Modifiers

Modifier 22 - Unusual Procedural Services:

• When a physician performs a surgical procedure and needs to perform additional work which is significantly greater than the usual requirement due to complications & medical emergencies then modifier 22 is used with surgical procedure to report the additional work.

Modifier 23 - Unusual Anesthesia:

• When a service requires local anesthesia but due to unusual circumstances & complications the physician gives general anesthesia to perform the service then modifier 23 is used.

• Local anesthesia is used to numb small areas of the body and a patient remains completely conscious. General anesthesia is used to make the patient completely unconscious.

• Modifier 23 can only be used with anesthesia CPT codes (00100-01999).

Modifier 24 - Unrelated Evaluation and Management Service by the Same Physician during a Postoperative Period: 

• When surgery is performed on a patient and during the postoperative period, an E/M service is performed which is not related and included in the surgery then the E/M code needs to be billed separately along with the 24 modifiers.

• Modifier 24 can only be used with Evaluation and Management codes.

Modifier 25 - Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service:

• When a service along with an E/M service are performed on the same day by the same physician or other qualified health care professional then modifier 25 is used with the E/M code to reimburse separately.

Modifier 26 - Professional Component, TC - Technical Component & Global Service Modifier:

• Modifier 26 is used in physician billing to bill the professional component of a service.

• Modifier TC is used in physician billing to bill technical components of a service.

• Global service is useful in the reimbursement of both professional & technical components in a single billing. CPT needs to be billed without a modifier.

• These services are most commonly submitted with radiology procedures.

• When an X-ray needs to be performed then it includes two components, 1) Technical Component - X-ray machine with necessary supply to take the service. & 2) Professional component - Physician who supervises and interprets the service.

• When a physician & X-ray machine with necessary supplies are part of the same clinic then the clinic bills the service without a modifier that would include both technical and professional components, it is known as global billing. 

• When a physician has not been employed or is part of the clinic then the physician bills the service separately with modifier 26 is known as the professional component and clinic bills for the technical component with the TC modifier are known as the Technical component.

Modifier 47 - Anesthesia by Surgeon:

• When a physician performs surgery and prior to performing surgery gives general anesthesia then 47 modifiers is used with the surgery code to include anesthesia under surgery.

• It is always used with Surgical codes.

Modifier 50 - Bilateral Procedure:

• Modifier 50 is used when the same services are performed on both sides of the body (left & right) during the same operative sessions or on the same day.

• Procedures on the left and right do not need to bill separately with LT and RT modifiers. It should be billed with a 50 modifier on a single line.

Modifier 51 - Multiple Procedures:

• When a physician performs multiple surgical services at the same session and the second procedure is not a component code of the first procedure then the secondary service is billed with a 51 modifier.

• Modifier 51 is always billed with surgical procedures.

 

Modifier 52 - Reduced Services:

• When a physician does not perform the service completely & reduces or cancels it before completion. Such services are billed with the same CPT code and the 52 modifier is helpful to identify that service is reduced.

• This modifier is applicable only with surgical & diagnostic CPT codes.

Modifier 53 - Discontinued Procedures:

• When a physician discontinues performing a service due to risk to the patient or due to equipment failure. Modifier 53 is useful to report a service that is discontinued.

Modifier 54 - Surgical Care Only, Modifier 55 - Postoperative Management Only, Modifier 56 - Preoperative Management Only:

• Surgery has 3 different phases - Preoperative, Intraoperative & Postoperative.

• Preoperative Phase - This phase occurs prior to the surgery where the provider gathers all the relevant information to make sure there is no obstacle when performing the surgery.

• Intraoperative Phase - This is a phase where actual surgery is performed.

• Postoperative Phase - This phase occurs after the surgery where the provider monitors the patient on a timely basis to make sure that the patient is safe & comfortable.

• When one physician performs a surgical procedure and other physicians perform the preoperative and postoperative services then the physician who performs the surgery uses modifier 54 with the surgery code to identify surgical services.

• A Physician who performs preoperative service will bill the service with modifier 56 with surgery code to identify preoperative service.

• A Physician who performs postoperative service will bill the service with modifier 55 with surgery code to identify postoperative service.

Modifier 57 - Decision for Surgery:

• When a physician needs to perform major surgery and an E/M service is given on the same day or a day before the surgery then to reimburse E/M service, modifier 57 is used.

• The only difference between Modifier 25 & Modifier 57 is: Modifier 25 is used with E/M service when it is performed along with minor surgery on the same day.

• Modifier 57 is used with E/M service when it is performed along with major surgery on the same day or the day prior to actual service.

Modifier 58 - Staged or Related Procedure or Service by the Same Physician During the Postoperative Period:

• When a physician performs surgery and while performing the surgery, the physician comes to know that it could lead to another problem in the future and needs to perform another service to solve the issue. So, when the same physician performs a second service, it should be billed with 58 modifier then it will not reduce the reimbursement of the second service. Because the second surgery is already planned by the physician.

Modifier 59 - Distinct Procedural Service:

• When 2 distinct services are performed on the same day and both are independent of each other & performed on 2 different body parts then modifier 59 is used to indicate both these services are distinct and separate procedures.

Modifier 76 - Repeat Procedure by Same Physician:

• Modifier 76 is used when a service is performed repeatedly on the same day by the same physician.

Modifier 77 - Repeat Procedure by Another Physician:

• Modifier 77 is used when a service is performed repeatedly on the same day by different physicians.

Modifier 78 - Return to the Operating Room for a Related Procedure During the Postoperative Period:

• When a physician performs surgery and the result of surgery leads to another problem and needs to perform another service to solve the issue then the same physician performs the second service which should be billed with a 78 modifier. The second surgery is not planned by the physician.

Modifier 79 - Unrelated Procedure or Service by the Same Physician During the Postoperative Period:

• When a physician performs surgery and during the postoperative phase, another surgery is performed which is not related to the first surgery then the second surgery is billed with Modifier 79.

• Note: Whenever a surgery is performed, there is a global period assigned for each surgery. Any other service which is performed within the global period will be included under the first surgery and if it is not related to the first surgery and needs to be reimbursed separately then these modifiers are useful to indicate service is different.

Modifier 80 - Assistant Surgeon:

• When an assistant surgeon assists a primary surgeon and is present for the entire operation or a substantial portion of the operation then the assisting physician reports the same surgical procedure as the operating surgeon. The operating surgeon does not append a modifier to the procedure that he/she reports. The assistant surgeon reports the same CPT code by appending modifier 80.

Modifier 81 - Minimum Assistant Surgeon:

• When an operating physician plans to perform a surgical procedure alone but during an operation, circumstances may arise that require the services of an assistant surgeon for a relatively short time. In this instance, the second surgeon provides minimal assistance, for which he/she reports the surgical procedure code by appending modifier 81.

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

• Modifier 82 is used when an assistant at surgery service is provided by an MD since there is not a qualified resident available. Documentation must include information relating to the unavailability of a qualified resident in this situation.

Modifier AS - Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist services for assistant-at-surgery, non-team member:

• Modifier AS is used when an assistant at surgery services is provided by a physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS).

Modifiers Q7, Q8 & Q9:

• Click Here to learn more about these modifiers

"CS" Modifiers:

• Click Here to learn more about this modifier