Modifiers in USA healthcare

Modifiers-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.

Tremors

A service or procedure can be further described by using 2-digit modifiers. the modifier Reference Guide lists Level I (CPT-4), Level II (non-CPT-4 alphanumeric), and Level III (local) modifiers. Level I and II modifier definitions are contained in the Healthcare Common Procedure Coding System (HCPCS). LevelIII modifiers are defined by the Fiscal Intermediary and may be added only to prior Centers for Medicare & Medicaid Services (CMS) approval. Modifiers can be used interchangeably with any code level.

Level 1 Modifiers

21– Prolonged E & M Services: When the face-to-face or floor/unit
service(s) provided is prolonged or otherwise greater than that usually
required for the highest level of evaluation and management (E&M)
service within a given category.

22– Unusual Procedural Services: When the service(s) provided is
greater than that usually required for the listed procedure. Note: This modifier
is not to be used to report procedure(s) complicated by
adhesion formation, scarring, and/or alteration of normal landmarks
due to late effects of prior surgery, irradiation, infection, very low weight
(neonates and infants less than 10 kg.) or trauma.

23– Unusual Anesthesia: Occasionally, a procedure, which usually
requires either no anesthesia or local anesthesia, because of unusual
circumstances must be done under general anesthesia.

24– Unrelated E&M Service, Same Physician, During Postoperative
Period: The physician may need to indicate that an E&M service was
performed during a postoperative period for a reason(s) unrelated to
the original procedure.
25– Significant, Separately Identifiable E&M Service by the Same
Physician on the Same Day of the Procedure or Other Service: The
physician may need to indicate that on the day a procedure or service
identified by a CPT code was performed, the patient’s condition
required a significant, separately identifiable E&M service above and
beyond the other service provided.
*26– Professional Component: Certain procedures are a combination of a
physician component and a technical component. When the physician
component is reported separately, the service may be identified by
adding the modifier 26 to the usual procedure number. Note: The 26
modifier should not be appended to procedure codes that represent a
professional component (example: 93010).

32– Mandated Services: Services related to mandated consultation and/or
related services (e.g., Peer Review Organization (PRO), 3rd party
payer, governmental, legislative or regulatory requirement).

47– Anesthesia by Surgeon: Regional or general anesthesia provided by
the surgeon.
50– Bilateral Procedure: Unless otherwise identified in the listings,
bilateral procedures that are performed in the same operative session
should be identified by adding the modifier 50 to the appropriate five
digit CPT code.
51– Multiple Procedures: When multiple procedures, other than E&M
services, are performed at the same session by the same provider, the
primary procedure or service may be reported as listed. The additional
procedure(s) or service(s) may be identified by appending the modifier
51 to the additional procedure or service code(s). Note: This modifier
should not be appended to designated “add-on” codes.

52– Reduced Services: Under certain circumstances, a service or
procedure is partially reduced or eliminated at the physician’s
discretion. Under these circumstances the service provided can be
identified by its usual procedure number and the addition of the
modifier 52, signifying that the service is reduced.
53– Discontinued Procedure: Under certain circumstances, the physician
may elect to terminate a surgical or diagnostic procedure. Due to
extenuating circumstances or those that threaten the well-being of the
patient, it may be necessary to indicate that a surgical or diagnostic
procedure was started but discontinued.
54– Surgical Care Only: When one physician performs a surgical
procedure and another provides preoperative and/or postoperative
management.
55– Postoperative Management Only: When one physician performs the
postoperative management and another physician has performed the
surgical procedure.
56– Preoperative Management Only: When one physician performs the
preoperative care and evaluation and another physician performs the
surgical procedure.
57– Decision for Surgery: An E&M service that resulted in the initial
decision to perform the surgery.
58– Staged or Related Procedure or Service by the Same Physician
During the Postoperative Period: The physician may need to indicate
that the performance of a procedure or service during the postoperative
period was: (A) planned prospectively at the time of the original
procedure (staged); or (B) more extensive than the original procedure;
or (C) for therapy following a diagnostic surgical procedure. Note: This
modifier is not used to report the treatment of a problem that requires a
return to the operating room. See modifier 78.
59– Distinct Procedural Service: Under certain circumstances, the
physician may need to indicate that a procedure or service was distinct
or independent from other services performed on the same day.
Modifier 59 is used to identify procedures/services that are not normally
reported together, but are appropriate under the circumstances.

62– Two Surgeons: When two surgeons work together as primary
surgeons performing distinct part(s) of a single reportable procedure,
each surgeon should report his/her distinct operative work by adding
the modifier 62 to the single definitive procedure code.

66– Surgical Team: Under some circumstances, highly complex
procedures (requiring the concomitant services of several physicians,
often of different specialties, plus other highly skilled, specially trained
personnel, various types of complex equipment) are carried out under
the “surgical team” concept.

73– Discontinued Outpatient Hospital/ASC Procedure Prior to the
Administration of Anesthesia: Due to extenuating circumstances or
those that threaten the well-being of the patient, the physician may
cancel a surgical or diagnostic procedure subsequent to the patient’s
surgical preparation (including sedation when provided, and being
taken to the room where the procedure is to be performed), but prior to
the administration of anesthesia. Under these circumstances, the
intended service that is prepared for but cancelled can be reported by
its usual procedure number and the addition of the modifier 73. Note:
The elective cancellation of a service prior to the administration of
anesthesia and/or surgical preparation of the patient should not be
reported.
74– Discontinued Outpatient Hospital/ASC Procedure After
Administration of Anesthesia: Due to extenuating circumstances or
those that threaten the well-being of the patient, the physician may
terminate a surgical or diagnostic procedure after the administration of
anesthesia or after the procedure was started. Under these
circumstances, the procedure started but terminated can be reported
by its usual procedure number and the addition of modifier 74. Note:
The elective cancellation of a service prior to the administration of
anesthesia and/or surgical preparation of the patient should not be
reported.
76– Repeat Procedure by Same Physician: The physician may need to
indicate that a procedure or service was repeated subsequent to the
original procedure or service. This circumstance may be reported by
adding modifier 76 to the repeated procedure.
77– Repeat Procedure by Another Physician: The physician may need to
indicate that a basic procedure or service performed by another
physician had to be repeated. This situation may be reported by adding
modifier 77 to the repeated procedure or service.
78– Return to the Operating Room for a Related Procedure During the
Postoperative Period: The physician may need to indicate that
another procedure was performed during the postoperative period of
the initial procedure. (For repeat on the same day, see modifier 76.)
79- Unrelated Procedure or Service by the Same Physician During the
Postoperative Period: The physician may need to indicate that the
performance of a procedure or service during the postoperative period
was unrelated to the original procedure. (For repeat procedures on the
same day, see modifier 76.)
80– Assistant Surgeon: Surgical assistant services may be identified by
adding the modifier 80 to the usual procedure number(s).
82– Assistant Surgeon (when qualified resident surgeon is not
available in a teaching facility): The unavailability of a qualified
resident surgeon is a prerequisite for use of this modifier.
*90– Reference (Outside) Laboratory: Physicians use of this modifier
when laboratory procedures are performed by a party other than the
treating or reporting physician.
91– Repeat Clinical Diagnostic Laboratory Test: In the course of
treatment of the patient, it may be necessary to repeat the same
laboratory test on the same day to obtain subsequent (multiple) test
results. Under these circumstances, the laboratory test performed can
be identified by its usual procedure number and the addition of modifier
91. Note: This modifier may not be used when tests are rerun to
confirm initial results; due to testing problems with specimens or
equipment; or for any other reason when a normal, one-time,
reportable result is all that is required. This modifier may not be used
when other code(s) describe a series of test results (e.g., glucose
tolerance tests, evocative/suppression testing). This modifier may only
be used for laboratory test(s) performed more than once on the same
day on the same patient.
99– Multiple Modifiers: Under certain circumstances more than four
modifiers may be necessary to completely delineate a service.

* Denotes modifiers which are valid for the first modifier field only.

Next blog we will learn about level 2 modifiers.

Best wishes

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2 Replies to “Modifiers in USA healthcare”

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