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We get a lot of questions regarding the correct use of modifiers. Well, actually the questions are usually more on the lines of “One of my services was denied, what modifier can I use to get the service paid?”

The first thing I want to make clear is that it is never okay to add a modifier strictly to get a service paid. Modifiers, like cpt codes, help to describe the services that were performed. So the provider, or a coder who is reviewing the chart would have to determine if a modifier would be appropriate. A biller, just looking at the services cannot add a modifier just to ensure payment.

Having said that, it is important that billers understand modifiers and their use. Many providers do not understand modifiers, or even know that they exist. As a biller, you can educate the provider as to what the modifiers mean and what situations they should be used in. It is ultimately the provider who must determine if the services that were performed warrant adding the modifier.

A good example of this is if you receive a superbill indicating that the patient was seen for hypertension, diabetes, hypercholesterolemia and bursitis of the shoulder. The doctor indicates that he did an established office visit level 4, or a 99214 and an injection of cortisone, 20610. The provider doesn’t indicate that a modifier should be used. If both of these charges are billed out for the same date of service, most insurance carriers will bundle the office visit in with the injection.

As a biller you should question if the provider should be reimbursed for both since there were other medical conditions that the provider addressed. You can’t assume this based on the information that you have and since you were not in the room. That’s why you must check with the provider, not just add the modifier. Ask the provider what the main reason for the office visit was, if the other medical conditions were addressed, how much of the office visit was spent on the bursitis vs the other conditions, and advise him/her that the codes will most likely be bundled together.

Then you can advise him/her that there is a modifier, 25, that indicates that the office visit was a significantly separately identifiable service from the other procedure that was performed. The provider would need to advise the biller if the 25 modifier would be appropriate to use for the situation.

There are many other modifier that can be very useful as well. It is important though that billers do not get caught up in the task of getting claims paid and just use modifiers to accomplish that task. They must be used appropriately, when indicated by the provider of service. You may want to have some of the most commonly used modifiers added to the superbill so that the provider can easily indicate when the modifier is to be used.

Here is a list of some of the more common modifiers:

RT - right

LT - left

25 - significantly separately identifiable E&M service

26 - professional component

TC - technical component

50 - bilateral

59 - Distinct procedural service

79 - Unrelated procedure or service by the same physician during the postoperative period

Copyright 2010 - Michele Redmond

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Importance of Using Proper Modifiers:

1. The physician performed multiple procedures

2. The procedure performed was bilateral

3. The E/M service was done on the same day of the procedure

4. The procedure was increased or decreased

5. The procedure has both professional and technical component

6. The procedure was performed by other provider (Anesthesiologist, Surgeon Physical Therapist, Speech Pathologists etc.)

7. Procedure on either one side of the body was performed

8. The E/M service was provided within the postoperative period

9. The E/M service resulted to Decision of Surgery

10. Unusual Circumstance

Maximize your reimbursement for bilateral procedures by using the correct modifier.

Bilateral Modifier (-50)

Depending upon the insurance payer, processing claims with bilateral procedure should be paid 150%

Medicare Part B requires one single line of bilateral procedure code with Modifier 50. They normally process the claim with 150% reimbursement. But again, you have to check on this in your state and in your region.

Some commercial insurance would prefer Two Lines of the same code, once with 50, second without 50. Then second modifier on the 1st line is RT or LT, modifier RT or LT on second line, with 1 unit of service each code. Must be reimbursed at 150%

Some commercial insurance would prefer two lines of the same code with modifier LT or RT on each line with 1 unit of service each code. Must be reimbursed at 150%

Always check on your Physician’s Fee Schedule if the procedure code is billable as bilateral J.

Using LT & RT modifier is used to specify which side of the body the procedure was done by the physician. Medicare Part B based on my experience requires specific modifier, either LT or RT. Example you may report procedure 64626 done on the Right C4-C7 Facet Joint Nerve Ablation as 64626-RT.

Modifier -26. Professional Component.

Example: Report procedure code 77003 - Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (epidural, transforaminal epidural, subarachnoid,, paravertebral facet joint, paravertebral facet joint nerve or sacroiliac joint) including neurolytic agent destruction) with modifier -26 to indicate the physicians Professional Component only reimbursement and not technical component. If the provider’s office owns the fluoroscopic equipment, do not append -26 modifier.

Modifier -25. Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service.

Example: Report E/M code 99213 (Office or other outpatient visit for the evaluation and management of an established patient) with Modifier -25 for procedure code 20610 Knee Joint Injection done on the same day of the procedure. Modifier -25 indicates significance and separate identifiable E/M service outside the procedure done on the patient. DO NOT use modifier -25 to report E/M service that resulted for initial decision for surgery.

Instead use modifier -57 for Decision for Surgery

Modifier -24. Unrelated Evaluation and Management Service by the Same Physician During Postoperative Period

Example: Report E/M code 99213 with Modifier -24 if the patient came back during the postoperative period. The physician must identify this service as completely unrelated with the recent procedure done on the patient. A detailed medical documentation is a good support for medical necessity.

Modifier -51 for Multiple Procedures.

Modifier -59 for Distinct Procedural Service

Modifier-GP Services Rendered under Outpatient Physical Therapy plan of care

Modifier-GO Services Rendered under Outpatient Occupational Therapy plan of care

Modifier -GN Services Rendered under Outpatient Speech Pathology plan of care

Always check your up to date CPT Book. Check the CMS CCI Edits. Check the insurance payor’s policies and guidelines.

WHAT YOU DON’T KNOW MIGHT HURT YOU. IF YOU DON’T KNOW IT, DON’T MAKE IT UP. FIND IT.

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I am writing this article again as a suggestion from many of my readers on my blog. This article is more comprehensive in a way that scenarios were cited to have a bigger look on the proper use of some of these important modifiers.

In this article, I will be describing the medical claims modifiers - Modifier -25, -24, -51, -57, -59, -26.

Modifier -25, 25: Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service:

This modifier must be appended with an E/M service. This is the modifier you will need to use with the evaluation and management service done on the same day with other procedure done by the same physician. It has to be above and beyond the usual preoperative and postoperative encounter with the procedure. In fact, by using this modifier, it doesn’t have to have a different diagnosis reported. The most important thing is that, the E/M level should meet its key components or if it is selected based on time with the patient (counseling and coordination). You have to be careful in using this modifier. It must meet medical necessity. As you know, there are procedures that already includes all other care and management.

Let’s describe this modifier 25:

A patient came in for her monthly follow up for her chronic back pain. At the same time, patient was complaining with severe headache. The pain doctor performed bilateral occipital block on the patient at the time of service. You will append modifier 25 for the E/M code to indicate that both services were rendered on the same day.

You don’t use modifier 25 with E/M encounter that resulted to Decision for Surgery (we have another modifier for this!)

Modifier -24, 24: Unrelated evaluation and management service by the same physician during postoperative period.

As the modifier indicates, this is another modifier that you can only append with an E/M counter. It indicates that the E/M encounter is not related during the global period.

Let’s describe this modifier 24:

A pain specialist performed facet nerve destruction for the patient. During the normal, postoperative global period, the patient came in to the office with severe knee pain due to fall on ice as evidenced by the patient’s subjective information. The pain specialist will then report that E/M encounter with the patient by appending modifier 24 to indicate that encounter is not related during the postoperative global period.

This modifier, like modifier 25 has no restriction as with the level of E/M code as long as it meets medical necessity, all its components or are time-based.

Modifier -57, 57: Decision for Surgery:

An Evaluation and Management service resulted in the initial decision to perform surgery during the E/M encounter.

Let’s describe this modifier:

An OB/GYN sees a patient who complains with severe abdominal pain. It turned out (through ultra sound, radiology and all other diagnostic testing and documentations), the patient is having an ectopic pregrancy. The OB/GYN performs the laparoscopic surgery on the same day. The E/M encounter will then be reported with modifier 57 which resulted to decision for surgery. The laparoscopic surgery should also be reported as performed on the same day without a modifier.

Modifier -50, 50: Bilateral Procedure

You will append modifier 50 for procedures that are obviously billable as bilateral (or two sides, both sides), performed on the same day, the same operative session, on identical anatomical sites, organs (arms, legs, spine).

A Facet Nerve block is unilateral (can be billed as bilateral). When using a modifier 50, make sure you only bill for one unit on the claim form since there is only 1 procedure is performed bilaterally. Though guidelines from other payers may differ. They may require you to list it twice (line 1 and line 2 on the claim form). You have to be responsible to clarify this with your payors.

You use this modifier with add-on codes too! Do not use this modifier with procedures which are already described as bilateral procedures.

Modifier -51, 51: Multiple Procedures

This modifier is used when reporting multiple procedures performed by the same physician on the same day. Do not use this modifier for “add-on” codes (see appendix D of the CPT Code book). Do not use this modifier for codes with “modifier -51 exempt” symbol (see appendix E of the CPT Code book). Do not use this modifier with an E/M code. This modifier can only be used by the same physician on the same day who performed the procedure.

Coding tip: List the highest reimbursable code (after the main procedure code) based on the fee schedule.

Modifier -59, 59: Distinct Procedural Service

Description of Modifier -59: 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. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.

Use this modifier only if the other procedure is a separately identifiable procedure code. Procedure that is distinct and can be described as independent procedure, on separate anatomical site, lesion, injury site, different organ system, and different session. Do not use this modifier for E/M code.

Modifier -26, 26: Professional Component

This modifier is used only for the professional component (physician) of a service or a procedure. Certain procedures are a combination of both professional and technical component. By using modifier 26, it indicates that procedure being reported as professional component only.

Professional Component versus the Technical Component. By illustration, procedures rendered at a facility such as outpatient hospital or ASC, these equipments are facility-owned. The facility will then report the technical component for such service while the physician will report the professional component for the that procedure. One very good example, the physician performs Paravertebral Facet Block under Fluoroscopic guidance using CPT code 77003. The physician will report the fluoro with modifier 26 for his/her professional component. While the facility will report the the same procedure with modifier -TC for the technical component.

Modifier -LT or -RT are used to indicate a Left or Right side or anatomical site. So if the pain specialist performed Left Cervical Facet Block, you will append a modifier -LT to report this procedure.The above modifiers are used to describe your claims for the services performed on the patient for appropriate payment. Always consult your local careers and third party payors for local determination, policies and guidelines on these modifiers. Looking at the edits is also very important!

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