cesarean section on a patient . Because of bleeding the

patient is called back into the OR for second procedure was unplanned in the
post operative period and performed by the same physician .

Modifier 79 : Unrelated procedure or by the same physician during the post-

operative period.

Example of Modifier 79 :

Patient has a biopsy taken of a lesion on his arm which has a 10 day global.
Patient then returns 5 days later to have a wart removed from his finger you
would append 79 modifier with procedure code.

Don’t append modifier E/M codes.

Example of Modifier 79 :

A patients right big toe is amounted because of an infection with the

postoperative period, the same physician amputed the patients right little toes
after it is crushed by falling weight . Modifier 79 is used .

Modifier 80: Assistant surgeon

Assistant surgeon: surgical assistant service may be identified by adding

modifier 80 to the usual procedure number.


Example of Modifier 80 :

One physician is done harvesting for CABG procedure it involves venous graft
only. The graft procurement performed by the assistant at surgery is reported
using modifier 80.

Modifer 81: Minimum assistant surgeon

 Minimum surgical assistant services are identified by adding

modifier 81.

34856

34856 - 81

Modifier 82 : Assistant surgeon (when qualified resident surgeon not available)

 When the assistant surgeon has done the surgery when qualified
surgeon is not available.
Modifier 90: Reference (outside) laboratory

When laboratory procedure are performed by a party other than the treating or
reporting physician or other than qualified Healthcare professional, the
procedure maybe identified by adding modifier 90 to the usual procedure
number..

Example of Modifier 90:

The physician in this office orders a CBC, the physician draws the blood and
send the specimen to an outside laboratory.

Modifier 91: Repeat clinical diagnostic laboratory test

In the course of treatment of the patient it may be necessary to repeat the same
laboratory test on same day to obtain subsequent ( multiple) test result. Under
these circumstances the laboratory test performed can be identified by its
usually procedure number and the addition of Modifier 91.

This modifier basically used to show that test of same specimen done at
same day at different time interval.

This modifier is used only lab and pathology cpt chapter.

When to use modifier 91

 Use modifier 91 to manage the patient’s treatment if you repeat a

clinical laboratory test on the same service date.
 Use modifier 91 if you need multiple, serial laboratory tests to treat
a patient, such as repeat blood glucose tests.
 Use modifier 91 if you repeat a test using a separate specimen draw
later the same day.

When not to use Modifier 91:

 On a repeat lab test performed only to confirm initials results.

 For confirmation without physician order to repeat it.
 Due to technician fault.

Example of Modifier 91
When a patient undergoes a blood transfusion, healthcare providers may find it
necessary to perform multiple blood tests throughout the day to ensure the
compatibility and safety of the transfusion. In this scenario, the extra tests
would be billed with the application of Modifier 91.

Modifier 92: Alternative laboratory platform testing

When laboratory testing is being performed using a kit or transportable

instrument that wholly or in part consists of a single use, disposable analytical
chamber, the service may be identified by adding modifier 92 to the usual
laboratory procedure code.

Example of Modifier 92:

A female patient presents to the office for a sexually transmitted disease (STD)
screening. The patient is concerned about HIV exposure after engaging in
unprotected sexual intercourse. The patient is tested for HIV using a hand-
carried transportable kit. Correct coding in this case would be 86701-92.
Modifier 92 is appropriate because the HIV testing is performed using the hand
held transportable kit.

Modifier 93: Synchronous Telemedicine Service Rendered Via Telephone or

Other Real-Time Interactive Audio-Only Telecommunications System.

Modifier 93 describes services that are provided via telephone or other real time
interactive audio only telecommunications systems.

This modifier is appropriate only if the real- time interaction occurs between a
physician/ other qualified Healthcare professional and a patient who is located
at distant site.

Modifier 95: Synchronous telemedicine service rendered via a real-time

interactive audio and video communications system.

Modifier 96: Habilitative services

Services that helps a person develop skills or functions they didn’t have before.

Example of Modifier 96:

An example of this would be a pediatric patient who experienced a
developmental delay and now requires therapy to learn the skill that they were
unable to learn on their own.

Modifier 97: Rehabilitative services

That help a person restore functions which have become either impaired or lost.

Example of Modifier 97:

An example of this would be a patient who suffered a complex lower extremity

fracture and now need to re-learn how to walk.

Modifier 99: Multiple modifier

Under certain circumstances two or more modifiers may be necessary to

completely delineate a service. In such situations modifier 99 should be added
to the basic procedure, and other.

Append modifier 99 to a procedure or service as the first modifier when there

are also two or more additional modifiers applicable to the service or
procedure.