Modifiers and Your Practice
By Diane E. Zucker, M.Ed., CCS-P
Health Care Management Consultant
Modifiers present many challenges in the care that you provide to patients as there are times they are “required” and there some times that we add them hoping that it helps get the payment for the services provided, but we are unsure they are really needed or are the correct ones to use. This article looks to clarify this process for you.
First, let’s review the modifiers that are used for diagnostic testing when the professional and technical components are not provided at the same time or by the same providers. An example would be a 92132 Scanning computerized ophthalmic diagnostic imaging segment with interpretation and report, unilateral or bilateral. If this scan was provide in location X for only the technical component, that entity would code the TC modifier on the CPT code and the professional interpretation by the ophthalmologist with the CPT code and modifier -26. If the scan was provided by both practice with both technical and professional services by the same provider then no modifier is used.
If the technical component of the test was provided on Monday and the interpretation was not completed until Thursday, then the CPT could be split between TC and modifier -26 because of the delay in interpretation for the date of the actual testing.
The can coding (example 92132) would require a location modifier of RT (right) or LT (left) if this was pertinent to the care process and correspond with the specific ICD 10 coding. If the assessment was bilateral no modifier would be required as the definition of the code is unilateral or bilateral.
For most ophthalmology practices one would not split out the professional and technical charges for testing unless there was a unique professional within the group that had a higher level of expertise for interpretation of testing.
In rare cases an ophthalmologist may review testing that was performed in another location. This interpretation would only be coded with the specific CPT code and modifier -26 if the findings of the initial interpretation are in question, require clarification or the second interpretation is requested for a specific situation.
In ophthalmology the provider can choose to use either the E/M CPT codes (99202 through 99215) or the specific ophthalmology codes 92002, 92004, 92012 and 92014. With this in mind remember there may be limitations by plans on the number of ophthalmology codes that can be coded (per year) or related diagnoses with ocular manifestation alone. The general E/M CPT codes are based on medical necessity supported by the diagnoses.
The following modifiers are used with E/M codes, whether the codes are the general E/M CPT codes of 99202 through 99215 or the specific ophthalmology codes 92002, 92004, 92012 and 92014.
Modifier -25 is used to identify a separate and significant identifiable Evaluation and Management (E/M) service when performed by the same physician or other qualified health care professional on the same day of a procedure or other service.
This modifier identifies that the procedure (foreign body removal) was assessed at the same time as the E/M service. This was not for a scheduled minor procedure nor would an E/M service be coded and billed when the intent of the visit is for diagnostic testing. In cases where the diagnostic testing leads to an E/M service to change a treatment plan, schedule and procedure or requires a higher level of care, then the E/M service would have the -25 appended to either the 9920x/9921x or the 920xx CPT code.
Modifier -24 is defined as an unrelated evaluation and management service by the same physician or other qualified health care professional during a post-operative period.
This can be appended to either the 99212-99215 level of care or 92012/92014 care but would require that the diagnoses being managed during global time frame for the procedure (normally 90 day global time periods) would be distinctly different and unrelated to the procedure diagnoses.
Modifier -57 is used to indicate that an evaluation and management (E/M) service performed on the same day or the day before a major surgery (090 global days) by the surgeon resulted in the decision to perform the procedure.
Modifier -57 is normally appended only to major procedures, those that have a 90 day global time frame. CPT code 67107 Repair of retinal detachment scleral buckling (such as lamellar scleral dissection, imbrication or encircling procedure), including, when performed, implant, cryotherapy, photocoagulation, and drainage of subretinal fluid would be a good example correct addition of modifier -57 to an E/M service for assessing this condition with immediate intervention planned.
None of the surgical modifiers, such as -22 (unusual procedural service) or the surgical modifiers (RT, LT, etc.) would be appended on an E/M service.
Modifier –GC is used, specific for Medicare and Medicaid, when care is performed in part by a resident under the direction of a teaching physician.
The teaching physician modifier can be used on E/M services, testing procedures or surgical procedures. In Ophthalmology the teaching physician must always have face to face contact with the patient so this modifier just identifies that a resident was part of the care process.
Surgical modifiers are appended to surgery procedure codes. The first set of modifiers are for the location of the surgical care.
- Modifier RT would be for the right eye
- Modifier LT would be for the left eye
- Modifier -50 would be if the procedure was performed on both the right and left eye.
For bilateral procedures one often codes each eye separately with two line items, one RT and one LT to assure the correct interpretation by insurance programs of the care provided. When a CPT code identifies the service as unilateral or bilateral one only appends the RT or LT in cases when care is unilateral. These modifiers might be appended to foreign body removal, laceration repair.
Specific eyelid modifiers:
- E1 Upper left, eyelid
- E2 Lower left, eyelid
- E3 Upper right, eyelid
- E4 Lower right, eyelid
These modifiers would be appended to Blepharoplasty procedures (15820, 15821, 15822, 15823) a Chalazion and other specific eyelid family of codes.
Modifiers that relate to the specific surgical procedure are appended to the surgery code alone, not any E/M service that may be provided and coded for the same date of care. When there are multiple modifiers for one CPT code, and up to 4 modifiers can be appended, there is no requirement for rank order of the modifier but the general coding principles place the location modifier as first. These modifiers are:
Modifier -51 would be appended to multiple procedures and be rank ordered based on RVU (fee) with the highest RVU coded first with only the locational modifiers as pertinent to care.
Modifier -52 is a reduced surgical procedure where the procedure performed did not meet the complete requirements of the CPT code.
Modifier -53 is a discontinued procedure that is appended to the CPT code for the intended surgical procedure. This would be where a case was discontinued after anesthesia had been initiated. Examples might be a case that was discontinued because of a power outage or a patient health emergency.
Modifier -54 is surgical care only where another provider or provider type is managing pre-operative care and post-operative care. A good example of this is when an optometrist provides pre and post care for cataract procedures.
Modifier -55 is post-operative management only. This would be appended to major procedures where one surgeon provided the operative care and another surgeon not of the same group or cross coverage process provided the post procedure care. A trauma case, such as 65286 Repair of laceration; application of tissue glue, wounds of cornea and/or sclera what was repaired in Florida but patient returns home to Ohio for follow up care.
Modifier -56 is preoperative care management only and is not used as any preoperative assessment can be coded with an E/M code.
Modifier -58 is coded for a staged or related procedures by the same provider during the global time frame that is anticipated at the time of surgery.
Modifier 59 is a distinct procedural service that may normally be bundled by CPT code definition or the CCI edits. Medicare has additional X modifiers that further define the -59 and these modifiers are now used by many commercial plans. The X modifiers are:
- XE Separate encounter, for a service that is distinct because it occurred during a separate encounter. This might be a return to the OR the same date as a primary procedure after the patient has gone to recovery.
- XS Separate structure is for a service that is distinct because it was performed on a separate organ/structure. In ophthalmology this would be identified in most cases with a specific eyelid modifier as well.
- XP Separate practitioner, as service that is distinct because it was performed by a Different provider (not in the same group or cross coverage entity. An example might be a procedure was performed by an ER physician and now you are involved in care.
- XU Unusual non overlapping service that is distinct because it does not overlap the usual components of the main service in this specific case (supported by the operative note).
Modifier -62 is for a case that requires two surgeons due to the complex nature of the case and normally this would not be two ophthalmologists.
Modifier -63 is for a procedure performed on infants less than 4kg and requires a prematurity diagnoses second to the eye code(s).
Modifier -66 is for a defined surgical team (trauma) and is most common with plastic surgery.
Modifier -76 is a repeat procedure by the same physician (or group) – an example would be a laceration repair that required re-suturing due to a wound dehiscence.
Modifier -77 is a repeat procedure by another physician
Modifier -78 is a return to the operating room for a related procedure during the global time frame and is diagnoses specific to the case.
Modifier -79 is an unrelated procedure during a global time frame. This procedure is based on the operative note as well as the specific ICD 10 coding involved in both the first procedure and the second procedure.
Modifier -80 is for an assistant surgeon – if this is a PA or APN then modifier AS would be appended.
Modifier -82 is for an assistant surgeon when you are in a teaching institution and there is no qualified resident available for the case and the case requires the physician level of expertise.
As you think about how you use modifiers there are a number of things to consider. Modifiers should only be appended when the documentation supports this process, in the office or in the procedure/operative room. Some examples to consider:
- A new patient who comes in for an assessment and requires a procedure or testing as part of that visit would require no modifier as a new patient service can be coded with a diagnostic test or procedure.
- An unrelated E/M visit during a global time frame must be clearly unrelated – so a patient who had blepharoplasty of the right eye and presents with conjunctivitis of the left eye would be appropriate for the -24. A patient post PRK (paid for by insurance due to occupation) and then has a trauma to the eye would be appropriate for the -24.
- A patient seen for acute trauma requiring immediate surgery scheduled that same day after assessment would be modifier -57 (and this can be appended for both new and established visits).
- For appending surgical modifiers it is critical that the CPT code correspond with the modifiers used and this information reflected within the header of the operative note as well as the body. So if the surgical assist is needed to expedite the procedure because of medical issues this would be part of the H&P as well as reflected in the indication for the procedure. In cases where repeat procedure modifiers are used the original date with the nature of the procedure would be identified. If related or unrelated to the initial procedure this would be clearly documented within the header and the body of the operative note.
Modifiers can be overwhelming but when we remember to only append them when needed and as many as we need for the specific case. Modifiers often correspond with specific diagnoses codes for location and a mismatch in this coding can result in denials and requests for documentation. Overuse of unnecessary modifiers can result in audits and reviews but misuse or incorrect use results in claim denials or suspension. When in doubt review the case CPT code by CPT code and identify the role of the procedure to the diagnoses for location and to other procedures and timing for the additional modifier options.
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