Modifiers

This info listed to assist Dr. W. with coding procedures.

From Cheryl Boyles, Jan '22, for noncompliance:  Z91.19

Modifiers (from ’04 list)

-21 Prolonged Evaluation and Management Services: When the face-to-face or floor/unit service(s) provided is prolonged or otherwise greater than that usually required for the highest level of evaluation and management service within a given category, it may be identified by adding modifier ‘-21’ to the evaluation and management code number. A report may also be appropriate.

-22 Unusual Procedural Services: When the service(s) provided is greater than that usually required for the listed procedure, it may be identified by adding modifier ‘-22’ to the usual procedure number. A report may also be appropriate.
(Dr. Reynolds, 10/04: this code makes bill go into review and often will delay payment)

-23 Unusual Anesthesia: Occasionally, a procedure, which usually requires either no anesthesia or local anesthesia, because of unusual circumstances must be done under general anesthesia. This circumstance may be reported by adding the modifier ‘-23’ to the procedure code of the basic service.

-24 Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period: The physician may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. This circumstance may be reported by adding the modifier ‘-24’ to the appropriate level of E/M service.
(per Katy Boese, for addit E&M svcs without additional procedure like injection or fx charge).

-25 (per Katy Boese, addit E&M with injection. If also for fx or surgery, add 57 modifier). Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service: The physician may need to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding the modifier ‘-25’ to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier ‘-57’.

-26 Professional Component: Certain procedures are a combination of a physician component and a technical component. When the physician component is reported separately, the service may be identified by adding the modifier ‘-26’ to the usual procedure number.

-32 Mandated Services: Services related to mandated consultation and/or related services (eg, PRO, third party payer, governmental, legislative or regulatory requirement) may be identified by adding the modifier ‘-32’ to the basic procedure.

-47 Anesthesia by Surgeon: Regional or general anesthesia provided by the surgeon may be reported by adding the modifier ‘-47’ to the basic service. (This does not include local anesthesia.) Note: Modifier ‘-47’ would not be used as a modifier for the anesthesia procedures.

-50 Bilateral Procedure: Unless otherwise identified in the listings, bilateral procedures that are performed at the same operative session should be identified by adding the modifier ‘-50’ to the appropriate five digit code.

-51 Multiple Procedures: When multiple procedures, other than Evaluation and Management services, are performed at the same session by the same provider, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by appending the modifier ‘-51’ to the additional procedure or service code(s). Note: This modifier should not be appended to designated “add-on” codes (see Appendix D).

-52 Reduced Services: Under certain circumstances a service or procedure is partially reduced or eliminated at the physician’s discretion. Under these circumstances the service provided can be identified by its usual procedure number and the addition of the modifier ‘-52’, signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service. Note: For hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers ‘-73’ and ‘-74’ (See Modifiers Approved for ASC Hospital Outpatient Use).

-53 Discontinued Procedure: Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. This circumstance may be reported by adding the modifier ‘-53’ to the code reported by the physician for the discontinued procedure. Note: This modifier is not used to report the elective cancellation of a procedure prior to the patient’s anesthesia induction and/or surgical preparation in the operating suite. For outpatient hospital/ambulatory surgery center (ASC) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers ‘-73’ and ‘-74’ (See Modifiers Approved for ASC Hospital Outpatient Use).

-54 Surgical Care Only: When one physician performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding the modifier ‘-54’ to the usual procedure number.

-55 Postoperative Management Only: When one physician performed the postoperative management and another physician performed the surgical procedure, the postoperative component may be identified by adding the modifier ‘-55’ to the usual procedure number.

-56 Preoperative Management Only: When one physician performed the preoperative care and evaluation and another physician performed the surgical procedure, the preoperative component may be identified by adding the modifier ‘-56’ to the usual procedure number.

-57 Decision for Surgery: An evaluation and management service that resulted in the initial decision to perform the surgery may be identified by adding the modifier ‘-57’ to the appropriate level of E/M service.

-58 Staged or Related Procedure or Service by the Same Physician During the Postoperative Period (PLANNED): The physician may need to indicate that the performance of a procedure or service during the postoperative period was: a) planned prospectively at the time of the original procedure (staged); b) more extensive than the original procedure; or c) for therapy following a diagnostic surgical procedure. This circumstance may be reported by adding the modifier ‘-58’ to the staged or related procedure. Note: This modifier is not used to report the treatment of a problem that requires a return to the operating room. See modifier ‘-78’.

-59 Distinct Procedural Service: Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier ‘-59’ is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician. However, when another already established modifier is appropriate it should be used rather than modifier ‘-59’. Only if no more descriptive modifier is available, and the use of modifier ‘-59’ best explains the circumstances, should modifier ‘-59’ be used.

-62 Two Surgeons: When two surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding the modifier ‘-62’ to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. Each surgeon should report the co-surgery once using the same procedure code. If additional procedure(s) (including add-on procedure(s)) are performed during the same surgical session, separate code(s) may also be reported without the modifier ‘-62’ added. Note: If a co-surgeon acts as an assistant in the performance of additional procedure(s) during the same surgical session, those services may be reported using separate procedure code(s) with the modifier ‘-80’ or modifier ‘-82’ added, as appropriate.

-63 Procedure Performed on Infants less than 4 kg: Procedures 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. This circumstance may be reported by adding the modifier ‘-63’ to the procedure number. Note: Unless otherwise designated, this modifier may only be appended to procedures/services listed in the 20000-69999 code series. Modifier ‘-63’ should not be appended to any CPT codes listed in the Evaluation and Management Services, Anesthesia, Radiology, Pathology/Laboratory, or Medicine sections.

-66 Surgical Team: Under some circumstances, highly complex procedures (requiring the concomitant services of several physicians, often of different specialties, plus other highly skilled, specially trained personnel, and various types of complex equipment) are carried out under the “surgical team” concept. Such circumstances may be identified by each participating physician with the addition of the modifier ‘-66’ to the basic procedure number used for reporting services.

-76 Repeat Procedure by Same Physician: The physician may need to indicate that a procedure or service was repeated subsequent to the original procedure or service. This circumstance may be reported by adding the modifier ‘-76’ to the repeated procedure/service.

-77 Repeat Procedure by Another Physician: The physician may need to indicate that a basic procedure or service performed by another physician had to be repeated. This situation may be reported by adding modifier ‘-77’ to the repeated procedure/service.

-78 Return to the Operating Room for a Related Procedure During the Postoperative Period (UNPLANNED): The physician may need to indicate that another procedure was performed during the postoperative period of the initial procedure. When this subsequent procedure is related to the first, and requires the use of the operating room, it may be reported by adding the modifier ‘-78’ to the related procedure. (For repeat procedures on the same day, see ‘-76’).   Might also add, since unplanned return wouldn't be from my doing a bad job, if pt is noncompliant:  From Cheryl Boyles, Jan '22, for noncompliance:  Z91.19

-79 Unrelated Procedure or Service by the Same Physician During the Postoperative Period: The physician may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. This circumstance may be reported by using the modifier ‘-79’. (For repeat procedures on the same day, see ‘-76’).

-80 Assistant Surgeon: Surgical assistant services may be identified by adding the modifier ‘-80’ to the usual procedure number(s). Denotes assisted in the majority of the case.

-81 Minimum Assistant Surgeon: Minimum surgical assistant services are identified by adding the modifier ‘-81’ to the usual procedure number (assisted in less than the majority of the case).

-82 Assistant Surgeon (when qualified resident surgeon not available): The unavailability of a qualified resident surgeon is a prerequisite for use of modifier ‘-82’ appended to the usual procedure code number(s).

-90 Reference (Outside) Laboratory: When laboratory procedures are performed by a party other than the treating or reporting physician, the procedure may be identified by adding the modifier ‘-90’ to the usual procedure number.

-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 the same day to obtain subsequent (multiple) test results. Under these circumstances, the laboratory test performed can be identified by its usual procedure number and the addition of the modifier -91. Note: This modifier may not be used when tests are rerun to confirm initial results; due to testing problems with specimens or equipment; or for any other reason when a normal, one-time, reportable result is all that is required. This modifier may not be used when other code(s) describe a series of test results (eg, glucose tolerance tests, evocative/suppression testing). This modifier may only be used for laboratory test(s) performed more than once on the same day on the same patient.

-99 Multiple Modifiers: 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 applicable modifiers may be listed as part of the description of the service.

Anesthesia Physical Status Modifiers
The Physical Status modifiers are consistent with the American Society of Anesthesiologists’ ranking of patient physical status, and distinguishing various levels of complexity of the anesthesia service provided. All anesthesia services are reported by use of the anesthesia five-digit procedure code (00100-03108) with the appropriate physical status modifier appended.

Example: 00100-P1

Under certain circumstances, when another established modifier(s) is appropriate, it should be used in addition to the physical status modifier.

Example: 00100-P4-53

Physical Status Modifier P1: A normal healthy patient

Physical Status Modifier P2: A patient with mild systemic disease

Physical Status Modifier P3: A patient with severe systemic disease

Physical Status Modifier P4: A patient with severe systemic disease that is a constant threat to life

Physical Status Modifier P5: A moribund patient who is not expected to survive without the operation

Physical Status Modifier P6: A declared brain-dead patient whose organs are being removed for donor purposes

Modifiers Approved for Ambulatory Surgery Center (ASC) Hospital Outpatient Use
CPT Level I Modifiers
-25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service: The physician may need to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding the modifier ‘-25’ to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier ‘-57’.

-27 Multiple Outpatient Hospital E/M Encounters on the Same Date: For hospital outpatient reporting purposes, utilization of hospital resources related to separate and distinct E/M encounters performed in multiple outpatient hospital settings on the same date may be reported by adding the modifier ‘-27’ to each appropriate level outpatient and/or emergency department E/M code(s). This modifier provides a means of reporting circumstances involving evaluation and management services provided by physician(s) in more than one (multiple) outpatient hospital setting(s) (eg, hospital emergency department, clinic). Note: This modifier is not to be used for physician reporting of multiple E/M services performed by the same physician on the same date. For physician reporting of all outpatient evaluation and management services provided by the same physician on the same date and performed in multiple outpatient setting(s) (eg, hospital emergency department, clinic), see Evaluation and Management, Emergency Department, or Preventive Medicine Services codes.

-50 Bilateral Procedure: Unless otherwise identified in the listings, bilateral procedures that are performed at the same operative session should be identified by adding the modifier ‘-50’ to the appropriate five digit code.

-52 Reduced Services: Under certain circumstances a service or procedure is partially reduced or eliminated at the physician’s discretion. Under these circumstances, the service provided can be identified by its usual procedure number and the addition of the modifier ‘-52’, signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service. Note: For hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers ‘-73’ and ‘-74’.

-58 Staged or Related Procedure or Service by the Same Physician During the Postoperative Period: The physician may need to indicate that the performance of a procedure or service during the postoperative period was: a) planned prospectively at the time of the original procedure (staged); b) more extensive than the original procedure; or c) for therapy following a diagnostic surgical procedure. This circumstance may be reported by adding the modifier ‘-58’ to the staged or related procedure. Note: This modifier is not used to report the treatment of a problem that requires a return to the operating room. See modifier ‘-78’.

-59 Distinct Procedural Service: Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier ‘-59’ is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician. However, when another already established modifier is appropriate it should be used rather than modifier ‘-59’. Only if no more descriptive modifier is available, and the use of modifier ‘-59’ best explains the circumstances, should modifier ‘-59’ be used.

-73 Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC) Procedure Prior to the Administration of Anesthesia: Due to extenuating circumstances or those that threaten the well being of the patient, the physician may cancel a surgical or diagnostic procedure subsequent to the patient’s surgical preparation (including sedation when provided, and being taken to the room where the procedure is to be performed), but prior to the administration of anesthesia (local, regional block(s) or general). Under these circumstances, the intended service that is prepared for but cancelled can be reported by its usual procedure number and the addition of the modifier ‘-73’. Note: The elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. For physician reporting of a discontinued procedure, see modifier ‘-53.’

-74 Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC) Procedure After Administration of Anesthesia: Due to extenuating circumstances or those that threaten the well being of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia (local, regional block(s), general) or after the procedure was started (incision made, intubation started, scope inserted, etc). Under these circumstances, the procedure started but terminated can be reported by its usual procedure number and the addition of the modifier ‘-74’. Note: The elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. For physician reporting of a discontinued procedure, see modifier ‘-53.’

-76 Repeat Procedure by Same Physician: The physician may need to indicate that a procedure or service was repeated subsequent to the original procedure or service. This circumstance may be reported by adding the modifier ‘-76’ to the repeated procedure/service.

-77 Repeat Procedure by Another Physician: The physician may need to indicate that a basic procedure or service performed by another physician had to be repeated. This situation may be reported by adding modifier ‘-77’ to the repeated procedure/service.

-78 Return to the Operating Room for a Related Procedure During the Postoperative Period: The physician may need to indicate that another procedure was performed during the postoperative period of the initial procedure. When this subsequent procedure is related to the first, and requires the use of the operating room, it may be reported by adding the modifier ‘-78’ to the related procedure. (For repeat procedures on the same day, see ‘-76’).

-79 Unrelated Procedure or Service by the Same Physician During the Postoperative Period: The physician may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. This circumstance may be reported by using the modifier ‘-79’. (For repeat procedures on the same day, see ‘-76’).

-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 the same day to obtain subsequent (multiple) test results. Under these circumstances, the laboratory test performed can be identified by its usual procedure number and the addition of the modifier -91. Note: This modifier may not be used when tests are rerun to confirm initial results; due to testing problems with specimens or equipment; or for any other reason when a normal, one-time, reportable result is all that is required. This modifier may not be used when other code(s) describe a series of test results (eg, glucose tolerance tests, evocative/suppression testing). This modifier may only be used for laboratory test(s) performed more than once on the same day on the same patient.

Level II (HCPCS/National) Modifiers
-E1 Upper left, eyelid

-E2 Lower left, eyelid

-E3 Upper right, eyelid

-E4 Lower right, eyelid

-F1 Left hand, second digit

-F2 Left hand, third digit

-F3 Left hand, fourth digit

-F4 Left hand, fifth digit

-F5 Right hand, thumb

-F6 Right hand, second digit

-F7 Right hand, third digit

-F8 Right hand, fourth digit

-F9 Right hand, fifth digit

-FA Left hand, thumb

-LC Left circumflex coronary artery (Hospitals use with codes 92980 92981 92982 -92984, 92995, 92996)

-LD Left anterior descending coronary artery (Hospitals use with codes 92980 92981 92982 -92984, 92995, 92996)

-LT Left side (used to identify procedures performed on the left side of the body)

-QM Ambulance service provided under arrangement by a provider of services

-QN Ambulance service furnished directly by a provider of services

-RC Right coronary artery (Hospitals use with codes 92980 92981, 92982 -92984, 92995, 92996)

-RT Right side (used to identify procedures performed on the right side of the body)

-T1 Left foot, second digit

-T2 Left foot, third digit

-T3 Left foot, fourth digit

-T4 Left foot, fifth digit

-T5 Right foot, great toe

-T6 Right foot, second digit

-T7 Right foot, third digit

-T8 Right foot, fourth digit

-T9 Right foot, fifth digit

-TA Left foot, great toe