Modifier

In CPT (Current Procedural Terminology) coding, a modifier is a two-character code (either numbers
or letters) that is appended to a CPT code to provide additional information about the service or
procedure performed. Modifiers don't change the fundamental definition of the CPT code but clarify
circumstances that may affect the service's description, level of effort, or payment.

Here's a more detailed explanation:

 Purpose:

Modifiers are used to provide specific details about the service or procedure that might not be
apparent from the CPT code alone.

 How they work:

They are added to the end of the five-digit CPT code.

Modifier 50 — Bilateral Procedure

🔹 Description:

Modifier 50 is used when the same procedure is performed on both sides (right and left) of the
body during the same session by the same physician.

🔹 Key Points:

 Use when both joints/sides are treated.

 Attach modifier 50 to the CPT code (or bill with 2 units using modifiers LT and RT depending
on payer policy).

 Reimbursement may be 150% of the fee schedule (100% for first side + 50% for the second
side).

🦵 Example: Knee Joint Injections on Both Knees

 Procedure: Intra-articular knee injections in both left and right knees using corticosteroids.

 CPT Code: 20610 – Arthrocentesis, aspiration and/or injection; major joint or bursa (e.g.,
knee)

🧾 How to Report:

✅ Method 1 (Medicare Preferred):

20610 RT (right knee)

20610 LT (left knee)

Use 2 lines with modifiers RT and LT.

✅ Method 2 (Modifier 50 approach – commercial insurers):

20610-50 (1 unit)

Use one line with modifier 50, and 1 unit.

Modifier 52 — Reduced Services

🔹 Definition:

Modifier 52 is used when a service or procedure is partially reduced or eliminated at the physician's
discretion. This applies only when the service was started but not fully completed, and not due to
complication (that would use modifier 53).

🔹 Key Use Case:

 Planned procedure not fully performed

 No change in surgical approach or intent

 Patient’s condition may or may not be a factor

 Must be clearly documented why the full procedure was not performed

🏥 Example Scenario: Bilateral Hip Osteotomy — Reduced Service

📋 Procedure:

The surgeon planned to perform bilateral hip osteotomies (on both hips) under one anesthesia
session. However, due to intraoperative findings (e.g., prolonged time, blood loss, instability), the
surgeon only completed the left hip osteotomy.

🧾 Coding Example:

 Planned Code for Bilateral:

27165 — Osteotomy, intertrochanteric or subtrochanteric, including internal fixation,
bilateral

 What Happened: Only left side was completed

→ So use Modifier 52 to show reduced service.
Modifier 53 — Discontinued Procedure

🔹 Definition:

Modifier 53 is used when a procedure is started but discontinued due to extenuating circumstances
or threat to the patient’s well-being — NOT simply because the physician chose to stop.

🔹 When to Use:

 Procedure is started (not just anesthesia or prep)

 Physician must discontinue due to patient safety, medical instability, or unexpected

complication

 Not used for elective cancellation or if full procedure was completed

🧪 Common Example: Colonoscopy with Modifier 53

📋 Scenario:

 Patient is undergoing a screening colonoscopy

 Physician advances the scope to the sigmoid colon, but the patient develops bradycardia
(low heart rate), so the procedure is stopped

 The colonoscope had already been inserted (i.e., procedure started)

✅ Final Coding:

plaintext

CopyEdit

45378-53

CPT 45378 – Colonoscopy, diagnostic, including collection of specimen(s) by brushing or washing,

when performed

🏥 Another Example: Laparoscopy with Modifier 53

📋 Scenario:

 Surgeon begins laparoscopic cholecystectomy

 After trocar insertion, discovers extensive adhesions and cannot proceed safely

 Surgeon discontinues the procedure after trying but before gallbladder is removed

✅ Final Coding:
plaintext

CopyEdit

47562-53

📄 Documentation Must Include:

 Start time of procedure

 Description of how far the procedure progressed

 Reason for discontinuation (e.g., vital signs unstable, safety risk)

 That the decision was made in the patient's best interest

⚠️Do Not Use Modifier 53:

 If the procedure was never started

 If it's a reduced service by choice → use Modifier 52

 On E/M services (Modifier 53 is for procedures, not office visits)

Modifier 54 – Surgical Care Only

🔹 Definition:

Used when the surgeon performs only the surgery, but not the pre-op or post-op care.

🧾 Example:

A surgeon in one city performs an appendectomy and the post-op care is handled by the PCP in the
patient’s hometown.

CPT Code:

plaintext

CopyEdit

44950-54

🔍 Documentation must show:

 Surgeon only provided the intraoperative portion (no pre-op/post-op care)

✅ Modifier 55 – Postoperative Management Only

🔹 Definition:
Used when a provider only provides post-op care, not the surgery itself.

🧾 Example:

A primary care physician provides post-op care for a patient who had surgery in another city.

CPT Code:

plaintext

CopyEdit

44950-55

Use with the same CPT code as the surgery, with modifier 55

🔍 Documentation must show:

 Dates of post-op care provided

 Surgical date and procedure done

 Transfer of care agreement if available

✅ Modifier 56 – Preoperative Management Only

🔹 Definition:

Used when the provider only performs preoperative evaluation and management, but not the
surgery or post-op care.

🧾 Example:

A cardiologist evaluates a patient before surgery due to cardiac risk. He does pre-op clearance, but
the surgery and post-op are handled by others.

CPT Code:

plaintext

CopyEdit

44950-56

Rarely used — typically in referral or consult situations only.

🧠 Easy Way to Remember:

Modifier Part of Surgical Package Role

54 Surgery only Surgeon only does procedure

55 Post-op care only Another provider manages recovery

56 Pre-op care only Provider evaluates before surgery

🎯 Quick Summary Table:

Example
Modifier Meaning Used By
Procedure

Surgical 44950-54
54 Surgeon
care only (Appendectomy)

PCP or
Post-op
55 44950-55 other
care only
doctor

Referring
Pre-op
56 44950-56 doctor or
care only
consultant

Modifier 58 with Cleft Repair – Explanation with Example

🔹 Modifier 58 - Definition

Modifier 58 is used to indicate:

“Staged or related procedure or service by the same

physician during the postoperative period.”

Use Modifier 58 when:

 A planned or anticipated (staged) procedure is

performed during the postoperative global period
of the initial surgery.

 The new procedure is more extensive than the

original.

 It’s therapeutic after a diagnostic procedure.

🔹 Cleft Lip and Palate Repair – Common CPT Codes

 40700 – Repair cleft lip, primary, partial or

complete, unilateral

 40701 – Repair cleft lip, primary, partial or

complete, bilateral

 42200 – Palatoplasty for cleft palate (soft and/or

hard palate)

 42205 – Palate repair with attachment of

 Example
Modifier Meaning Used By
Procedure

pharyngeal flap (more extensive repair)

🧠 Concept: Cleft repairs are often done in stages

Many patients require multiple surgeries to repair cleft lip

and/or palate fully. For example:

1. Initial lip repair in infancy

2. Palate repair at 9-18 months

3. Pharyngeal flap or revision later

✅ Example Case: Use of Modifier 58

Initial Surgery:

 CPT 40700 – Repair cleft lip, primary, unilateral

(Day 0)

Planned Later Surgery During Postop Period:

 CPT 42200 – Repair cleft palate (soft/hard palate)

➡️Use Modifier 58 on 42200:

42200–58 (because it is a planned, staged procedure

following the initial lip repair, and it falls within the
postoperative global period of 40700).

📌 Documentation Tip

Clearly document:

 That the second surgery was planned or staged at

the time of the first.

 The clinical rationale for the second procedure.

 Reference the first procedure in the operative

notes (e.g., “second stage of cleft repair”).

⚠️Do Not Use Modifier 58 When:

 The second procedure is for a complication → Use

Modifier 78

 The second procedure is unrelated → Use

 Example
Modifier Meaning Used By
Procedure

Modifier 79

✅ Modifier Use Decision Chart for Surgeries During

Postoperative Period

Situation Modifier Use When...

Next surgery is
Planned/staged/anticipated related and was
58
next procedure planned during
the initial surgery

Unplanned return
to the OR for a
Complication or return to OR
78 complication
(unplanned)
related to the first
surgery

Surgery is not
related to the
Unrelated surgery 79 initial procedure
and done in
global period

🧠 Cleft Repair Surgery Pathway with Modifier Examples

📌 Stage 1: Cleft Lip Repair

 CPT 40700 – Primary cleft lip repair, unilateral

 Global Period: 90 days

📌 Stage 2: Planned Palate Repair (within 90 days)

 CPT 42200 – Palatoplasty for cleft palate

 Code as: 42200-58

🔍 Reason: This is a planned staged procedure to complete

the full cleft repair.

🔁 If There’s a Complication Example

After palatoplasty (42200), child develops oronasal fistula

requiring repair within 90 days:

 New Procedure: Surgical closure of fistula (e.g.,

 Example
Modifier Meaning Used By
Procedure

CPT 42215 – repair of palate with flap)

 Code as: 42215-78

🔍 Reason: This is due to a complication, not a planned

stage.

🔄 Unrelated Surgery Example

Within 90-day global after cleft lip surgery (40700), child

falls and breaks nose (needs nasal fracture repair):

 New Procedure: CPT 21310 – Closed nasal fracture

reduction

 Code as: 21310-79

🔍 Reason: This is unrelated to the cleft lip surgery.

📄 Summary Chart – Cleft Surgery Modifiers

CPT
Procedure Modifier Why?
Code

Cleft Lip Repair 40700 — Initial procedure

Planned second stage

Palate Repair 42200 58
of cleft repair

Related, unplanned
Fistula Repair
42215 78 return due to
(complication)
complication

Unrelated surgery
Unrelated Nasal
21310 79 during global period
Fracture
of cleft repair

Modifier 76 — Repeat Procedure by the Same Physician

➤ Definition:

Modifier 76 is used when the same provider performs a repeat procedure on the same day.
✅ EKG Example with Modifier 76:

📌 Scenario:

A patient comes to the ER with chest pain.

 The ER physician orders a 12-lead EKG (CPT 93000) at 10:00 AM.

 Later that afternoon, the same physician repeats the EKG due to worsening symptoms.

➤ Coding:

 93000 (first EKG)

 93000–76 (repeat EKG by same physician on same day)

✅ Use 76 modifier to show the same service repeated by the same provider.

🔹 Modifier 77 — Repeat Procedure by a Different Physician

➤ Definition:

Modifier 77 is used when a different provider performs the same procedure again on the same day.

✅ EKG Example with Modifier 77:

📌 Scenario:

A patient has an EKG in the clinic by Dr. A in the morning.

 Later, the patient goes to the ER, and Dr. B (different provider) repeats the EKG.

➤ Coding:

 93000 (first EKG by Dr. A)

 93000–77 (second EKG by Dr. B on same day)

✅ Use 77 to indicate repeat by a different physician.

🧠 Tip to Remember:

Modifier Mnemonic Meaning

76 "Same doctor" Repeat procedure, same provider

77 "Another doctor" Repeat procedure, different provider

📄 Summary Table – EKG with Modifiers

Situation CPT Code Modifier Explanation

First EKG in ER at 9 AM by Dr. Smith 93000 — Initial EKG

Situation CPT Code Modifier Explanation

Second EKG at 3 PM by Dr. Smith (same doctor) 93000 76 Repeat by same physician

Second EKG at 3 PM by Dr. Jones (different doctor) 93000 77 Repeat by different physician