CPT modifier 21

Prolonged evaluation and management services - Use only with

highest level of care code for the category when the face-to-face or
floor/unit service provided is prolonged or otherwise greater than that
usually required for the highest level code.

CPT modifier 24

Unrelated E/M service during a post-op period - Use with E/M codes
only to indicate that the E/M performed during a postoperative period
for a reason(s) unrelated to the original procedure. Modifier 24 applies
to unrelated E/M services for either a MAJOR or MINOR surgical
procedure.- Failure to use modifier when appropriate may result in
denial of the E/M service

CPT modifier 25

Separately identifiable service on same day as procedure - Use with

E/M codes only to indicate that the patient’s condition required a
significant, separately identifiable E/M service above and beyond the
other service provided or beyond the usual pre- and postoperative
care for the procedure performed- Failure to use modifier when
appropriate may result in denial of the E/M service

CPT modifier 57

Decision for surgery - Use with E/M codes billed by the surgeon to
indicate that the E/M service resulted in the decision for surgery (E/M
visit was NOT usual pre-operative care). For E/M visits prior to MAJOR
surgery (90 day post-op period) only.- Failure to use modifier when
appropriate may result in denial of the E/M service.

CPT Modifier 26

Professional component only - Use to indicate that the physician

component is reported separately from the technical component for
the diagnostic procedure performed

CPT Modifier 90
Reference Lab - Used to indicate a lab test sent to an outside lab. e.g.,
lab procedure performed by a party other than the treating or
reporting laboratory. NOTE: Outside lab name, address and UPIN must
be included on the claim. Section 20 must be marked "yes" and your
actual cost for each test, net any discounts, must be included in the
charges section.

CPT Modifier GH

Diagnostic mammogram converted from screening mammogram on

the same day.

CPT Modifier QP

Documentation is on file showing that the laboratory test(s) was

ordered individually or ordered as a CPT

Modifiers

A modifier 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. The judicious
application of modifiers obviates the necessity for separate procedure
listings that may describe the modifying
circumstance. Modifiers may be used to indicate to the recipient of a
report that:
A service or procedure has both a professional and technical
component
A service or procedure was performed by more than one physician
and/or in more than one location
Read more »
Labels: CPT Modifier, Modifiers
TUESDAY, DECEMBER 1, 2009

ASC Modifiers

AMBULATORY SURGICAL CENTER MODIFIERS

73 - Discontinued outpatient hospital/ambulatory surgery center

(ASC) procedure prior to the administration of anesthesia
74 - Discontinued outpatient hospital/ambulatory surgery center
(ASC) procedure after administration of anesthesia
SG - Ambulatory Surgical Center (ASC) Facility service

CPT surgery Modifiers

CPT modifier 62 and 66
CPT Modifiers for Global period
CPT modifier 22 and 51

Ambulatory surgery center billing

ASC Modifier SG
Labels: ASC, CPT Modifier, Modifiers

CPT Anesthesia Modifier codes

Anesthesia Modifier List

AA - Anesthesia services personally performed by anesthesiologist

AD - Medical supervision by a physician: More than 4 concurrent
anesthesia procedures
AE - Direction of residents in furnishing not more than two concurrent
anesthesia services - attending physician relationship met
QK - Medical direction of 2, 3, or 4 concurrent anesthesia procedures
involving qualified individuals
QS - Monitored anesthesia care
QX - CRNA service with medical direction by physician
QY - Medical direction of one concurrent anesthesia procedure
involving qualified individuals
QZ - CRNA service without medical direction by a physician
23 - Unusual anesthesia - Used to report a procedure which usually
requires either no anesthesia or local anesthesia; however, because of
unusual circumstances must be done under general anesthesia
47 - Anesthesia by surgeon - Used to report regional or general
anesthesia provided by the surgeon (not for local anesthesia)
CPT surgery Modifiers
CPT modifier 62 and 66
CPT Modifiers for Global period
CPT modifier 22 and 51
Anesthesia Medical billing guidelines
Anesthesia billing modifiers
How to do anesthesia billing
Anesthesia claim denial
Labels: Anesthesia billing, CPT Modifier, Modifiers
FRIDAY, NOVEMBER 20, 2009

What is CPT Modifiers and why we use CPT modifiers?

CPT Modifiers

• two-digit numeric modifiers reported in CPT*

• modifier descriptions listed in Appendix A and in the guidelines of
each major section
• two-character alpha HCPCS modifiers used in certain situations to
describe a modification
to the procedure performed

Why use a modifier?

• to indicate that a service or procedure that has been performed has

been altered by some
specific circumstance but not changed in its definition or code.
• may use a modifier to report —
• a service or procedure has either a professional or a technical
component
•a service or procedure was provided more than once
•a service or procedure has been increased or reduced
Read more »
Labels: CPT Modifier, Modifiers
TUESDAY, NOVEMBER 10, 2009

What is CPT modifiers

Modifiers and their Role in Billing

Modifiers are used to modify payment of a procedure code, assist in

determining appropriate coverage, or otherwise identify the detail on
the claim. The use of modifiers ensures the appropriate reimbursement
by the insurer.
Modifiers are entered in box 24 D on the HCFA-1500 (CMS-1500) claim
form or UB 92 (CMS 1450).

For the most current list of modifiers, refer to the current CPT or
HCPCS Code book.

Note: The modifiers are updated on a yearly basis, and the tables are
supplied to each RPMS site by the IHS Office of Information
Technology (OIT). It is the responsibility of each Area IT to install the
updated tables.

CPT surgery Modifiers

CPT modifier 62 and 66

Global surgery modifiers

Labels: CPT and HCPCS codes, CPT Modifier, Modifiers
SATURDAY, NOVEMBER 7, 2009

CPT modifier 59

Modifier 59

The 59 modifier should only be used to identify codes that are on the
Correct Coding Initiative bundling table, unless specific instructions
have been published for additional functions for this modifier. A good
example is for multiple anesthesia services on the same day. We
published instructions in the Medicare Advisory for use of the 59
modifier on the second anesthesia service. This applies only when a
second operative session is involved. We extended this modifier to the
Mohs micrographic surgery procedures when a stage is repeated on a
different site during the same operative session. The modifier identifies
procedures that were performed on a separate site or during a
separate operative session. This modifier does not apply to billing the
same procedure code during the same session, such as 20550. If the
injection is performed on different knees, then
Read more »
Labels: CPT Modifier, Modifiers

CPT modifier 26 and TC

Modifiers 26 and TC

Recently Palmetto GBA has noticed a number of diagnostic services

being filed on the same day by different providers. In some of these
instances one provider has filed for either the professional or the
technical component while the other provider has filed a global charge.
It is important to make sure you only file for the portion of the
services you rendered.

If you are billing for the interpretation or the technical component of a

diagnostic procedure, p lease ensure that you use the appropriate
modifier. If you are performing the professional component of a
service you
Read more »
Labels: CPT Modifier, Modifiers

CPT Modifier 52 and 53

Modifier 52 for Reduced Serv ices

Under certain circumstances a service or procedure is partially reduced

or eliminated at the physician ’ s direction. 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. This provides a means of reporting reduced services without
disturbing the identification of the basic service.

Modifier 53 for Discontinued Procedures

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. This circumstance may be r eported by
Read more »
Labels: CPT Modifier
FRIDAY, NOVEMBER 6, 2009

CPT Modifier 22 and 24

Modifier 22

The 22 modifier is used to identify an unusual procedural service. By

using this modifier you are indicating that the procedure in question
required a level of care greater than that usually required. When using
this modifier medical records must be submitted with the claim to
support the increased level of care and allow for possible additional
payment. The documentation for the 22 modifier should include
statements specific to the added time spent, or the complicating
factors that added to the difficulty of the procedure. The operative
note alone often provides no such details on the added time. If records
are not submitted with the claim the procedure will pay based on the
standard fee schedule amount.

Modifier 24 for E&M Services During the Global Period of a

Surgical Procedure

The -24 modifier is used to report unrelated Evaluation and

Management (E&M) services performed during the postoperative,
global period by surgeon. This applies to providers of all specialties
who perform
Read more »
Labels: CPT Modifier, Modifiers

CPT modifiers - Assistan physician

Assistant at Surgery (CPT Modifiers 80 81 82 and AS)

We will continue to pay assistants at surgery at 16 percent of the

surgical allowance, with the exception of Physician Assistants (PA) and
Nurse Practitioners (NP), which are further reduced because these
specialties are allowed 85% of the fee schedule allowed amounts. The
NP and PA receive an allowed amount of 85% of the 16% for acting as
the assistant surgeon. The NP or PA must have a provider
identification number (PIN) to bill such services, as they can not bill
surgery services under the incident to rules.

Example: Here is an example of the pricing difference for a surgeon

and the NP specialty. Procedure code
Read more »
Labels: CPT Modifier
MONDAY, NOVEMBER 2, 2009

CPT Modifier 22 and 51

Modifier 22

The 22 modifier is used to identify an unusual procedural service. By

using this modifier you are indicating that the procedure in question
required a level of care greater than that usually required. When using
this modifier medical records must be submitted with the claim to
support the increased level of care and allow for possible additional
payment. The documentation for the 22 modifier should include
statements specific to the added time spent, or the complicating
factors that added to the difficulty of the procedure. The operative
note alone often provides no such details on the added time. If records
are not submitted with the claim the procedure will pay based on the
standard fee schedule amount.

Modifier 24 for E&M Services During the Global Period of a

Surgical Procedure

The -24 modifier is used to report unrelated Evaluation and

Management (E&M) services performed during the postoperative,
global period by surgeon. This applies to providers of all specialties
who perform
Read more »
Labels: CPT Modifier
WEDNESDAY, OCTOBER 28, 2009

CPT Modifier 62 and CPT modifier 66

Two Surgeons (CPT Modifier 62)

For co -surgeons, we will continue the current predominant carrier
practice of paying 125 percent of the global fee and dividing the
payment equally between the two surgeons. No payment will be made
for an assistant at surgery in these cases. Each surgeon needs to file
with the 62 modifier and documentation of his/her co ntribution to the
procedure. If one surgeon files with no modifier and you file with the
62 modifier, then you will receive a denial for documentation. We will
contact the other surgeon to refund the overpayment and add the 62
modifier to his/her claim.

Example: Here is an example of the pricing. The fee schedule amount

allowed is $1908.48, multiplied by 125%, then split between the two
surgeons. Code 4855462 would allow $1192.80 for each surgeon.

Surgical Team (CPT Modifier 66)

We will continue to allow our Carrier Medical Directors (CMDs) to

determine the payment amounts for team surgery on an individual
basis. Each doctor on the team must file hard copy with
documentation of his/her unique contribution to the procedure and
each physician ’ s claim will be manually priced based on those
records.

CPT Modifier 51

CPT surgery Modifiers

Labels: CPT Modifier

CPT Modifier 51 - Multiple Surgery

If a surgeon performs more than one procedure on the same
patient on the same day, we will pay 100 percent of the global fee for
the highest value procedure only and 50percent of the global fee for
the second, third, fourth, and fifth procedure. Each procedure after the
fifth procedure will require submission of documentation and special
carrier review to determine the payment amount. This rule applies to
surgery codes listed under rule 2 in the April 2002 Medicare Advisory .
These codes should be submitted using the 51 modifier and if the 51
modifier is missing, the system will automatically add it to the rule 2
code with the lower fee schedule allowed amount.

Example: Mrs. Smith comes to your office for a tendon sheath

injection (20550). She requires injections in two different anatomical
sites. The first line is filed with no modifier and the next line is
submitted using the 51 modifier as code 20550 falls under the multiple
reduction rule. This means line one will allow $52.76 and line two will
allow $26.38.

Some procedures are described in CPT as a second or subsequen t

procedure, such as code 17003 for the second through fourteenth
lesion and the payment level is already set at a reduced rate. These
procedures will not be reduced further and therefore do not require a
51 modifier. These codes appear on the list of surgical codes with
indicator zero in the surgical rule field. Please refer to your July 2002
Medicare Advisory for the most current list of surgical indicators.

CPT modifiers for surgery

Labels: CPT Modifier, Modifiers
THURSDAY, OCTOBER 15, 2009

Ambulatory surgery center modifier SG

Ambulatory Surgery Centers (ASC) modifier SG

Every ASC must file using the surgery code with the SG modifier. This
identifies you are filing for the facility fee. If you file without the SG
modi fier you may receive the fee schedule amount for the surgery
instead of the payment from the group rate for the facility fee This is
sometimes much lower than the facility fee and it will cause the
surgeon ’ s claim to deny. You would have to file a first line appeal to
have the SG modifier added and receive any additional payment due
to you. You will only be paid for services that the Centers for Medicare
and Medicaid (CMS) approved as an ASC service. These updates are
published yearly as they are received from CMS. Code 69635SG allows
$957.36 (Richland and Lexington Counties), but when filed without the
SG (69635) it allows $826.74.