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Medical Billing Intricacies: What are Modifier Codes?

July 19, 2012

Modifier Intricacies

A modifier is a code that provides the means by which the reporting physician can indicate that a service or procedure that has been performed has been altered by some specific circumstance but has not changed in its definition or code. The judicious application of modifiers obviates the necessity for separate procedure listings that may describe the modifying circumstance.

Modifiers are a critical component of coding and using them incorrectly will result in lost revenue and possible audits.  Know your modifiers and reduce the risk of lost revenue and improve audit compliance. 

Below you will find a brief overview of common modifiers used in medicine.  Modifier guidelines continue to change so you should always have the most recent copy of the CPT book produced by the AAPC or AMA.

Modifier 22: Increased procedural services

This modifier will most likely trigger an audit, so we recommend avoid using modifier 22 unless there is no CPT code describing the increased work.  Clear documentation must support the increased service and give reason for any additional work (i.e. increased intensity, time, technical difficulty, severity of patient’s condition, etc).  Do not append modifier 22 to an E/M service.

Modifier 25: Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service. This modifier may only be appended to an E/M CPT code.  The chart notes MUST indicate that the procedures were separately identifiable.  There are different guidelines for new and established patients:

New Patients: An initial E/M service code can be billed when performed on the same date of service as a minor surgical code with a 25 modifier appended to the E/M CPT code. The diagnosis may be the same for E/M and surgical code, if appropriate.

Established Patients: E/M service may be billed on the same date of service as a surgery code only if the diagnosis codes are different – there must be no correlation between the E/M service and the surgery.  There is one exception – if an established patient presents a new problem that requires a new E/M service, the same diagnosis may be used with adequate documentation showing the need for the E/M service.

Modifier 57Decision for Surgery.
This modifier replaces modifier 25 when the E/M results in a decision for major surgical procedures (90 day global).  The “Global Surgery Policy” includes the E/M service provided on the day before or the day of the major surgical procedure unless the E/M service resulted in the decision to perform the major surgery.  Modifier 57 may be used with E/M codes 99201-99499.

Modifier 24: Unrelated E/M service during post-op period.
When used correctly, this modifier is a great way to get paid for an E/M service during a post-op period – but, if used incorrectly, you may become a target for an audit.  Only append this modifier to an E/M CPT code when you perform an E/M service during the follow-up period of an unrelated surgical procedure.  Documentation must clearly state and show that the E/M performed is not related to the original surgical procedure.  Make sure you reference this E/M code to the appropriate unrelated diagnosis on the billing claim.

Modifier 59: Distinct procedural service.
Modifier 59 will most likely get you paid every time you use it, but OIG reports that 40% of it’s usage is incorrect, and audits will uncover incorrect usage.  Modifier 59 must only be used as a last resort – if no other modifiers are available.  Modifier 59 is used to identify procedures or services, other than E/M services, that are not normally reported together but are appropriate under the circumstances.  Documentation must support a different session, different surgery or procedure, different site or organ system, separate incision or excision, separate lesion or separate injury not ordinarily encountered or performed on the same day by the same individual.  When using modifier 59, all four of these guidelines must be met:

1)    To be used only on procedure codes, never E/M services.
2)    Procedure code was a distinct or separate service from other services performed on the same day.
3)    It is an anatomical modifier (there is no other available anatomical modifier to show that the procedure was a separate service from other services performed the same day.
4)    It is a multiple procedure modifier.

When using modifier 59, append it to the first CPT code.

Modifier 79: Unrelated procedure by the same physician during the post-operated period.
Use this procedure when performing an unrelated procedure or service during the post-operative period of another surgical procedure.  Diagnosis code must be different than that of the original procedure.  Must be used in conjunction with modifiers 24 and 25 if you want to bill for an E/M service as well.

CPT codes, descriptions and other data are copyright by American Medical Association (AMA).


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