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.

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 :

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 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.

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.

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


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:

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.

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.

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.

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.

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.

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.

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 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.

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.

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.

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 .

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.

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 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.

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.

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 .

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 .

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.

 Minimum surgical assistant services are identified by adding modifier 81.

34856

34856 - 81

 When the assistant surgeon has done the surgery when qualified surgeon is not
available.

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.

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.

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.
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 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.

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.
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.