A list of modifiers

I was searching for a good listing of HCPCS level I and level II modifiers.  I found this and wanted to share with you.  I can't take credit for putting it together, but it is really a helpful Listing.    Enjoy!
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LIST OF MODIFIERS

Modifier - as the name implies these are the two digit codes that modifies a service / procedure or an item under certain circumstances. Modifiers may add information or change the description according to the physician documentation to give more specificity for the service or procedure rendered. Appending of an appropriate modifier will effectively respond to reimbursement.

Modifiers are categorized into two levels

1. Level  I Modifiers: Normally known as CPT Modifiers and consists of two numeric digits and are updated annually by AMA - American Medical Association.

2. Level  II Modifiers: Normally known as HCPCS Modifiers and consists of two digits (Alpha / Alphanumeric characters) in the sequence AA through VP. These modifiers are annually updated by CMS - Centres for Medicare and Medicaid Services.

Both the above levels of Modifiers are recognized nationally.

List of Level I Modifiers:
 
Modifier -21 Prolonged Evaluation and Management Services (Deleted, please use CPT 99354- 99359)

Modifier -22 Unusual Procedural Services

Modifier -23 Unusual Anesthesia

Modifier -24 Unrelated Evaluation and Management Service by the Same Physician during a Postoperative Period

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

Modifier -26 Professional Component

Modifier -27 Multiple Outpatient Hospital E/M Encounters on the Same Date.

Modifier -29 Global procedures, those procedures where one provider is responsible for both the professional and technical component. This modifier has been deleted. If a provider is billing for a global service, no modifier is necessary.

Modifier -32 Mandated Services

Modifier -33 Preventive Service

Modifier -47 Anesthesia by Surgeon

Modifier -50 Bilateral Procedure

Modifier -51 Multiple Procedures

Modifier -52 Reduced Services

Modifier -53 Discontinued Procedure

Modifier -54 Surgical Care Only

Modifier -55 Postoperative Management Only

Modifier -56 Preoperative Management Only

Modifier -57 Decision for Surgery

Modifier -58 Staged or Related Procedure or Service by the Same Physician During the Postoperative Period

Modifier -59 Distinct Procedural Service

Modifier -62 Two Surgeons

Modifier -63 Procedure Performed on Infants less than 4kg

Modifier -66 Surgical Team

Modifier -73 Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedure prior to the Administration of Anesthesia

Modifier -74 Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedure after Administration of Anesthesia

Modifier -76 Repeat Procedure by Same Physician

Modifier -77 Repeat Procedure by Another Physician

Modifier -78 Return to the Operating Room for a Related Procedure During the Postoperative Period

Modifier -79 Unrelated Procedure or Service by the Same Physician During the Postoperative Period

Modifier -80 Assistant Surgeon

Modifier -81 Minimum Assistant Surgeon

Modifier -82 Assistant Surgeon (when qualified resident surgeon not available)

Modifier -90 Reference (Outside) Laboratory

Modifier -91 Repeat Clinical Diagnostic Laboratory Test

Modifier -92 Alternative Laboratory Platform Testing

Modifier -99 Multiple Modifiers

List of Level II Modifiers:

AA Anesthesia services personally performed by anesthesiologist.

AD Medical supervision by a physician: More than 4 concurrent anesthesia procedures.

AE Registered Dietician

AF Specialty Physician

AG Primary Physician

AH Clinical Psychologist

AI Principal Physician of Record

AJ Clinical Social Worker

AK Non Participating Physician

AM Physician, team member service

AP Determination of refractive state was not performed in the course of diagnostic ophthalmological examination.

AQ Service performed in a Health Professional Shortage Area

AR Physician providing services in a physician scarcity area

AS Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist services for assistant-at-surgery, non-team member.

AT Acute treatment (chiropractic claims) - This modifier should be used when reporting CPT codes 98940, 98941, 98942 or 98943 for acute treatment.

AU Item furnished in conjunction with a urological, ostomy, or tracheostomy supply

AV Item furnished in conjunction with a prosthetic device, prosthetic or orthotic

AW Item furnished in conjunction with a surgical dressing

AX Item furnished in conjunction with dialysis services

AY Item or service furnished to an ESRD patient that is not for the treatment of ERSD

AZ Physician providing a service in a dental Health Professional Shortage Area for the purpose of an Electronic Health Record Incentive Payment

A1 Dressing for one wound

A2 Dressing for two wounds

A3 Dressing for three wounds

A4 Dressing for four wounds

A5 Dressing for five wounds

A6 Dressing for six wounds

A7 Dressing for seven wounds

A8 Dressing for eight wounds

A9 Dressing for nine or more wounds

BA Item furnished in conjunction with parenteral enteral nutrition (PEN) services

BL Special Acquisition of blood and blood products

CA Procedure payable only in the inpatient setting when performed emergently on an outpatient who expires prior to admission.

CB Services ordered by a dialysis facility physician as part of the ESRD beneficiary's dialysis benefit.

CC Procedure code change- CARRIER USE ONLY - Used by carrier to indicate that the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed.

Automated Multi-Channel Chemistry (AMCC) Tests Modifiers - Effective date: Claims processed on or after April 5, 2010

CD – AMCC test has been ordered by an ESRD facility or MCP physician that is part of the composite rate and is not separately billable.

CE – AMCC tests has been ordered by an ESRD facility or MCP physician that is a composite rate test but is beyond the normal frequency covered under the rate and is separately reimbursable based on medical necessity.

CF – AMCC tests has been ordered by an ESRD facility or MCP physician that is not part of the composite rate and is separately billable.

Reference: http://www.cms.gov/MLNMattersArticles/downloads/MM6683.pdf

Modifiers Used to Report the Severity of Functional Limitations (Effective for the year 2013)

CH 0 percent impaired, limited or restricted

CI At least 1 percent but less than 20 percent impaired, limited or restricted

CJ At least 20 percent but less than 40 percent impaired, limited or restricted

CK At least 40 percent but less than 60 percent impaired, limited or restricted 

CL At least 60 percent but less than 80 percent impaired, limited or restricted 

CM At least 80 percent but less than 100 percent impaired, limited or restricted

CN 100 percent impaired, limited or restricted 

Reference: http://www.cms.gov/Outreach-and-Education/Outreach/NPC/Downloads/FunctionalReportingNPC.pdf

CR Catastrophe/Disaster Related

CS Item or service related, in whole or in part, to an illness, injury, or condition that was caused by or exacerbated by the effects, direct or indirect, of the 2010 oil spill in the Gulf of Mexico, including but not limited to subsequent clean-up activities.

DA Oral health assessment by a licensed Health Professional other than a dentist

EA Erythropetic stimulating agent (ESA) administered to treat anemia due to anti-cancer chemotherapy.

EB Erythropetic stimulating agent (ESA) administered to treat anemia due to anti-cancer radiotherapy.

EC Erythropetic stimulating agent (ESA) administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy.

ED Hematocrit level has exceeded 39% (or Hemoglobin level has exceeded 13.0 G/DL) for 3 or more consecutive billing cycles immediately prior to and including the current cycle

EE Hematocrit level has not exceeded 39% (or Hemoglobin level has not exceeded 13.0 G/DL) for 3 or more consecutive billing cycles immediately prior to and including the current cycle.

E1 Upper left, eyelid

E2 Lower left, eyelid

E3 Upper right, eyelid

E4 Lower right, eyelid

EJ Subsequent claims for a defined course of therapy, e.g., EPO, sodium hyaluronate, infliximab.

EM Emergency reserve supply (for ESRD benefit only)

ET Emergency treatment - Use to designate a dental procedure performed in an emergency situation.

FA Left hand, thumb

F1 Left hand, second digit

F2 Left hand, third digit

F3 Left hand, fourth digit

F4 Left hand, fifth digit

F5 Right hand, thumb

F6 Right hand, second digit

F7 Right hand, third digit

F8 Right hand, fourth digit

F9 Right hand, fifth digit

FB Item provided without cost to provider, supplier or practitioner, or credit received for replaced device (examples, but not limited to covered under warranty, replaced due to defect, free samples)

FC Partial credit received for replaced device

G1 - Most recent URR of less than 60%

G2 - Most recent URR of 60% to 64.9%

G3 - Most recent URR of 65% to 69.9%

G4 - Most recent URR of 70% to 74.9%

G5 - Most recent URR of 75% or greater

G6 - ESRD patient for whom less than seven dialysis sessions have been provided in a month.

G7 Pregnancy resulted from rape or incest or pregnancy certified by physician as life threatening

GA Waiver of liability statement on file - Use to indicate that the physician's office has a signed advance notice retained in the patient's medical record.The notice is for services that may be denied by Medicare.

GC This service has been performed in part by a resident under the direction of a teaching physician.

GD Units of service exceeds medically unlikely edit value and represents reasonable and necessary services.

GE This service has been performed by a resident without the presence of a teaching physician under the primary care exception.

GF Physician services provided by a nonphysician in a critical access hospital; nonphysician: NP, Certified Registered Nurse Anesthetist (CRNA), Certified Registered Nurse (CRN), CNS or PA

GG Diagnostic Mammography - Use to indicated performance and payment of a screening mammography and diagnostic mammography on same patient, on the same day.

GH Diagnostic mammogram converted from screening mammogram on same day

GJ Opted Out physician or practitioner - Use to indicate services performed in an emergency or urgent service.

GM Multiple patients on one ambulance trip

GN Services delivered under an outpatient speech language pathology plan of care.

GO Services delivered under an outpatient occupational therapy plan of care.

GP Services delivered under an outpatient physical therapy plan of care.

GQ Telehealth services via asynchronous telecommunications system

GR This service was performed in whole or in part by a resident in a department of Veterans Affairs Medical Center or clinic supervised in accordance with VA policy.

GS Dosage of EPO or Darbepoietin Alfa has been reduced and maintained in response to hematocrit or hemoglobin level.

GT Telehealth services via interactive audio and video telecommunication systems

GU Waiver of liability statement issued as required by a payer policy, routine notice

GV Attending physician not employed or paid under agreement by the patient's hospice provider.

GW Service not related to the hospice patient's terminal condition.

GY Use to indicate when an item or service statutorily excluded or does not meet the definition of any Medicare benefit.

GZ Use to indicate when an item or service expected to be denied as not reasonable and necessary.Used when no Advanced Beneficiary Notice (ABN) signed by the beneficiary.

HM Less than Bachelor’s degree level

HN Bachelor’s degree level

HO Master’s degree level

HP Doctoral level

HQ Group setting (for behavioral health use)

HT Multidisciplinary team (for behavioral health use)

J1 Competitive Acquisition Program, no-pay submission for a prescription number

J2 Competitive Acquisition Program, restocking of emergency drugs after emergency administration

J3 Competitive Acquisition Program, (CAP) drug not available through CAP as written, reimburse under ASP Methodology

JA Administered intravenously

JB Administered subcutaneoulsly

JC Skin substitute used as a graft

JD Skin substitute NOT used as a graft

JW Drug or biological amount discarded/not administered to any patient

KB Beneficiary requested upgrade for ABN, more than 4 modifiers identified on claim

KC Replacement of special power wheelchair interface

KD Drug or Biological infused through implanted DME

KE Bid under round one of the DMEPOS competitive bidding program for use with non-competitive bid base equipment

KF Item designated by FDA as Class III device

KL DMEPOS Item Delivered via Mail

KM Replacement of facial prosthesis - including new impression/moulage

KN Replacement of facial prosthesis - Using previous master model

KR Rental item, durable medical equipment – billing for partial month

KX Specific required documentation on file (used for DMERC providers)

KZ New Coverage not implemented by managed care

LC Left circumflex coronary artery

LD Left anterior descending coronary artery

LM Left main coronary artery (Effective for the year 2013)

LR Laboratory Round Trip.

LT Left Side - Used to identify procedures performed on the left side of the body.

M2 Medicare Secondary Payer

NB Nebulizer system, any type, FDA-Cleared fo ruse with specific drug

NU New equipment (DME)

P1 A normal healthy patient

P2 A patient with mild systemic disease

P3 A patient with severe systemic disease

P4 A patient with severe systemic disease that is a constant threat to life

P5 A moribund patient who is not expected to survive without the operation

P6 A declared brain-dead patient whose organs are being removed for donor purposes

PA Surgery Wrong Body Part

PB Surgery Wrong Patient

PC Wrong Surgery on Patient

Please refer http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM6718.pdf for proper usage of PA, PB and PC Modifiers

PD - Diagnostic or related non-diagnostic item or service provided in a wholly owned or wholly operated entity to a patient who is admitted as an inpatient within 3 days, or 1 day. (New modifier for the year 2012, Check for Usage and reimbursement)

PI PET Tumor init tx strategy

PS PET Tumor subsq tx strategy

PT Colorectal cancer screening test; converted to diagnostic test or other procedure

Q0 Investigational clinical service provided in a clinical research study that is in an approved clinical research study.

Q1 Routine clinical service provided in a clinical research study that is in an approved clinical research study.

Q3 Liver Kidney Donor Surgery and Related Services.

Q4 Service for ordering/referring physician qualifies as a service exemption -

Q5 Service furnished by a substitute physician under a reciprocal billing arrangement

Q6 Service furnished by a locum tenens physician

Q7 One CLASS A finding

Q8 Two CLASS B findings

Q9 One CLASS B and two CLASS C findings

QA FDA Investigational device exemption (IDE) - The IDE project number must be included on the claim when modifier QA is billed.

QB Physician service in a rural HPSA.

QC Single channel monitoring.

QD Recording and storage in solid state memory by a digital recorder.

QJ Services/items provided to a prisoner or patient instate or local custody.

QK Medical direction of 2, 3 or 4 concurrent anesthesia procedures involving qualified individuals.

QL Patient pronounced dead after ambulance called

QM Ambulance service provided under arrangement by a provider of services

QN Ambulance service furnished directly by a provider of services

QP Panel test - Documentation is on file showing that the laboratory test(s) was ordered individually or ordered as a CPT-recognized panel other than automated profile codes.

QS Monitored anesthesia care

QT Recording and storage on tape by an analog tape recorder.

QU Physician service in an urban HPSA.

QV Item or service provided as routine care in a medical qualifying clinical trial

QW CLIA Waived Test - Effective October 1, 1996, all new waived tests are being assigned a CPT code (in lieu of a temporary five-digit G- or Q-code).

QX CRNA service with medical direction by physician.

QY Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist.

QZ CRNA service without medical direction by a physician.

RA Replacement of a DME item, Orthotic or Prosthetic Item
 
RB Replacement of a Part of DME, Orthotic or Prosthetic Item furnished as Part of a Repair

RC Right coronary artery

RD Drug provided to beneficiary, but not, administrated incident-to

RE Furnished in full compliance with FDA-Mandated Risk Evaluation and Mitigation Strategy (REMS)

RI Ramus intermedius (Effective for the year 2013)

RP Replacement and repair

RT Right Side - Used to identify procedures performed on the right side of the body.

RR Rental (use the RR modifier when DME is a rental)

SB NP (for use by midwives only)

SC Medically necessary service or supply (w.e.f Jan 1, 2012)

SF Second opinion ordered by a Professional Review Organization (PRO) per section 9401, P.L. 99-272 (100 % reimbursement – no Medicare deductible or coinsurance)

SG Ambulatory Surgical Center (ASC) modifier
 

SH Second concurrently administered infusion therapy

SJ Third or more concurrently administered infusion therapy

SK Member of high risk population (Use only with codes for immunization)

SS Home infusion services provided in the infusion suite of the IV therapy provider

SW Services provided by a certified diabetes educator

TA Left foot, great toe

T1 Left foot, second digit

T2 Left foot, third digit

T3 Left foot, fourth digit

T4 Left foot, fifth digit

T5 Right foot, great toe

T6 Right foot, second digit

T7 Right foot, third digit

T8 Right foot, fourth digit

T9 Right foot, fifth digit

TC Technical component only - Use to indicate the technical part of a diagnostic procedure performed.

TD Registered Nurse (RN) (for behavioral health use)

TE Licensed Practical Nurse (LPN) (for behavioral health use)

TJ  Child/Adolescent Program GP:  To be used for enhancement payment for foster care children screening exams. 

TK Extra member or passenger, nonambulance transportation

TS Follow-up service

UE Used durable medical equipment
 
UN Portable X-ray Modifiers; two patients

UP Portable X-ray Modifiers; three patients

UQ Portable X-ray Modifiers; four patients

UR Portable X-ray Modifiers; five patients

US Portable X-ray Modifiers; six patients

V1 Level of MMI for Treating Doctor - This modifier would be added to the "Work related or medical disability examination by the treating physician..." CPT code 99455 when the office visit level of service is equal to a "minimal" level.

V2 Level of MMI for Treating Doctor - This modifier would be added to the "Work related or medical disability examination by the treating physician..." CPT code 99455 when the office visit level of service is equal to "self limited or minor" level.

V3 Level of MMI for Treating Doctor - This modifier would be added to the "Work related or medical disability examination by the treating physician..." CPT code 99455 when the office visit level of service is equal to "low to moderate" level.

V4 Level of MMI for Treating Doctor - This modifier would be added to the "Work related or medical disability examination by the treating physician..." CPT code 99455 when the office visit level of service is equal to "moderate to high severity" level and of at least 25 minutes duration.

V5 Level of MMI for Treating Doctor - This modifier would be added to the "Work related or medical disability examination by the treating physician..." CPT code 99455 when the office visit level of service is equal to "moderate to high severity" level and of at least 45 minutes duration.

V5 Any Vascular Catheter (alone or with any other vascular access) - Part A only modifier

V6 Arteriovenous Graft (or other vascular access not including a vascular catheter) - Part A only modifier

V7 Afteriovenous Fistula (or other vascular access not including a vascular catheter) - Part A only modifier

V8 Dialysis related infection present during the billing month - Part A only modifier

V9 No dialysis related infection present during the billing month - Part A only modifier

VR Review report - This modifier shall be added to the "Work related or medical disability examination by the treating physician..." CPT code 99455 to indicate that the service was the treating doctor's review of report(s) only.

Modifier ZA (Anesthesia modifier especially used for Medi-cal insurance of California) denotes prone position or surgical field avoidance. To be used only for procedures that have a base value of three (3) units. These techniques are included in the anesthesia base value of surgical procedures with a base value of more than three.

Modifier ZE (Anesthesia modifier especially used for Medi-cal insurance of California) To be billed with the appropriate five-digit CPT-4 anesthesia code to identify a normal, uncomplicated anesthesia provided by a Certified Registered Nurse Anesthetist (CRNA).

Modifiers table - Great resource found on the web

Just a quick post to let you know about this on the web.  It is a table from the Kansas Medical Assistance Program, but it provides good insight as to which modifiers can/cannot be used together.  It is in a PDF format.  I downloaded it and have it on my desktop for reference.  I hope that you find it as helpful as I did. 

https://www.kmap-state-ks.us/Documents/Content/Provider/Coding%20Modifiers%20Table.pdf

Modifier 33 - Confusion Reigns!

The growing confusion over Modifier 33 - New CPT Modifier for Preventative Services

As of January 1, 2011 the Patient Protection and Affordable Care Act (PPACA) of 2010 requires all health insurance plans to begin covering preventative services and immunizations without any cost sharing requirements.

A cost sharing requirement means co-pays, coinsurance, or deductibles. If the preventative services are part of an office visit then the office visit may not have cost sharing if the primary reason for the visit is the preventative service. If the office visit and preventative service are billed separately and the primary reason for the office visit was not the preventative service then cost sharing is permitted for the office visit.

To better facilitate proper claim processing for preventative services, CPT modifier 33 has been created. This new modifier is effective January 1, 2011 and should be used when the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventative Services Task Force A or B rating or other services identified in preventative services mandates (legislative or regulatory).

So to summarize from above:

• 
  Cost Sharing: Co-pay, Co-insurance, or Deductible (patient's portion to pay the provider of service)


• 
  Primary Preventive Services provided in-office WITHOUT an additional E&M type visit = NO co-pay, NO co-insurance, No deductible. These $ requirements should not be taken from the patient, nor should the 3rd party payer adjudicate for one.


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  Primary E&M visit with a Preventive visit on the same day: collect a co-pay or a deductible only applicable to the E&M service, and not to the preventive service. These co-pays may be adjudicated on your claim and on the EOB to the patient.

What this means to coders:

Modifier 33 informs carriers, that you believe that the preventive/screening service that you provided to your patient should not be subject to cost sharing, co-pay, co-insurance, or deductible.

Below is a good website to check out, it goes into detail regarding Modifier 33. This info is straight from the AMA regarding the implementation of modifier 33. This is a PDF document, so you can download. : )

http://www.ama-assn.org/ama1/pub/upload/mm/362/new-cpt-modifier-for-preventive-services.pdf

Happy Coding!

Modifiers - significant issues & changs

To my readers: I found this post on the Advance site and thought this info was too good not to share! *********************************************

Don't Let Modifiers Change Your Coding

Take a look at some of the more significant issues and changes to CPT modifiers.

By Melissa Brown, RHIA, CPC, CPC-I, CFPC

An annual phenomenon for coders is the eager anticipation of the arrival of the new CPT manuals. We know to look for added, deleted, and revised codes -- all critical pieces -- but we may not pay enough attention to the little details, the ones so little they are only two characters in length. That's right: I'm talking about modifiers.

While modifiers have been fairly stable over their history, they have gone under some key modifications in recent years. We saw the most drastic changes in 2008, and 2011 offers a few more tweaks. Let's take a look at some of the more significant issues and changes. Realize that some payers will have their own interpretations, which could affect reimbursement or how you apply the modifiers, so be sure to check with your payer to know what to expect.

Modifier 22
Prior to 2008, this modifier was described in CPT as "Unusual Procedural Services." Due to ambiguity of what would be considered "unusual," the modifier was changed in 2008 to read "Increased Procedural Services" and the descriptor expanded to define criteria for increased work. Some specialist have fallen into the trap of believing every service they provide warrants a modifier 22 because every patient they have is "unusual" by nature of their specialty or expertise. While the patient population they serve may indeed be unusual in nature, this alone does not justify the use of modifier 22. Specifically, CPT has indicated the documentation has to support a significant increase time, complexity or effort. It's important that the documentation include the reasons for additional time or work, and not just a generic statement. The more detailed the documentation, the better justification if/when the payer needs more details.

For example, "50 percent more time than usual was required to excise the tumor due to the presence of an unusually dense mass of adhesions at the operative site; causing the total procedure to last 90 minutes instead of the average 60 minutes" is more effective than, "procedure took an extra 30 minutes due to adhesions." The more detailed description gives the payer a comparison for considering how much to increase pay for the service and specific reasons for the increased work.

Appropriate circumstances to report modifier 22 (when properly documented):

• Intra-operative hemorrhage resulting in a significant amount of increased operative time.
• Emergency situations that require significant effort beyond the normal service. This does not include minor intra-operative complications that sometimes occur.
• Abnormal pathology, anatomy, tumors and/or malformations that directly and significantly interfere with the normal progression of a procedure.

Inappropriate circumstances:

• Additional time alone does not justify the use of modifier 22.
• Do not use this modifier when the existing CPT code describes the service.
• Do not use to indicate a specialist (no matter how specialized) performed the service.
• If the complication is due to the surgeon's choice of approach; for example, the surgeon has elected a vaginal approach for a hysterectomy that would not have resulted in increased time or effort if performed abdominally.

Modifiers 25 and 59
Because there was confusion between these two modifiers, the language in the descriptors were changed in 2008 to emphasize that modifier 25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service is to be used with E/M services only and modifier 59 Distinct Procedural Service is for use with non-E/M services. Both descriptions were modified to remove restrictions as to which types of providers could use them. This allows providers that are recognized by various payers to use the modifiers (e.g., chiropractors, physician assistants, physical or occupational therapists).

There is much confusion on the appropriate use of modifier 25. For instance, there is a popular belief that modifier 25 can be applied only if the diagnosis for the E/M is different than the diagnosis for the procedure. According to the CPT descriptor, different diagnoses are not required for reporting modifier 25.

Appropriate circumstance for reporting Modifier 25

• A significant E/M service unrelated to the reason for the procedure is performed (e.g., patient presents with complaint of irritated skin tags, which the provider removes. Prior to leaving, patient mentions in passing a lesion related to a recent burn. After evaluating the lesion, the provider prescribes a topical treatment for the burn. In this case, the E/M related to the burn can be billed with a modifier 25 to separate that work from the removal of the skin tags)
• A significant E/M service above and beyond the other service provided on the same day is performed (e.g., a patient comes with complaints of a sore throat. The condition is evaluated and treated. Later the same day, the patient presents for treatment after stepping on a nail.)
• E/M work above and beyond the typical pre- and post-op work associated with the procedure is performed (e.g., patient becomes dizzy, falls resulting in a laceration to the head. During the visit, the provider repairs the laceration and evaluates the reasons for the patient's dizziness.)

Inappropriate circumstances:

• Do not use modifier 25 on the procedure code.
• Do not use modifier 25 when the E/M resulted in a decision to perform major surgery.
• Do not use modifier 25 when the E/M is mainly related to the procedure (e.g., patient presents for follow-up for ongoing acne treatment. During the visit, acne cysts are injected. In this case, the E/M would be included in the acne surgery.)

Modifier 59 continues to be used to report services as distinct from each other, and aids in communicating to the payer that both services should be paid even though they normally are considered part of each other. While using modifier 59 may seem like the magic ticket to unbundling CCI edits to get paid, be careful. Inappropriate use of this modifier can be interpreted as fraudulent behavior. The key with this modifier is to ensure the documentation clearly supports a distinct procedure within the parameter of the modifier's description.

Modifier 58 and 78
Prior to 2008, modifier 58 and 78 were being used interchangeably; therefore, both definitions were changed to distinguish appropriate use.

The descriptor for modifier 58 was changed to expand its application to other billing providers instead of limiting use to physicians. Additionally, the phrase "planned prospectively" has been changed to "planned or anticipated." This allows for a broader application in situations where the subsequent procedure is dependent on the outcome of the surgery. We are no longer limited to using this modifier only in situations where the additional procedures were planned ahead of time. For example, during the post-op period, a re-amputation is performed to raise the level of amputation on a diabetic foot. The second procedure would be coded with a 58 modifier. This tells the payer that it was hoped the original surgery would be sufficient, yet the need for additional surgery was anticipated if the patient didn't progress well enough.

Modifier 78, on the other hand, is reserved for those unplanned returns to the operating/procedure room. In these cases, the patient undergoes the surgery or procedure with no expectations of additional surgeries/procedures. Note that the expansion of this modifier description to include "procedure room" allowed for this modifier to be used outside the inpatient setting. A common scenario for using modifier 78 is a return to the OR to control post-op bleeding.

For 2011, the phrase "or other qualified health care professional" as been added to the descriptor of Modifiers 76, 77 and 78 to expand the scope of these modifiers to more than just physicians.

As you can see, if you've ignored the changes to the modifiers over the past few years, you may have missed some key billing opportunities. When you dive into the treasure of the new CPT manuals, it's important to explore every aspect -- even the smallest of details can make a difference for you!

Melissa Brown is vice chair of AAPC Chapter Association Board of Directors.

CPT is registered trademark of the American Medical Association