In this article, we explain modifiers and provide a list of modifiers used in cpt in medical coding , first of all we explain modifiers, and then we explain all modifiers with appropriate example. For example modifiers 24 ,25 and 57 are used in ENM , For bilateral procedures, we append the 50 modifier.

What is Modifiers in Medical Coding :-

A medical coding modifier is two characters (letters or numbers) appended to a CPT or HCPCS Level II code. The modifier provides additional information about the medical procedure, service, or supply involved without changing the meaning of the code.

INTRODUCTION :

Modifiers are two- character suffixes (alpha and/or numeric) that are attached to a procedure code.
CPT modifiers are defined by the American Medical Association (AMA).
A modifier provides the means to report or indicate that a service or procedure that has been performed has been altered by some specific circumstances but not changed in its definition or code.

What is a CPT Code?

The Current Procedural Terminology (CPT) code is a standardized medical code set designed to provide doctors, healthcare professionals, and

administrative entities with a unified language, improve reporting accuracy, streamline processes, and increase efficiency. It is used for documenting and reporting medical, surgical, radiological, laboratory, anesthesiological, genomic sequencing, evaluation, and management (E/M).

CPT codes serve multiple roles:

Clinical Reporting: They help healthcare providers accurately report the various procedures, services, and interventions they administer to patients.
Administrative and Management: They are instrumental in administrative tasks, such as medical claims processing and creating guidelines for medical care review.
Electronic Medical Billing: They are used alongside ICD-9-CM or ICD-10-CM diagnostic codes during the electronic medical billing process to communicate information to entities like physicians, health insurance companies, and accreditation bodies.

Modifier 22( unusual procedural services) :

This modifier is used for increased procedural services). We use this modifier whenever the doctor do extra things as compared to normal .

Note: This modifier should not be appended to the E&M service.

INAPPROPRIATE USE OF MODIFIER 22 :-

Modifier 22 should not be used for the following circumstances:
If you bill from a facility (22 is a physician-only code),
If another CPT code adequately defines the provided service
If the additional work is included in the primary code and not separately reimbursable
If the additional work arises only from the surgeon’s choice of procedure when a simpler approach would have sufficed.

Example of Modifier 22 :

A physician performs an induced abortion of the fetus, aged 21 weeks, by dilation and evacuation. We should report the claim with a procedure code along with modifier 22.

Modifier 23 ( unusual Anesthesia):

Modifier 23 should be appended to the Anesthesia code to indicate a procedure that is normally performed under local anesthesia or with regional block required general anesthesia.

When the provider administers general anesthesia for a procedure that does not normally require it or administers anesthesia due to unusual circumstances.

Example of Modifier 23 :

A cystoscopy does not usually general anaesthetic. However, if performed on a young child who can’t be controlled, general anesthetic may never.append modifier 23 in this case.

Modifier 24 :

Unrelated evaluation and management services was performed during a postoperative period.

The physician may need to indicate that an evaluation and management service was performed during a postoperative period for a reasons unrelated to the original procedure.

Example of Modifier 24 : A physician operated on the patients anus. Then , a month later she sees the patient for a stomach problem. Bill modifier 24 in this case.

Modifier 25:

Significant, separately identifical evaluation and management (E/M) service by the same physician on the same day of a procedure.

A physician performs an E/M service on a patient on the same day that a procedure is performed, and the E/M service is for unrelated to the procedure.

Example of Modifier 25 :

0-10 days global period are minor surgical procedures that include complications related to the procedure and cannot be billed separately for 10 days after the procedure, such as the excision of a benign lesion on the trunk, arms or legs; pressure Equalizer tubes inserted under local anesthesia, and debridement.

When Not to Use the Modifier 25

Do not use a 25 Modifier when billing for services performed during a postoperative period if related to the previous surgery.
Do not append Modifier 25 if there is only an E/M service performed during the office visit (no procedure done).
Do not use a Modifier 25 on any E/M on the day a “Major” (90 day global) procedure is being performed.
Do not append Modifier 25 to an E/M service when a minimal procedure is performed on the same day unless the level of service can be supported as significant, separately identifiable. All procedures have an “inherent” E/M service included.
Patient came in for a scheduled procedure only

Modifier 26 : Professional component

Certain procedures are a combination of a physician component and a technical component. When the physician component is reported separately, add 26.

Example of Modifier 26 : A 72 year old woman comes to the emergency room complaining of chest discomfort. The physician orders a complete 2D echocardiography using hospital equipment. The physician provides the written interpretation. Then append 26 modifier with CPT code.

Appropriate Usage:

To bill for only the professional component portion of a test when the provider utilizes equipment owned by a hospital/facility
To report the physician’s interpretation of a test, which is separate, distinct, written, and signed

Inappropriate Usage:

When the same provider performs both the technical and professional components; unless the same provider reports both components and the technical portion is purchased
Reporting it for re-read results of an interpretation provided by another physician

Appending it to:

Global test-only codes
Professional component-only codes
Technicalcomponent-only codes

Example of Modifier 26:

A sleep center performs polysomnography for a patient. A physician not associated with the sleep center facility interprets the findings of the test. This physician would append modifier 26 to 95811 to represent her interpretation of the polysomnography.

Modifier 47: Represents Anesthesia given by the surgeon.

This modifier is to be used when the surgeon performs and administers regional or general anesthesia in addition to the surgical procedure.

Example of Modifier 47 :

Patients in critical state and physician administers the Anesthesia and performs the emergency surgery. In this case we can append 47 modifiers to the procedure code.

50 Modifier: Bilateral Procedure

Bilateral procedure are typically performed on both sides of the body during the same operative session by same physician in either separate operative areas (e.g., hands, feet, legs, arms, ears) or In the same operative areas (e.g., nose, eyes, breasts).

Modifier 50 – Incorrect Usage

Inappropriate usage includes:

Do not use modifier 50 when performing the procedure on different areas of the same side of the body.
Do not use modifier 50 when the BILATERAL SURG indicator is 0, 2 or 9.
Do not use modifier 50 when removing a lesion on the right arm and a lesion on the left arm. Use the RT and LT modifiers.
Do not use modifier 50 with a procedure code that is described as bilateral, or unilateral or bilateral, in its CPT description.
Do not report a bilateral procedure on two lines of service by appending modifier 50 to the second line of service.
Do not submit modifier 50 on procedures for midline organs such as the bladder, uterus, esophagus and nasal septum.

Example of Modifier 50 :

Surgery done on both eyes is bilateral procedure whereas on only one eyes is a unilateral procedure.

Modifier 51: Multiple procedure

This modifier indicates that multiple procedures were performed at the same session.

When multiple procedures , other than E/M service, performed at the same session by the same provider, report the primary procedure as listed and add modifier 51 to the additional codes.

Inappropriately Usage:

Do not append to add-on codes (See Appendix D of the CPT manual)
Do not report on all lines of service
Do not append when two or more physicians each perform distinctly, different, unrelated surgeries on the same day to the same patient

Appropriate Usage:

The Modifier is appended when:

The same physician performs more than one surgical service at the same session.
The technical component of multiple diagnostic procedures, the Multiple Procedure Payment Reduction.
The multiple surgical procedures are done on the same day but billed on two separate claims.
The surgical procedure code is the lower physician fee schedule amount.
The diagnostic imaging procedure with the lower technical component fee schedule amount.

Example of Modifier 51 :

Colonoscopy was performed at same session as upper endoscopy. Both procedure are performed on same day.

Use modifier 51 on upper endoscopy procedure.

Example of Modifier 51 :

A surgeon performs a 24500 (Closed treatment of humeral shaft fracture; without manipulation) and a 23500 (Closed treatment of clavicular fracture; without manipulation). You would apply the multiple procedures reduction to 23500, which is the lower-paying code if your payer requires modifier 51.

Modifier 52 : Reduce services

Append modifier 52 to a procedure to show that the physician didn’t perform the complete procedure in the code descriptor.

WHEN NOT TO USE MODIFIER 52

The code description includes unilateral or bilateral.
An existing CPT or HCPCS code properly identifies the reduced service.
Anesthesia administration and/or the patient’s wellbeing at risk were factors in ending the procedure.

Example of Modifier 52 :

43770 laproscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device.

For individual component placement, report 43770 with modifier 52.

Example of Modifier 52:

A provider performs a unilateral tonsillectomy for a ten-year-old patient (CPT code 42820). In this case, apply modifier 52. This CPT assumes bilateral surgery, so to show that it was only performed on one side, or electively reduced, modifier 52 would be appropriate.

Modifier 53: Discontinued Procedure

Used to indicate that a surgical or diagnostic procedure was started but discontinued due to exteruating circumstances that threatened the patients well being.

This modifier is used to report services or procedures when disconnected after anesthesia is administered to the patient.

Modifier 53 would not apply for:

Elective cancellation of a procedure
Discontinued surgeries prior to anesthesia or surgical prep
Evaluation and management (E/M) CPTs
Time-based codes (such as for critical care)

Example of Modifier 53 :

A provider attempts to perform phenol injection to the superior hypogastric plexus; following multiple needle positioning attempts at the right or left L5 region, the procedure is discontinued due to the patient increased heart rate and suboptimal dye spread.

Example of Modifier 53:

A surgeon has a patient under anesthesia and fully prepared to proceed with surgery. However, the physician cuts himself and therefore cannot carry out the operation. Modifier 53 may apply to the surgical CPT to indicate an extenuating circumstance that prevented the procedure from being performed. In this scenario, the surgical prep and anesthesia indicate the procedure had already begun but had to be discontinued.

Modifier 54 : Use for surgical Care Only

Indicates the surgeon has transferred postoperative care( partial or total) to another provider.

Do not append modifier 54 if patient is under the surgeon’s care for the full 10 or 90 days of postoperative care.

Example of Modifier 54 :

A neurosurgeon travel to a rural location to to perform a craniatomy for drainage of an intracranial abscess. He assessed the patient the day before, and performed the procedure. Follow up care was provided by a local surgeon.

Modifier 57: Decision for surgery

This modifier is appended to the appropriate E/M service to denote the visit where the decision to perform major surgery (90 global days) was made.

Modifier is used when the decision for major surgery is made the day of or the day prior to performing the procedure.

Uses of Modifier 57:

Assign with E/M code only ( including opthalmolgical service)
Used only for major Surgical procedure, a procedure with a 90 days global period.
E/M service must be related to the procedure that follows
Surgery should be performed on same day of E/M or next day.

Example of Modifier 57 :

A surgeon receives a request to evaluate the patient for acute upper quadrant pain and tenderness.following full evaluation , the surgeon decide to remove the gallbladder and schedule an immediate laproscopic cholecystectomy .

Example of Modifier 57:

A surgeon see a patient in the emergency department then perform repair of laceration, comes and/or sclera, perforating and reposition or reaction of uveal tissue on same day.

Modifier 58:

Modifier 58 is a surgical – specific, used to indicate a staged or related procedure or service by the same physician during the post operative period.

It may be necessary to indicate that the performance of a procedure or service during the post-operative period was

Planned or staged;
More extensive than the original procedure;
For therapy following a surgical procedure.

Example of Modifier 58 :

A surgeon performs a biopsy on a patient. The results indicate that the sample is cancerous. The surgeon performs a second procedure to remove the cancer. Use modifier 58 when billing for the second procedure.

Modifier 59: Distinct Procedural

Service indicate that a procedure is separate and distinct from another procedure on the same date of service.

Indications for use of modifier 59:

Different session or encounter on the same date of service
Different procedure distinct from the first procedure
Different anatomic site
Separate incision, excision, injury or body part.

Example of Modifier 59:

A patient had a colonoscopy and a lesion is removed proximal to the splenic flexure. During the same colonoscopy a biopsy is taken of a different lesion. Both codes are reportable using modifier 59 on the second procedure.

Example of Modifier 59 :

A patient was planned appendectomy today. Today before the procedure he fell down and got some laceration in right knee. Do physician now going to do both appendectomy and laceration and simple laceration procedure on same day.

Modifier 62 : Two surgeon

When two surgeon work together as primary surgeon performing distinct parts of a procedure, each surgeon should report the co-surgery once using the same procedure code and report his/her distinct operative work by adding modifier 62 and any associated add-on codes for the procedure.

Additional procedure including add-on procedure

Report without modifier 62
Co-surgeon act as a assistant in performance of additional procedures
Report using modifier 80 and 81 as appropriate.

Example of Modifier 62 :

A neurological surgeon and an otolaryngologists are working as co-surgeons in performing transphenoidal excision of a pituitary neoplasm.

Modifier 63: Procedure performed on infant less than 4 kg

Procedure 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 .

Modifier 66: Surgical Team

When a team of surgeons three or more works together to complete a procedure reported using a single CPT code.

Use of modifier modifier 66 :-

Highly complex procedure
Require differently specialties
Modifier 66 appended to procedure coded by surgical team.
May require assistance of specially trained ancillary personal or specialized equipment
Approved procedure for modifier 66 include most of your transplant codes(heart,lungs, kidneys, including live donor procedure).

Example of Modifier 66 :

kidney transplant was performed by team of surgeons modifier 66 is append to the procedure code.

Modifier 76 : Repeat procedure or service by same physician or other qualified Healthcare professional.

It may be necessary to indicate procedure or service was repeated subsequent to original procedure or service.

Modifier 76 used for :

Used to indicate that a procedure or service was repeated subsequent to the original procedure or service by the same provider ID on for the same member on the same date of service or within the post-operative period.

Inappropriate usage:

It’s inappropriate to use modifier 76 with any lab codes for repeat laboratory test within the same day- use modifier 91 instead of 76.
It’s inappropriate to use modifier 76 with subsequent repeat procedure due to technical fault or equipment issue.
It’s inappropriate to use modifier 76 with subsequent repeat procedure but at different anatomic site (Right and left or upper and lower part) use 59 modifier 59.

Example of Modifier 76:

When a physician (A) order 2 views of chest xray at 10 am and due to medical necessity another physician (B) order for another 2 views of chest xray at 11 am on the same day both the physician belongs to same speciality.
A patient who goes to the emergency room with a trauma to the chest. A two views chest xray is taken that shows a pneumothorax. After a chest tube is placed a repeat two views chest xray is taken to verify the placement of the chest tube.

Modifier 77 : Repeat procedure or service by another physician

Modifier 77 is used to indicate that another physician repeated a procedure or service in a separate operative session on the same day.

Service originally performed by another physician. Documentation must include for repeat procedure.

Inappropriate usage:

Appending to a surgical procedure code.
Appending when the repeat procedure is performed by the same physician.
Appending to E/M coodes.

Can modifer 76 and 77 be used together

You don’t report repeated procedures on one line with multiple units, So you would never use both 76 and 77 on the same line.

Example of Modifier 77:

A patient who sees the family practitioner for chest pain and the physician does an EKG and then refers the patient to a cardiologist. The patient is able to see the cardiologist on the same day and the cardiologist performs a repeat EKG . The second EKG would be reported with modifier 77.

Modifier 78: Unplanned return to the operating room or procedure room during the global period of the initial procedure by the same physician.

Indicates second operative session is used and occurs during the post-operative period.

Second procedure is related to the first procedure usually due to complications or other problem related to initial surgery.

The purpose of this modifier is to report a related products performed during the postoperative period of the initial procedure ( unplanned procedure following initial procedure ) and requires use of the operating procedure room.
Modifier 78 should not be used if complications does not require use of the operating procedure room.
Modifier may be used to report procedures performaned on the same day ( usually in emergency situation).

Example of Modifier 78 :

A physician performed cesarean section on a patient . Because of bleeding the patient is called back into th OR for second procedure was unplanned in the post operative period and performed by the same physician .

Modifier 79 : Unrelated procedure or by the same physician during the post-operative period.

The purpose of this modifier is to report service during the post-operative period that are unrelated to the original procedure.
The procedure must be performed by the same physician and modifier 79 is appended to the procedure code.

Conditions that must be fulfilled to append modifier 79:

Assign always with procedure CPT code Don’t assign with any E/M codes.
Procedure documentation must be maintained in the patient medical record.
Performed by same physician during postoperative.
Service must be unrelated to previous surgery.

Example of Modifier 79 :

Patient has a biopsy taken of a lesion on his arm which has a 10 day global. Patient then return 5 days later to have a wart removed from his finger you would append 79 modifier with procedure code. Don’t append modifier E/M codes.

Example of Modifier 79 :

A patients right big toe is amounted because of an infection with the postoperative period, the same physician amputed the patients right little toes after it is crushed by falling weight . Modifier 79 is used .

Modifier 80: Assistant surgeon

Assistant surgeon : surgical assistant service may be identified by adding modifier 80 to the usual procedure number.

Modifier 80 attached to surgical procedure:

Surgical procedure are performed by an assistant at surgery.
Assistant is usually paid a small portion of the surgical fee by the carrier.
Generally private payors pay 20-25% of the surgical fee to the assistant .
An assistant at surgery serves as an additional pair of hands for the operating surgeon.

Example of Modifier 80 :

One physician is done harvesting for CABG procedure it involves venous graft only. The graft procurement performed by the assistant at surgery is reported using modifier 80.

Modifer 81: Minimum assistant surgeon

Minimum surgical assistant services are identified by adding modifier 81.
This includes MD,DO, and DPM provider type and is an assistant surgeon providing minimal assistance to the primary surgeon .
This modifier may be used when more than one assistant is involved or if one person assist during a portion of surgery . This modifier is not intended for use by non physician assistants (e.g RN, PA)
When minor problem is encountered during the operation that requires the service of an assistant surgeon for relatively short period of time, this is considered a minimum assistant surgeon

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

When the assistant at surgery service was provided by an MD and there was not a qualified resident available.
This modifier may only be submitted by teaching hospital.
Payment is not made for a first assistant when the service is provided in a teaching hospital that has a training Program related to the particular surgical procedure and qualified resident is available. But the teaching hospital has no qualified resident available or no teaching program related to the particular medical speciality required for the procedure , or if the primary surgeon has an across the board policy of not using resident, Medicare will cover the service of PA first assistant.

Modifier 90: Reference (outside) laboratory

When laboratory procedure are performed by a party other than the treating or reporting physician or other than qualified Healthcare professional, the procedure maybe identified by adding modifier 90 to the usual procedure number.

Use of Modifier 90:

Possible for one lab to bill service performed by Another lab.
Must append modifier 90 to referred lab test code.
Appropriate modifier 90 claims include two different clinical labs improvement ammendment numbers .
Reflect billing provider information
Laboratory where the services were performed (reference lab).

Don’t use modifier 90:

Do not report modifier 90 with anatomic pathology and lab services.
Don’t append modifier 90 for drawing fee (36415).
Cannot be referenced out to another lab.

Example of Modifier 90:

The physician in this office orders a CBC, the physician draw the blood and send the specimen to an outside laboratory.

Modifier 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 same day to obtain subsequent ( multiple) test result. Under these circumstances the laboratory test performed can be identified by its usually procedure number and the addition of Modifier 91.

This modifier basically used to show that test of same specimen done at same day at different time interval.

This modifier is used only lab and pathology cpt chapter.

When to use modifier 91

Use modifier 91 to manage the patient’s treatment if you repeat a clinical laboratory test on the same service date.
Use modifier 91 if you need multiple, serial laboratory tests to treat a patient, such as repeat blood glucose tests.
Use modifier 91 if you repeat a test using a separate specimen draw later the same day.

When not to use Modifier 91:

On a repeat lab test performed only to confirm initials results.
For confirmation without physician order to repeat it.
Due to technician fault.

Example of Modifier 91

When a patient undergoes a blood transfusion, healthcare providers may find it necessary to perform multiple blood tests throughout the day to ensure the compatibility and safety of the transfusion. In this scenario, the extra tests would be billed with the application of Modifier 91.

Modifier 92: Alternative laboratory platform testing

When laboratory testing is being performed using a kit or transportable instrument that wholly or in part consists of a single use, disposable analytical chamber, the service may be identified by adding modifier 92 to the usual laboratory procedure code.

Example of Modifier 92:

A female patient presents to the office for a sexually transmitted disease (STD) screening. The patient is concerned about HIV exposure after engaging in unprotected sexual intercourse. The patient is tested for HIV using a hand-carried transportable kit. Correct coding in this case would be 86701-92. Modifier 92 is appropriate because the HIV testing is performed using the hand held transportable kit.

Modifier 93: Synchronous Telemedicine Service Rendered Via Telephone or Other Real-Time Interactive Audio-Only Telecommunications System.

Modifier 93 describes services that are provided via telephone or other real time interactive audio only telecommunications systems.

This modifier is appropriate only if the real- time interaction occurs between a physician/ other qualified Healthcare professional and a patient who is located at distant site.

Use of Modifier 93:

The communication during the audio-only service must be of an account or nature that meets the same key component and/or requirement of face -to-interaction.

Modifier 95: Synchronous telemedicine service rendered via a real-time interactive audio and video communications system.

The 2020 CPT manual includes Appendix P, which lists a summary of CPT codes that may be used for reporting synchronous (real-time) telemedicine services when appended by modifier 95.

Synchronous telemedicine service is defined as a Real-Time interaction between a physician and other healthcare professionals and a patient who is located at a distant site from the physician and other healthcare professionals.
The totality of communication of information exchanged between the physician and other healthcare professionals and the patient during the course of synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirments of the same service when renderd via face to face interaction.

Modifier 96: Habilitative services

Services that helps a person develop skills or functions they didn’t have before.

The therapy is intended to maintain or develop skills needed to perform ADLs or IADLs which, as a result of illness (including developmental delay), injury, loss of a body part, or congenital abnormality, either:
have not (but normally would have) developed; or
are at risk of being lost; and
There is the expectation that the therapy will assist development of normal function or maintain a normal level of function;
An individual would either not be expected to develop the function or would be expected to permanently lose the function (not merely experience fluctuation in the function) without the habilitative service.

Example of Modifier 96:

An example of this would be a pediatric patient who experienced a developmental delay and now requires therapy to learn the skill that they were unable to learn on their own.

Modifier 97: Rehabilitative services

That help a person restore functions which have become either impaired or lost.

The therapy is aimed at improving, adapting or restoring functions which have been impaired or permanently lost as a result of illness, injury, loss of a body part, or congenital abnormality; and
There is an expectation that the therapy will result in a practical improvement in the level of functioning within a reasonable and predictable period of time.

Example of Modifier 97:

An example of this would be a patient who suffered a complex lower extremity fracture and now need to re-learn how to walk.

Modifier 99: Multiple modifier

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.

Append modifier 99 to a procedure or service as the first modifier when there are also two or more additional modifiers applicable to the service or procedure.

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