What are and When to Use Modifier Codes

Some key facts about modifier codes:

• Modifiers always follow the 5-digit CPT or HCPCS code they modify.
• There are two types of modifiers – CPT modifiers developed by the American Medical Association and HCPCS Level II modifiers developed by CMS.
• Over 340 modifier codes exist today.
• Modifiers help avoid incorrect or denied claims by specifying additional details.
• They should only be used when appropriate and necessary.
• Inappropriate use of modifiers can be considered fraudulent billing.

Simply put, modifiers enable medical coders to report specific variations in a procedure or medical service outside of the standard definition. This added detail is essential for accurate billing, reimbursement, and avoiding audits.

Modifier codes serve several important purposes:

• Specify service variations: Modifiers indicate if the procedure was altered from the stated CPT definition. This could involve different site, technique, multiple procedures, or other variations.
• Indicate additional services: Modifiers can convey when additional services are provided during the same session as a primary procedure. For instance, repairing incidental damage during surgery.
• Prevent denied claims: Modifiers supply the details needed to demonstrate medical necessity and support reimbursement for certain services.
• Bypass edits: Some modifiers override National Correct Coding Initiative (NCCI) edits to allow payment of service combinations normally bundled or not allowed.
• Meet payer requirements: Many payers require particular modifiers to be appended to certain codes before they will reimburse it.

In summary, modifiers add clarity and details needed for accurate billing, reimbursement, and avoiding lengthy appeals or audits down the road. Applying modifiers judiciously is a key component of compliant coding.

We’ll break down some of the most common modifier categories with examples:

Anatomic Modifiers

Anatomic modifiers indicate the body site or part where a procedure was performed.

Using these modifiers is essential since many CPT codes can be performed on different areas, which impacts billing:

• Eyes and Eyelids: -LT (left), -RT (right), -E1 (upper left), -E2 (lower left), -E3 (upper right), -E4 (lower right)

Example: 67810 – Repair of ectropion; excision tarsal wedge -E1 (upper left eyelid)

• Digits: -FA (fingers), -TA (toes), -F1-F9 (specify finger), -T1-T9 (specify toe)

Example: 26850 – Hammertoe operation; one toe -T2 (second toe)

• Limbs: -LC (left circumferential), -RC (right circumferential), -LD (left distal), -RD (right distal), -LP (left proximal), -RP (right proximal)

Example: 27524 – Repair, tendon or muscle; rotator cuff -RC (right shoulder)

Careful use of anatomic modifiers eliminates any ambiguity about which body part was treated.

Global Surgery Modifiers

Global surgery modifiers are crucial to convey the specific services provided during complex surgical cases:

• -54: Surgical care only. Apply when one physician does the surgical procedure while another provides pre/post-operative management.
• -55: Post-operative management only. Used when a physician provides post-op care but was not involved in the surgery itself.
• -56: Pre-operative management only. Indicates a physician handled pre-op care but did not perform the actual surgery.
• -58: Staged/related procedure. Links two or more procedures split into different sessions of the global period.
• -78: Unrelated procedure during global period. Shows full reimbursement warranted when an unrelated procedure falls in the global window.
• -79: Unrelated procedure in post-op period. Same as -78 but used when the unrelated procedure is performed during the post-op phase only.

These modifiers are imperative to bypass global surgery package rules and obtain proper payment in complex cases with multiple providers.

Bilateral Surgery Modifiers

Bilateral modifiers should be applied when the same procedure is performed on contralateral, bilaterally symmetrical body parts:

• -50: Bilateral procedure. Reports a procedure performed bilaterally at a single session. Reimbursement varies by payer.
• -LT: Left side. Use with bilateral codes when performed on one side only.
• -RT: Right side. Same principle as -LT but for the right side only.

Some payers prefer billing bilateral procedures on two separate line items with -LT and -RT modifiers rather than using -50. Check payer policies to ensure accurate billing.

Repeat/Multiple Procedure Modifiers

These modifiers indicate repeat or multiple procedures:

• -76: Repeat procedure. Identifies a procedure repeated by the same physician on the same date.
• -77: Repeat procedure by another physician. Codes a procedure repeated by a different physician on the same day.
• -59: Distinct procedural service. Documents a distinct procedure separate from the primary procedure or service.

Proper application of these modifiers helps bypass edits for repeat services and ensures maximum reimbursement.

Assistant Surgeon and Co-Surgeon Modifiers

Modifiers for surgical assistants and co-surgeons include:

• -80: Assistant surgeon. Denotes a procedure where an assistant surgeon participated. Reimbursement percentage varies by payer.
• -81: Minimum assistant surgeon. Used when an assistant surgeon assisted on only a small portion of the procedure. Reduced payment applies.
• -62: Co-surgeon. Indicates two surgeons worked together as primary surgeons performing distinct parts of a procedure. Each surgeon bills the full procedure code with this modifier.

Understanding when to apply these modifiers prevents payment issues for surgical assistance services.

Significant Procedure Modifiers

These modifiers identify significant or highly complex procedures that may warrant added reimbursement:

• -22: Increased procedural service. Documents substantial additional work required beyond what is conveyed by the base code.
• -52: Reduced services. Indicates a procedure was reduced or eliminated due to extenuating circumstances discovered during the procedure.

Use these modifiers judiciously when the procedure performed was significantly different than normal for that code based on objective evidence in the medical record.

With hundreds of modifiers to choose from, the key is understanding accurate usage principles:

• Never use modifiers just to bypass edits. Modifiers should only be applied when the procedure legitimately meets modifier criteria.
• Do not overuse modifiers. Use them only when the medical record clearly documents the specific variation in procedure or service.
• Check payer guidelines. Many payers publish lists of procedures requiring certain modifiers and rules for reimbursement.
• Use specific anatomic modifiers whenever a procedure is performed on a non-typical site as defined by the code.
• Apply repeat/multiple procedure modifiers any time the same procedure is repeated or multiple procedures performed at the same session.
• Use bilateral modifiers when the identical procedure is performed bilaterally at the same session.
• Clarify surgeries involving surgical teams, concurrent procedures, and staged operations with appropriate global surgery modifiers.
• Indicate assistant or co-surgeon participation using the correct corresponding modifiers.
• Highlight unusual circumstances using modifiers like increased/decreased procedural service when very distinct from the norm.

In general, modifiers should be applied when needed to accurately communicate details that affect coding, billing, and reimbursement. Using them improperly can lead to fraudulent billing allegations. When in doubt, err on the side of not using modifiers versus misusing them.

Below we’ll explore examples of appropriate modifier application in specific medical coding scenarios:

Anatomic Modifiers

Scenario: A patient undergoes excision of a thigh lipoma on the left proximal thigh.

CPT code billed:

• 23915 – Neoplasm, soft tissue of lower extremity; excision

Modifier used: -LP (left proximal)

Reason: The excision of a left proximal thigh lipoma matches the -LP anatomic site modifier. Anatomic modifiers should be used any time the procedure is performed on a different body part than what is typical for that code.

Repeat Procedure Modifiers

Scenario: A patient returns to the ER with chest pain 2 days after initial treatment. A repeat EKG is performed during the second ER visit.

CPT codes billed:

• 93000 – Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only
• 93000-76 – Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only (repeat procedure by same physician)

Modifier used: -76 (repeat procedure by same physician)

Reason: The repeat EKG on the follow-up ER visit for chest pain is appropriately identified by appending modifier -76 to the second 93000 code.

Bilateral Surgery Modifiers

Scenario: A patient undergoes bilateral knee arthroscopies with meniscectomy during the same surgery.

CPT codes billed:

• 29881 – Arthroscopy, knee, surgical; with meniscectomy (medial OR lateral)
• 29881-50 – Arthroscopy, knee, surgical; with meniscectomy (medial AND lateral)

Modifier used: -50 (bilateral procedure)

Reason: Billing the meniscectomy CPT code on two separate lines with modifier -50 indicates this procedure was performed bilaterally during one surgical session.

Global Surgery Modifiers

Scenario: Dr. Smith performed a hip replacement surgery. Dr. Jones provided the post-operative hospital follow up care.

CPT codes billed:

• 27130 – Total hip arthroplasty
• 99024 – Postoperative follow-up visit, normally included in surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure.

Modifier used: -55 (post-operative management only)

Reason: Modifier -55 conveys Dr. Jones handled post-op care after Dr. Smith completed the actual hip replacement surgery. This modifier bypasses global surgical package rules to allow both physicians to be reimbursed for their distinct services.

These examples demonstrate the importance of properly assigning modifiers to avoid denied claims and receive appropriate payment. Take time to learn modifier definitions and payer billing requirements related to their use.

While modifiers are invaluable for reporting special circumstances, there are also inappropriate ways they are sometimes misused:

• Appending modifiers to bypass edits when there is no supporting medical documentation.
• Using modifiers improperly to obtain higher reimbursement.
• Failing to use modifiers when required to convey special circumstances impeding reimbursement.
• Overusing modifiers on every claim whether they are warranted or not.
• Assigning modifiers randomly without verifying correct usage.
• Applying modifiers contradictory to CPT definitions or payer policies.
• Listing modifiers that do not provide added value or useful information.
• Using modifiers without linking them to the appropriate procedure code.
• Unbundling codes and adding modifiers to gain higher payment when a comprehensive code should be billed instead.

To summarize, modifiers must be applied accurately and ethically based on documentation in the medical record. Incorrect use of modifiers to influence reimbursement is considered fraud.

Given the complexity of modifier rules and potential for misuse, regular auditing is essential:

• Verify documentation – Audit a sample of records where modifiers were applied to ensure appropriate use is clearly documented in the medical record.
• Check billing accuracy – Review operative reports and other documentation to confirm billed procedures, diagnoses, and modifier usage match what was actually performed/documented.
• Compare modifier percentages – Compare use of modifiers as a percentage of total claims against historical baselines and watch for unusual increases.
• Assess high-usage areas – Conduct regular risk analysis of procedures, providers, and modifier types with frequent or disproportionate use.
• Review denials – Analyze reasons for denied claims related to modifier use and improper documentation.
• Provide education – Offer additional training on modifiers to departments/providers with higher incidence of incorrect usage.

Proactive auditing helps fix issues early before they become ingrained habits leading to compliance headaches. It also provides valuable physician education on proper modifier use.

Key takeaways include:

• Modifiers enable reporting of important variations in procedures and services.
• Hundreds of modifiers exist, with common types including anatomic, global surgery, bilateral, repeat, assistant surgeon, and significant procedure modifiers.
• Modifiers should only be used when supported by documentation and medical necessity.
• Inappropriate use of modifiers to bypass edits or increase payment is fraudulent.
• Regular auditing helps ensure modifiers are applied properly according to usage rules.
• Ongoing training is key to consistent ethical application of modifiers.

With the intricate modifier guidelines, it’s normal for questions to surface. Reach out to experienced coding professionals when unsure if a modifier is warranted.