Modifiers are among the essential tools medical billers and administrators have in their arsenal. They can clarify complicated procedures, indicate special circumstances, and more. This post will explain what modifiers are and how billers should use them. Stay tuned for future posts that will dive into more specific applications of modifiers!
What are modifiers and how are they be used?
A medical coding modifier is an appendix to a CPT® or HCPCS Level II code. A modifier typically consists of two characters (letters or numbers). The purpose of the modifier is to provide additional details about the services or supplies performed at the place of service without changing the meaning of the code. For example, a biller should use a modifier to indicate which side of the body the procedure was done when billing for orthopedic surgery. Modifiers are also critical in reporting if the procedure was performed twice to a specific part of the body or performed to a particular part of the body. The appropriate modifier will determine how the claim is processed and prevent the payer from denying the claim as a duplicate or bundled procedure. This blog will explore the most commonly used modifiers in medical billing and offer some examples of using them.
The Common Modifiers
24 Unrelated Evaluation and Management Services by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period
25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Source–(The most used modifier in medical billing) Use this modifier if other services were performed not related to E/M.
26 Professional Component–Used to indicate that the service provided was the interpretation of results with a written report of the interpretation of a technical component (laboratory and/or diagnostic service.
50 Bilateral procedure–(Commonly used in orthopedic surgery)
Before utilizing this modifier, the biller must familiarize themselves with the preference of RT or LT instead of the 50 modifiers.
51 Multiple Procedures–Used when multiple procedures, other than E/M services, or provision of supplies are performed at the same session by the same provider**PROCEDURES SHOULD BE DIFFERENT
52 Reduced Services–Under certain circumstances, a service or procedure is partially reduced or eliminated at the physician’s or other qualified healthcare professional’s discretion. Under these circumstances, the service provided can be identified by its usual procedure code and the addition of modifier 52.
54 Surgical care only
57 Decision for surgery
59 Distinct procedural service–Used to indicate a service should not be considered a bundled service when it normally might be bundled.
78 Unplanned return to the operating/procedure room by the same physician or other qualified healthcare professionals following initial procedure for a related procedure during the postoperative period (complication).
79 Unrelated procedure or service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period
95/GT Synchronous Telemedicine Service Rendered Via a Realtime Interactive Audio and Video Telecommunications System
GQ Via asynchronous telecommunications system
Some examples of correct use of modifiers
(Out-patient and office visits)
Using Modifier 51
A 79-year-old male has acute cholecystitis and abnormal liver function test. He has elected to go for surgery. A laparoscopy is placed through an epigastric incision with the insertion of two lateral 5mm ports. The gallbladder is elevated, and the cystic duct is located and dissected out. In the process of transecting the duct, the gall bladder tears and several gallstones were released. These are removed with a gallstone retriever along with removal of the gallbladder. The cystic duct stump is tied off and the common bile duct is incised. A large stone is seen and removed. The common bile duct is closed over a T-tube catheter which is brought out through the abdominal wall and connected to a drainage bag. What CPT® code(s) should be reported for this procedure?
B. 47480, 47564-51
C. 47420, 47562-51
D. 47480, 47562-51
Using Modifier 59
Operative Note #1:
Procedures Performed: Excision with layered closure right lower leg; Excision of a melanoma in situ on left dorsal forearm.
Preoperative Diagnosis: Basal cell carcinoma right lower leg and Melanoma in situ, left dorsal forearm.
Postoperative Diagnosis: Basal cell carcinoma right lower leg and Melanoma in situ, left dorsal forearm.
Indications: Well-marginated, erythematous, slightly scaly, plaque(s): posterior right lower leg.
Biopsy revealed a superficial BCC (basal cell carcinoma). The patient is allergic to Codeine. The patient takes the following medication(s): Hydroxyurea, alegralide, Boniva. Informed consent was obtained from the patient. Risks of the procedure including, bleeding, infection, scarring, and recurrence were explained, and the patient acknowledged understanding of these potential complications.
Procedure: The preoperative measurement of the lesion on the right lower leg was 0.9 cm. The proposed excision lines were drawn. Anesthesia was delivered locally with 12.0 cc of 1% Xylocaine with epinephrine buffered 1:10. The site was cleansed with Betadine. The site was prepped and draped in the usual sterile fashion. An incision was performed with a number 15 blade 0.5 cm outside the margin of the identified neoplasm extending deep, through the dermis, and into the subcutaneous fat. The excised diameter (total preoperative dimensions including margins) measured 1.9 cm. The specimen was tagged at the superior tip. This tissue was dissected from the patient with care to preserve histologic features. The surgical site was undermined to a distance of 2.0 cm. Hemostasis was obtained by electrocautery and vessels ligated as necessary. The specimen was placed in a bottle of Formalin labeled with the patient’s identifying information. The specimen was sent for pathologic and margin analysis. In order to prevent dehiscence due to wound tension, an intermediate layered closure was performed. Seven 4-0 Polysorbtm sutures were placed subcuticularly utilizing a simple inverted interrupted stitch. Seven 4-0 nylon sutures were placed cutaneously utilizing a simple interrupted stitch. The final length of the surgical repair was 2.5 cm. The surgical site was cleansed with saline. A sterile dressing was applied utilizing the following: sterile petrolatum, gauze, and taped into place to form a pressure bandage. The patient tolerated the procedure well. Postoperative instructions were given to the patient. The patient was instructed to return in nine days for suture removal.
Lesion Treatment: The lesion on the left dorsal forearm was cleansed with alcohol and anesthetized with lidocaine with epinephrine. Electrodesiccated and curetted x 3. Appropriate dressing was applied, and post-op instructions were given. The final defect measures 0.9 cm in size.
The patient tolerated both procedures well. Recommended routine skin examination in three months. The patient was released in good condition.
What are the CPT® and ICD-10-CM codes for this procedure?
Wheeww! Now a simpler example of 59 modifier in use!
Using Modifier 59 Pt. II
A 5-year-old female presents to the doctor’s office with a sore throat, fever, and fatigue. A Streptococcus, Group A, and Influenza A and B tests are performed in the office.
What CPT® code(s) should be reported for this procedure?
B. 87880, 87804-50
**Please scroll to the bottom for correct answers with rationale**
Answers with rationale
Example 1: C
Rationale: In the CPT® Index, look for Bile Duct/Removal/Calculi (Stone). Review the codes to choose the appropriate service. Code 47420 is correct. A choledochotomy (incision of the bile duct) was done for removing a stone, and a choledochostomy ( a stoma was made in the abdominal wall from the bile duct for drainage) was done. In the CPT® Index, look for Gallbladder/Excision- See Cholecystectomy. Look for Cholecystectomy/Laparoscopic referring you to codes 47562-47564. Review the codes to choose the appropriate service. Code 47562 is correct. There was a removal of the gallbladder through a laparoscope without cholangiography.
Example 2: 11602-59, 12031-59, 17261, C44.712, D03.62
Rationale: The first lesion is basal cell carcinoma right lower leg and is excised with a layered closure. Basal cell carcinoma is a malignant lesion, so you will begin by looking in the CPT® codebook at the range for excision of malignant lesion (11600-11646) (Excision /Lesion/Skin/Malignant). The range is narrowed by the location of the excision–right lower leg (1160-11606). The size of the lesion is determined by the excised diameter which is 1.9 cm, further defining the code to be 11602. This was closed with an intermediate layered closure. When an excision is closed with an intermediate closure, the closure can be coded separately. The wound is 2.5 cm in length and reported with 12031. The diagnosis is for a basal cell carcinoma of the right lower leg.
The second lesion is Melanoma in situ, left dorsal forearm. The lesion is treated using electrodissection indicating it was destroyed. To find the CPT® code, look in the CPT® Index for Destruction/Lesion/Skin/Malignant. Code range 17260-17286 is for destruction, malignant lesion, any method. Code range 17260-17266 is further narrowed to lesions of the trunk, arms, or legs. The lesion measures .9 cm, so CPT® code 17261 is appropriate. The diagnosis is for malignant neoplasm of the arm. Code 17000 is for destruction of premalignant lesions.
Modifier 59 is appended to 11602 and 12031, indicating it was performed on a different site than 17261. Code 11602 and 17261 are mutually exclusive according to NCCI edits, but a modifier is allowed to report the services. The codes are listed in RVU order. Modifier 59 can be reported on a primary CPT® code because in this case, code 11602 is in column 2 on the NCCI table when reported with code 17261. Modifier 59 is reported on codes in column 2 listed in the NCCI Table. **You will not be tested on listing codes in RVU order or reporting modifier 59 for NCCI edits on the CPC exam.**
To find the first diagnosis code, look at the Table of Neoplasms in the ICD-10-CM codebook. Look for skin NOS/limb NEC/lower basal cell carcinoma and use the code from the Malignant Primary column C44.71-. In the Tabular List, C44.712 is reported for basal cell carcinoma of the skin of the right lower limb. In the ICD-10-CM Alphabetic Index, look for Melanoma/in situ/forearm referring you to D03.6-. In the Tabular List, D03.6 requires a 5th character to indicate laterality. Code D03.62 is for Melanoma in situ of the left upper limb.
Example #3: D
Rationale: In the CPT® Index, look for Streptococcus, Group A. Since there is no mention of whether it was for Antigen Detection, you would look at the next category: Direct Optical Observation, 87880. When you look at the code with description, it clearly states, Streptococcus, group A. The code 87880 is correct.
The other procedure performed was Influenza A and B. In the CPT® Index, look for Influenza Virus/Detection/With Direct Optical Observation. You would not look under Influenza A or B in the index, as it does not state there was Antigen Detection performed. The correct answer is 87804.
You would report the code, 87804 twice since Influenza A and B were performed, then append the 59 modifier on the second code to indicate as a separate procedure from the first code.
That’s all folks!
That’s it for our discussion of modifiers! We know they can be confusing, but they are essential to understand to get paid correctly for the services you provide. If you have any questions or need further clarification on a specific modifier, please leave us a comment below, and we will do our best to help out. In the meantime, keep an eye out for future blog posts that will go into more detail about specific CPT® codes and how to bill them accurately. And as always, happy coding!
American Medical Association. (2020). CPC Certification 2021. Salt Lake City: AAPC.
American Medical Association. (2021). CPT 2021 Professional Edition. AMA.
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