What Would Not Occur When Using An Incorrect Place Of Service Code

What Are Medical Coding Modifiers?

Medical coding modifiers A medical coding modifier is 2 characters (letters or numbers) appended to a CPT^® or HCPCS Level II code. The modifier provides additional information most the medical process, service, or supply involved without changing the meaning of the lawmaking. Medical coders use modifiers to tell the story of a particular encounter.

For example, a coder may utilize a modifier to indicate a service did non occur exactly equally described by a CPT^® or HCPCS Level 2 code descriptor, only the circumstance did not change the code that applies. A modifier also may provide details not included in the code descriptor, such equally the anatomic location of the procedure. Some payer programs may have modifiers that apply only when you're reporting codes in connection with those programs, too.

The CPT^® lawmaking book Introduction provides these additional examples of when a modifier may be advisable:

The service or procedure has both professional and technical components.
More than one provider performed the service or process.
More than i location was involved.
A service or procedure was increased or reduced in comparing to what the lawmaking typically requires.
The procedure was bilateral.
The service or procedure was provided to the patient more than once.

Proper use of modifiers is of import both for authentic coding and because some modifiers impact reimbursement for the provider. Omitting modifiers or using the wrong modifiers may crusade merits denials that pb to rework, payment delays, and potential reimbursement loss.

CPT^® Modifiers

The American Medical Clan (AMA) holds copyright in CPT^®. CPT^® modifiers are generally two digits, although performance measure modifiers that utilize only to CPT^® Category Two codes are alphanumeric (1P-8P).

These are examples of some of the most commonly used CPT^® modifiers:

25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service
26 Professional component
59 Distinct procedural service

You'll discover CPT^® modifiers listed in your CPT^® code volume. A complete online CPT^® resource also should include CPT^® modifiers. Notation that CPT^® code books often include an abbreviated list of HCPCS Level II modifiers.

HCPCS Level Ii Modifiers

HCPCS Level II codes and modifiers are maintained past the Centers for Medicare & Medicaid Services (CMS). HCPCS Level II modifiers are alphanumeric or accept two letters.

Below are some examples of HCPCS Level Two modifiers:

E1 Upper left, eyelid
TC Technical component; under certain circumstances, a charge may be fabricated for the technical component lone; under those circumstances the technical component charge is identified by adding modifier 'tc' to the usual process number; technical component charges are institutional charges and not billed separately by physicians; however, portable x-ray suppliers only pecker for technical component and should utilize modifier tc; the charge data from portable x-ray suppliers volition then be used to build customary and prevailing profiles
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure

You can find HCPCS Level II modifier lists in HCPCS Level II code books and in online coding resource. Because the HCPCS Level Ii code fix is not copyrighted, the modifiers are also publicly available on CMS' Alpha-Numeric HCPCS site and HCPCS Quarterly Update site.

Pricing Modifiers and Informational Modifiers

In addition to separating modifiers based on whether they're from the CPT^® or HCPCS Level II code set, modifiers are also categorize by type. Two important categories are pricing modifiers (too called payment-impacting modifiers or reimbursement modifiers) and informational modifiers.

Pricing Modifiers

A pricing modifier is a medical coding modifier that causes a pricing change for the code reported. The Multi-Carrier System (MCS) that Medicare uses for claims processing requires pricing modifiers to be in the outset modifier position, before whatever informational modifiers. On the CMS 1500 merits grade, the advisable field is 24D (shown below). You lot enter the pricing modifier directly to the right of the procedure lawmaking on the claim. Most providers use the electronic equivalent of this grade to nib Medicare for professional (pro-fee) services.

Pricing Modifiers

Claims that practise not have the pricing modifier in the starting time position may encounter processing delays. To help with proper reporting and modifier placement, individual payers may provide lists that distinguish pricing modifiers from informational modifiers for their claims. For instance, the WPS Government Wellness Administrators (WPS GHA) site includes a Pricing Modifier Fact Sheet that not only lists pricing modifiers, but too identifies which of those modifiers you should put in a secondary position if some other pricing modifier is required for the lawmaking.

Informational Modifiers

An informational modifier is a medical coding modifier non classified as a payment modifier. Another proper noun for informational modifiers is statistical modifiers. These modifiers vest subsequently pricing modifiers on the claim.

Notation that informational modifiers may affect whether a code gets reimbursed, so they may be relevant to payment, despite the proper noun "informational." For instance, coders frequently apply modifier 59 to override Medicare'south National Correct Coding Initiative (NCCI) Procedure-to-Procedure (PTP) edits, bringing in payment for both codes in the lawmaking edit pair. Although you would non receive payment for the Column 2 code of the edit without modifier 59 on one of the codes from the edit pair, you may observe modifier 59 classified as an informational modifier rather than a payment modifier. To return to our WPS GHA example, the payer lists modifier 59 every bit an informational modifier.

One payer's list of pricing and advisory modifiers may non friction match another'due south list, and then medical coders demand to stay current on individual payer policy to avoid wrong modifier placement that could touch on merits processing.

NCCI Modifiers

An NCCI PTP-associated modifier is a modifier that Medicare and Medicaid take to bypass an NCCI PTP edit nether appropriate clinical circumstances. Bypassing or overriding an edit is as well chosen unbundling.

Modifier 59, referenced in the previous department, is but 1 of the modifiers that tin can featherbed an NCCI edit. Identical NCCI PTP-associated modifier lists are shown in the National Correct Coding Initiative Policy Manual for Medicare Services bachelor on CMS' NCCI edits page and in the National Correct Coding Initiative Transmission for Medicaid Services bachelor on the Medicaid NCCI reference documents page.

Table ane shows the complete listing of NCCI PTP-associated modifiers. The categories (Anatomic Modifiers, Global Surgery Modifiers, and Other Modifiers) are how Medicare and Medicaid dissever these modifiers.

Table 1: NCCI PTP-Associated Modifiers

Modifier	Abbreviated Description
Anatomic Modifiers
E1-E4	Eyelids
FA, F1-F9	Fingers and thumbs
TA, T1-T9	Toes
LT, RT	Left side and right side of body
LC, LD, RC, LM, RI	Coronary arteries
Global Surgery Modifiers
24	Unrelated postoperative evaluation and management (E/Yard) service
25	Separate E/M on same solar day equally other service
57	Determination for surgery
58	Staged/related postoperative procedure
78	Unplanned postoperative return to the operating room
79	Unrelated postoperative procedure
Other Modifiers
27	Multiple same-date outpatient hospital E/M services
59	Distinct procedural service
91	Echo lab tests
XE, XP, XS, XU	Carve up meet, practitioner, construction, service

While each of these modifiers is important, a few deserve special attention because they're amidst the nigh used (or misused). Beneath is an overview of these modifiers.

NCCI Modifier 25: Separate E/M

When a patient has a split E/M service along with a procedure or other service on the same twenty-four hour period by the same provider, you lot may report that E/Thousand lawmaking separately for reimbursement by appending modifier 25 Significant, separately identifiable evaluation and management service past the aforementioned doctor or other qualified health care professional person on the same day of the procedure or other service.

Based on the descriptor, an E/Grand encounter must see the criteria below to qualify for split reporting using modifier 25.

Significant, Separately Identifiable E/M Service

Many coders find that determining whether an E/One thousand service is meaning and separately identifiable is the nearly problematic requirement for modifier 25 use. The documentation must conspicuously testify that the provider performed extra E/M work across the usual work required for the other procedure or service on the aforementioned date. In other words, if yous removed all the documentation represented by the code for the other process or service, would the remaining documentation support reporting an E/G code?

Regarding diagnoses for these encounters, the Medicare and Medicaid NCCI manuals say the diagnosis tin be the same for the process/service and separate E/M (both manuals include this in Affiliate I.D). Although carve up diagnoses are not required, experienced coders accept plant that linking one ICD-ten-CM code to the procedure/service code and another ICD-ten-CM code to the Due east/One thousand code may speed claim processing. The split up ICD-10-CM codes make the distinct reasons for the Due east/M and other procedure or service more obvious. You should report different diagnosis codes, even so, only if the documentation supports them.

Same Physician or Other Qualified Healthcare Professional

To interpret the "aforementioned medico" requirement correctly, medical coders must recall that Medicare follows this dominion found in Medicare Claims Processing Manual, Affiliate 12, Section 30.6.5:

Physicians in the aforementioned group exercise who are in the same specialty must bill and exist paid equally though they were a unmarried dr.. If more than than one evaluation and management (contiguous) service is provided on the aforementioned day to the same patient by the same physician or more ane doc in the same specialty in the aforementioned group, only one evaluation and direction service may be reported unless the evaluation and management services are for unrelated problems. Instead of billing separately, the physicians should select a level of service representative of the combined visits and submit the appropriate code for that level.

Same Day of the Procedure or Other Service

Determining whether an East/G service occurred on the aforementioned date of service every bit another procedure or service is typically straightforward. But keep in listen some points related to Medicare's global surgery rules.

You may suspend modifier 25 to an East/M lawmaking reported on the aforementioned date as a small-scale surgical procedure code, which is a code with global menses indicator 000 or 010 on the Medicare Physician Fee Schedule (MPFS), according to Chapter I.Due east of the Medicare NCCI manual. The manual also states you may append modifier 25 to an E/M code performed on the aforementioned date as a code with a global indicator of XXX.

Before you report an E/One thousand code on the aforementioned date every bit a procedure code with indicator 000 (0-24-hour interval global), 010 (ten-day global menses), or 30 (global rules not applicable), consider that those codes include the pre-, intra-, and mail service-procedure work involved. Yous should not report an East/One thousand code for that work, fifty-fifty with modifier 25 appended.

Medicare besides includes the decision to perform a small-scale surgical procedure in the procedure code, the NCCI manual states. Then, you shouldn't written report a split up E/Chiliad code for that work. When you're reporting an E/M code representing the decision to perform a major surgery (one with a 090 global indicator, which represents a 90-day global period), you should suspend modifier 57 Decision for surgery, and not modifier 25.

Modifier 25 Example

Here is an example of when to use modifier 25 based on a scenario in Medicare Claims Processing Manual, Chapter 12, Section 40.ane.C. Suppose the md sees a patient with caput trauma and decides the patient needs sutures. After checking allergy and immunization status, the physician performs the process. An E/M is non separately reportable in this scenario. But, if the medico performs a medically necessary full neurological exam for the head trauma patient, then reporting a separate E/M with modifier 25 appended may be appropriate.

NCCI Modifiers 59 and 10{EPSU}: Distinct Service

Modifier 59 Distinct procedural service is a medical coding modifier that indicates documentation supports reporting not-Eastward/M services or procedures together that you usually wouldn't report on the same date. Appending modifier 59 signifies the code represents a procedure or service contained from other codes reported and deserves separate payment.

Similar modifier 25, modifier 59 is difficult to master considering it requires determining whether the code is truly distinct and separately reportable from other codes. The CPT^® definition of modifier 59 advises that the modifier may be advisable for a lawmaking when documentation shows at least one of the following:

A split patient encounter or session
A different procedure or surgery
A different anatomic site or organ system
A separate incision/excision
A separate lesion
A separate injury (or area of injury in the case of an extensive injury)

The CPT^® definition also states that you should not use modifier 59 when a more descriptive modifier is bachelor. For instance, you may be able to utilize anatomic modifiers to demonstrate that procedures occurred at separate sites on the torso.

Equally an example, the commencement-quarter 2021 Medicare NCCI PTP edits include the edit pair 29827 Arthroscopy, shoulder, surgical; with rotator cuff repair and 29820 Arthroscopy, shoulder, surgical; synovectomy, partial. The edit has a modifier indicator of "one," which means you may featherbed the edit in appropriate clinical circumstances. An commodity about modifier 59 in MLN Matters SE1418 states y'all shouldn't study 29820 (with or without an NCCI modifier) "if both procedures are performed on the same shoulder during the aforementioned operative session. If the procedures are performed on different shoulders, modifiers RT and LT should be used, not Modifiers 59 or -Ten{EPSU}."

X{EPSU} Modifiers

When considering whether to append modifier 59, medical coders must factor in the and so-chosen 10{EPSU} modifiers. These are HCPCS Level Ii modifiers that Medicare created as more specific alternatives to modifier 59:

XE Separate encounter, a service that is distinct because it occurred during a separate run into
XP Separate practitioner, a service that is distinct because it was performed past a different practitioner
XS Separate structure, a service that is distinct considering it was performed on a separate organ/structure
XU Unusual non-overlapping service, the utilise of a service that is singled-out because information technology does not overlap usual components of the main service

In the annunciation about the creation of the X{EPSU} modifiers in 2014, CMS stated, "Usage to identify a separate run across is infrequent and usually right; usage to define a separate anatomic site is less mutual and problematic; usage to define a distinct service is common and not infrequently overrides the edit in the verbal circumstance for which CMS created the edit in the first place." The use of the more specific modifiers shows the reason the service was separate or singled-out in a way that modifier 59 does non. This specificity gives auditors, payers, and providers more data to help them determine which type of reporting is decumbent to errors.

Medicare still accepts modifier 59, simply bank check with private payers to see which modifiers they prefer for a distinct procedural service.

NCCI Medicare Global Packet Modifiers

Modifiers likewise play an of import role in reporting procedures and services performed during a surgical code's global period, which is the timeframe when the global surgical package concept applies.

Medicare's global surgical package is a policy that incorporates payment in the surgery code fee for necessary, routine services before, during, and afterwards a procedure. The policy applies to work performed past aforementioned-specialty members of the same group.

This article has already explained that global period indicators are relevant to modifier 25 and 57 use. Below are additional modifiers NCCI identifies every bit Global Surgery Modifiers, which means the modifiers may let you to identify that a service is separately payable fifty-fifty though it occurred during a surgery'due south global period.

Modifier 24: Unrelated East/Yard

Modifier 24 Unrelated evaluation and management service by the same doctor or other qualified health care professional during a postoperative period is appropriate for use merely on East/Chiliad codes and just for services unrelated to the original process (the one with the global period).

Note that using modifier 24 to report an Eastward/M related to the underlying illness process may be appropriate. Suppose, for example, that a biopsy reveals a malignant tumor. The patient returns during the biopsy'due south global catamenia for suture removal and, on the same engagement, has a distinct E/M visit with the md to discuss the diagnosis and treatment options. The piece of work and time related to suture removal and routine post-biopsy care are non separately reportable, simply you tin can report the Eastward/M service using modifier 24.

Medicare's Global Surgery Booklet supports this use of modifier 24, stating, "Treatment for the underlying condition or an added class of handling which is not part of normal recovery from surgery" is non included in Medicare'south global surgical package. The CPT^® Surgery section guidelines provide similar wording: "Care of the status for which the diagnostic procedure was performed or of other concomitant conditions is not included and may be listed separately."

Modifier 58: Staged/Related Procedure

Another of import global package modifier is modifier 58 Staged or related procedure or service by the same physician or other qualified wellness care professional during the postoperative period.

Medicare'southward Global Surgery Booklet states that using modifier 58 signifies that performing a process or service during the postoperative period was one of the following (the CPT^® code book uses similar language):

Planned prospectively or at the time of the original procedure
More extensive than the original procedure
For therapy following a diagnostic surgical procedure

Y'all should append modifier 58 to the code for the staged or related process. A new postoperative period begins when you report that next procedure in the series.

Modifier 78: Unplanned Return to OR

When the patient returns to the operating or procedure room during the global menstruation for an unplanned but related procedure, y'all should append modifier 78 Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period.

A common use for modifier 78 is to study handling for complications. The global surgical bundle does non include "treatment for postoperative complications which requires a return trip to the operating room (OR)," according to Medicare Claims Processing Manual, Chapter 12, Section twoscore.one.B.

The manual goes on to explain that an "OR for this purpose is defined as a place of service specifically equipped and staffed for the sole purpose of performing procedures. The term includes a cardiac catheterization suite, a laser suite, and an endoscopy suite. It does not include a patient's room, a modest treatment room, a recovery room, or an intensive care unit (unless the patient's condition was so critical in that location would be bereft time for transportation to an OR)."

As Medicare Administrative Contractor (MAC) Palmetto GBA explains in its modifier 78 page, "If the subsequent surgery is related to the initial surgery but does not require a return to the operating room, and both are performed by the same surgeon, the subsequent surgery cannot be submitted separately. The global fee for the initial surgery includes additional related surgical procedures that do non require a return to the operating room."

The CPT^® Surgery department guidelines are non equally specific as the Medicare global rules regarding the operating/procedure room requirements. The CPT^® guidelines land that "complications, exacerbations, recurrence, or the presence of other diseases or injuries requiring boosted services should be separately reported." Because rules may differ, medical coders should cheque individual payer policies on reporting complications treated during the global period.

Modifier 79: Unrelated Procedure

For unrelated procedures during the postoperative period, the CPT^® code ready provides modifier 79 Unrelated procedure or service past the same doctor or other qualified wellness care professional during the postoperative period.

Reporting the same lawmaking for the initial process and the "unrelated" procedure may be appropriate, as this example of proper modifier 79 utilize shows: Suppose a patient has a correct-eye cataract extraction reported using 66984 Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), transmission or mechanical technique (eg, irrigation and aspiration or phacoemulsification); without endoscopic cyclophotocoagulation. The same patient then has a left-eye cataract extraction (again, 66984) by the aforementioned physician during the global menstruum for the showtime procedure. You should suspend modifier 79 to the lawmaking for the second procedure. Although both procedures require the same code, they are unrelated because each surgery was on a different eye.

Modifiers on the MPFS

The terminal grouping of modifiers covered hither relate to the MPFS, which is funded by Medicare Office B. The MPFS lists fee maximums Medicare uses to pay physicians and other healthcare professionals on a fee-for-service basis. MPFS relative value files of form include relative value units (RVUs), but those files besides provide information essential to proper use of the modifiers below for Medicare claims.

Modifiers 26 and TC: Professional and Technical Components

Medicare (forth with many other payers) splits some codes into professional person and technical components. For services like radiologic exams where the entity performing the exam and the interpreting provider are frequently different, having separate professional and technical components simplifies reporting and payment. CPT^® code 71046 Radiologic exam, chest; ii views is an example of a code that has both professional and technical components.

Using modifier 26 Professional component allows the provider to claim reimbursement for the provider'southward work, including supervision, interpretations, and reports. PC is an abbreviation for professional person component, merely medical coders must take intendance not to accidentally append modifier PC Wrong surgery or other invasive procedure on patient in identify of modifier 26.

Modifier TC Technical component represents costs similar paying technicians and paying for equipment, supplies, and the infinite used.

The PCTC IND (PC/TC Indicator) column in the MPFS relative value files reveals whether a code has a PC/TC split and whether you may append modifiers 26 and TC to the code. With 10 distinct indicators, medical coders benefit from referring to a current list of MPFS modifier indicator definitions to ensure they're using the modifiers correctly.

If a code has both a technical and a professional component and you report the code without using modifier 26 or TC, yous're challenge that you've earned reimbursement for both components. This type of lawmaking with a PC/TC split is called a global code (not to be confused with the global period and global surgical package). For codes that accept modifiers 26 and TC, the MPFS RVU spreadsheet provides RVUs and indicators specific to the global code and the individual components. The global service rate equals the sum of the rates for the two components.

Modifier 53: Discontinued Procedure

In addition to modifiers 26 and TC, the Medicare relative value files includes modifier 53 Discontinued procedure. Four colonoscopy codes (44388, 45378, G0105, and G0121) have one row for the code and one row for the lawmaking with modifier 53. The reason is that Medicare wants contractors to pay a consistent corporeality for those colonoscopy codes with modifier 53 appended.

CPT^® guidelines country that appending modifier 53 is appropriate when a patient is scheduled and prepared for a full colonoscopy, but "the physician is unable to advance the colonoscope to the cecum or colon-small intestine anastomosis due to unforeseen circumstances."

Modifier fifty: Bilateral Procedure

The MPFS includes a BILAT SURG (Bilateral Surgery) column that identifies how payment will differ if y'all study the code bilaterally. "Bilateral surgeries are procedures performed on both sides of the body during the same operative session or on the same day," states Medicare Claims Processing Manual, Affiliate 12, Section 40.seven.

To indicate a procedure was bilateral, it may be appropriate to append modifier l Bilateral procedure. Simply as the definition of bilateral indicator "1" shows, MACs bank check for multiple means of reporting bilateral procedures, including modifier 50, modifiers RT Right side and LT Left side, or 2 units:

1: 150% payment adjustment for bilateral procedures applies. If the code is billed with the bilateral modifier or is reported twice on the aforementioned twenty-four hours by whatsoever other means (e.thou., with RT and LT modifiers, or with a two in the units field), base the payment for these codes when reported as bilateral procedures on the lower of: (a) the total bodily accuse for both sides or (b) 150% of the fee schedule amount for a unmarried lawmaking. If the code is reported as a bilateral procedure and is reported with other procedure codes on the same 24-hour interval, apply the bilateral aligning before applying any multiple procedure rules.

Modifier 51: Multiple Procedures

The MULT PROC (Multiple Procedure) column in the Medicare relative value files is continued to modifier 51 Multiple procedures. However, your MAC and many other payers may instruct you non to append modifier 51 to codes. The payer will apply the multiple-procedure fee reduction rules based on the codes reported and which of the ix possible MULT PROC indicators the fee schedule assigns to the code.

Consequently, for those payers that do non accept modifier 51, the MULT PROC column offers data almost expected payment rather than nearly whether to use modifier 51. As an example of how this column affects payment, this is Medicare'south definition for multiple-procedure indicator "2":

2: Standard payment adjustment rules for multiple procedures apply. If procedure is reported on the same twenty-four hours as some other process with an indicator of 1, 2, or 3, rank the procedures by fee schedule amount and apply the appropriate reduction to this code (100%, l%, 50%, 50%, 50% and past report). Base the payment on the lower of (a) the bodily charge, or (b) the fee schedule amount reduced past the appropriate percent.

Pre-Op, Intra-Op, and Post-Op Modifiers

The MPFS splits the piece of work required for a surgery into the PRE OP (Preoperative Percentage), INTRA OP (Intraoperative Pct), and POST OP (Postoperative Percentage) columns, which show how much of the fee each portion of the surgical work earns in cases where the same provider is not responsible for every aspect of care.

To warning the payer that different providers are involved, CPT^® provides these modifiers:

54 Surgical care only
55 Postoperative management merely
56 Preoperative direction only

Review payer rules for proper use of these modifiers. For instance, the Medicare Global Surgery Booklet clarifies that modifier 55 is advisable only when at that place has been a transfer of care. Yous'll use the surgery appointment equally the date of service and can merely use the modifier if the code has a global menstruation of 10 days or ninety days.

Modifiers for Multiple Surgeons

The MPFS relative value files also include columns to betoken Medicare'south code-specific policies on modifier employ and payment when multiple providers perform a procedure at the same session.

The CO-SURG (Co-surgeons) column is related to modifier 62 2 surgeons. Medicare'due south Global Surgery Booklet provides these examples:

A process requires ii physicians of unlike specialties to perform it. Each reports the code with modifier 62 appended
Two surgeons simultaneously perform parts of a process, such as for a centre transplant or bilateral knee replacements. Once more, each surgeon reports the code with modifier 62 appended.

The Team SURG (Team Surgery) column is connected to modifier 66 Surgical team. This modifier is advisable when more than two surgeons of dissimilar specialties perform a procedure. Each surgeon bills the code with modifier 66 appended.

The ASST SURG (Assistant at Surgery) cavalcade provides data related to these modifiers:

lxxx Assistant surgeon
81 Minimum assistant surgeon
82 Banana surgeon (when qualified resident surgeon non bachelor)
AS Medico assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery

The ASST SURG indicator will let you know whether payment for the boosted provider is permitted, not permitted, or possibly permitted if documentation supports medical necessity.

With modifier 62, the Medicare fee for each co-surgeon is 62.5% of the global surgery fee schedule amount. For team surgeons using modifier 66, the Global Surgery Booklet advises that claims must have enough information to allow the MAC to decide pricing "past written report." For assistant-at-surgery services by physicians, the Medicare rate is 16% of the surgical payment. These examples testify notwithstanding again that proper use of medical coding modifiers is essential both for coding precision and for accurate payment.

CPT^® and HCPCS Level Ii Modifier FAQs

Can you lot use modifiers on CPT^® add-on codes?

Modifiers may exist appropriate on CPT^® add-on codes (identified here and in many coding resources with a +), but you should confirm that the private modifier is advisable for the code you're reporting.

Examples of when information technology is appropriate to suspend a modifier to an add-on code include:

The CPT^® code ready includes add-on code +74248 Radiologic small-scale intestine follow-through study, including multiple serial images (List separately in addition to code for primary procedure for upper GI radiologic exam). The MPFS shows that information technology is appropriate to suspend modifier 26 Professional component or TC Technical component to this code when you are reporting only one of those components for this service.
Medicare includes some add-on codes in NCCI PTP edit pairs. For case, +22845 Anterior instrumentation; 2 to 3 vertebral segments (List separately in add-on to lawmaking for primary procedure) is a cavalcade 2 lawmaking for +22853 Insertion of interbody biomechanical device(southward) (eg, constructed muzzle, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to lawmaking for primary procedure) in the first-quarter 2021 edits. The edit has a modifier indicator of "1," which means you may bypass the edit by using one or more NCCI PTP-associated modifiers. Note that in many cases improver codes are not included in NCCI PTP edits because if an edit prevents payment of the master code, the payer also will not reimburse the add-on code for that primary code. This domino effect makes an edit for the improver code unnecessary.

An case of when it's non advisable to suspend a specific modifier to an add together-on lawmaking include:

CPT^® guidelines land that yous should not use modifier fifty Bilateral procedure on add-on codes: "When the improver procedure can be reported bilaterally and is performed bilaterally, the appropriate improver lawmaking is reported twice, unless the code descriptor, guidelines, or parenthetical instructions for that item improver lawmaking instructs otherwise. Do not study modifier 50, Bilateral procedures, in conjunction with addition codes."

Can yous utilise CPT^® modifiers on HCPCS Level 2 codes and vice versa?

There is no full general restriction on using the modifiers from one lawmaking set up (CPT^® or HCPCS Level II) with the codes from some other lawmaking set, and such use is common. Individual modifiers may be appropriate only with certain codes, so be sure to check the rules specific to the case y'all're reporting.

Every bit an instance, modifier QW CLIA waived test is a HCPCS Level II modifier that alerts the payer that the test beingness reported has waived status nether the Clinical Laboratory Improvement Amendments (CLIA). The listing of CLIA-waived tests on the CMS site provides a long list of CPT^® lab codes that are appropriate to report with modifier QW. A handful of HCPCS Level 2 codes are included in the list, as well.

Tin yous append more than one modifier to a CPT^® or HCPCS Level 2 code?

Appending both CPT^® and HCPCS Level Two modifiers to a unmarried lawmaking may be advisable. For instance, an run across may call for both CPT^® modifier 22 Increased procedural services and HCPCS Level Ii modifier LT Left side (used to identify procedures performed on the left side of the body) on one procedure code.

Claim forms provide space for multiple modifiers. Depending on payer rules, the number of modifiers required, and the space bachelor, it may be appropriate to append modifier 99 Multiple modifiers to the code and so identify boosted modifiers in another section of the claim, such as CMS 1500 box nineteen.

What is the difference between modifier 52 and modifier 53?

Pro-fee coders may consider appending modifier 52 Reduced services or modifier 53 Discontinued procedure to a medical code when a provider does not complete the full procedure or service described by that lawmaking.

Appendix A of the AMA CPT^® code book explains that appending modifier 52 to a code is appropriate when provider discretion is the reason for partially reducing or eliminating a service or procedure.

Y'all should append modifier 53 when the provider terminates a surgical or diagnostic procedure "due to extenuating circumstances or those that threaten the well existence of the patient," Appendix A states. You should not apply modifier 53 for constituent cancellation of a procedure before anesthesia consecration or surgical grooming in the operating suite.

Outpatient hospitals and convalescent surgery centers (ASCs) should use modifier 73 Discontinued out-patient hospital/convalescent surgery eye (ASC) procedure prior to the administration of anesthesia and modifier 74 Discontinued out-patient infirmary/ambulatory surgery center (ASC) procedure afterwards assistants of anesthesia for reporting.

Modifiers 73 and 74 apply only when the procedure is discontinued due to extenuating circumstances or issues that threaten the wellbeing of the patient.

When should you use echo modifiers 76 and 77?

Modifier 76 Echo procedure or service past same physician or other qualified health care professional is appropriate to use when the same provider repeats the process or service subsequent to the original procedure or service. Keep in mind that payers, including Medicare, may require same-specialty physicians in the same grouping to nib as if they are a single medico.

Modifier 77 Repeat procedure past another physician or other qualified health intendance professional person is appropriate to use when a dissimilar provider repeats a procedure or service subsequent to the original process or service.

You should not use either modifier 76 or 77 on an E/M code, according to Appendix A of the AMA CPT^® code book.

Individual payers may provide boosted guidance. For instance, WPS Regime Wellness Administrators has a Modifier 76 Fact Sheet that clarifies you should use the modifier for repeat procedures performed on the aforementioned day.

What are the ABN modifiers (GA, GX, GY, GZ)?

An Advance Beneficiary Detect of Noncoverage (ABN) class helps a beneficiary decide whether to become an item or service that Medicare may non cover. The ABN lets the beneficiary know they may be financially liable if Medicare denies payment.

ABN claim reporting modifiers are listed in the MLN booklet Medicare Advance Written Notices of Noncoverage with the following explanations:

Modifier GA Waiver of liability statement issued as required by payer policy, private case

Append modifier GA when you issue a mandatory ABN for a service as required, and the ABN is on file. You do not demand to submit a re-create of the ABN to Medicare, just you must take information technology available on request. Use modifier GA when both covered and noncovered services appear on an ABN-related merits.

Modifier GX Discover of liability issued, voluntary under payer policy

Append modifier GX when you issue a voluntary ABN for a service Medicare never covers because the service is statutorily excluded or is not a Medicare benefit. You may use this modifier combined with modifier GY.

Modifier GY Item or service statutorily excluded, does not see the definition of any Medicare benefit or, for non-Medicare insurers, is not a contract benefit

Append modifier GY when Medicare statutorily excludes the item or service, or the item or service does not meet the definition of whatsoever Medicare benefit. You may use this modifier combined with modifier GX.

Modifier GZ Item or service expected to be denied as not reasonable and necessary

Suspend modifier GZ when y'all wait Medicare to deny payment of the item or service because it is medically unnecessary, and you issued no ABN.

Is drug-waste material modifier JW only for Medicare?

Modifier JW Drug amount discarded/not administered to whatever patient is not limited to use for Medicare claims. Other third-party payers also may take this HCPCS Level Two modifier.

Bank check payer policy to confirm, merely non-Medicare payers may follow Medicare rules. For instance, Medicare states you lot should employ modifier JW only with drugs designated as single use or single dose on the FDA-canonical label or parcel insert.

Medicare requires reporting the corporeality used on one line and the amount discarded on a second line. Medicare Claims Processing Manual, Chapter 17, Department 40, provides the example of a single-utilise vial labeled to contain 100 units that has 95 units administered and 5 units discarded. In that case, you should report the 95-unit dose on one line. And then report the discarded 5 units on another line with modifier JW appended to the supply code.

When should you use modifier KX?

Modifier KX Requirements specified in the medical policy take been met is appropriate in a variety of circumstances. In particular, Medicare and some other payers may take KX for these types of claims:

Outpatient physical therapy, occupational therapy, or oral communication linguistic communication pathology
Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS)
Gender-specific services for patients who are transgender, are intersex, or have ambiguous genitalia

For instance, on physical therapy claims reported to Medicare, modifier KX may show that services are medically necessary and reasonable subsequently the beneficiary has exceeded the defined threshold.

For DMEPOS claims, modifier KX indicates the supplier ensured coverage criteria was met and that there is documentation to support medical necessity.

Modifier KX is also advisable on Part B professional claims to place gender-specific services performed on transgender or intersex patients or those with ambiguous ballocks. The modifier alerts the payer to procedure the claim as usual despite any gender-specific edits that may apply.

When should you lot use hospice modifiers GV and GW?

The hospice modifiers are modifier GV and GW:

GV Attending physician not employed or paid nether arrangement by the patient's hospice provider

GW Service not related to the hospice patient's terminal condition

Before appending modifier GV to a code, you should bank check these points:

The patient is enrolled in a hospice.
The provider is not employed by the hospice.
The provider (dr. or nonphysician practitioner) was identified as the patient's attending physician when the patient enrolled in hospice.

Medicare Claims Processing Transmission, Chapter 11, Section twoscore.1.3, provides more information about attention physicians for hospice patients. For example, the manual states, "When hospice coverage is elected, the beneficiary waives all rights to Medicare Part B payments for professional services that are related to the treatment and direction of his/her terminal illness during any period his/her hospice benefit ballot is in force, except for professional services of an independent attention dr., who is non an employee of the designated hospice nor receives compensation from the hospice for those services."

You should utilise modifier GW when a provider renders a service to a patient enrolled in a hospice, and the service is not related to the patient's terminal status.

Does Medicare provide information about preventive services modifier 33?

Modifier 33 Preventive services is referenced in Medicare Claims Processing Manual, Chapter xviii.

Department ane.2 and Section lx.one.1 both land, "Coinsurance and deductible are waived for moderate sedation services (reported with G0500 or 99153) when furnished in conjunction with and in support of a screening colonoscopy service and when reported with modifier 33. When a screening colonoscopy becomes a diagnostic colonoscopy, moderate sedation services (G0500 or 99153) are reported with simply the PT modifier [Colorectal cancer screening examination; converted to diagnostic test or other procedure]; only the deductible is waived."

Section 140.eight about advance care planning (ACP) as an element of an annual wellness visit (AWV) also references modifier 33: "The deductible and coinsurance for ACP will only exist waived when billed with modifier 33 on the same twenty-four hours and on the aforementioned claim equally an AWV (code G0438 or G0439), and must also be furnished by the same provider. Waiver of the deductible and coinsurance for ACP is limited to once per year. Payment for an AWV is express to once per yr. If the AWV billed with ACP is denied for exceeding the once per year limit, the deductible and coinsurance volition exist applied to the ACP."

What is the difference between telemedicine modifiers 95 and GT?

Elements such as payer policy and setting will determine whether y'all use modifier 95 Synchronous telemedicine service rendered via a real-fourth dimension interactive audio and video telecommunications system or modifier GT Via interactive audio and video telecommunication systems.

For Medicare, professional claims use identify of service (POS) 02 Telehealth to indicate the service was a telehealth service from a distant site (but see Annotation beneath). Modifier GT is used on institutional claims for distant site services billed under Critical Admission Hospital (CAH) method II.

Other payers may require you to employ modifier 95 to indicate the functioning of a telehealth service.

Note: Medicare and many other payers implemented temporary rules related to reporting telehealth codes, modifiers, and POS during the Public Health Emergency (PHE) related to COVID-19, then be sure to follow the guidance that applies to your service.

Terminal Reviewed on January 25, 2021 by AAPC Thought Leadership Team