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All about Medical Modifiers

Why do we have to know how to properly use the right modifiers?  Well, here
are the simple reasons why we need 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

But, do you know what are these numerical modifiers? Let me enumerate
them, define and site some examples for you to understand how is it being

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

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, 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 perion.

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, 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, 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, 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 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 toidentify
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

Modifier -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.
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