Using Insurance Modifiers

Medical coding is the means of getting the "story" out to an insurance company and modifers provide additional information about the service performed. Modifiers often provide justification as to why additional procedures should be paid. Using modifiers can prevent bundling of procedures, however, they should only be used if the chart note justifies it.

The following are descriptions of some commonly used modifiers followed by a broader list. This list is intended as a quick guide. Be sure to consult your CPT code book for more details about modifiers.

Commonly Used Modifiers

25 is billed with an evaluation and management (E/M) code to indicate that the patient’s condition required a significant, separately identifiable E/M service on the same day a procedure was performed. This modifier indicates that the E/M service was required beyond the procedure that was provided.

59 indicates that a procedure or service was distinct or independent from other services that were performed on the same day. It is used to identify procedures that are not normally reported together but are appropriate under the circumstances.

51 is used to reflect multiple procedures other than evaluation and management services, are performed at the same session by the same provider. The primary procedure is reported first and the additional procedure(s) are identified by adding modifier 51.

79 is used to indicate an unrelated procedure or service by the same physician during the postoperative period. To avoid audits, coders should ensure sufficient documentation exists to support modifier 79 use. Use modifier 79 only when a visit within the global period is unrelated to the surgery.

GA is a Medicare modifier used to indicate that the patient has signed an ABN (Advanced Beneficiary Notification). This allows the provider to bill the patient if the service is not covered by Medicare. Use of this modifier ensures that upon denial, Medicare will automatically assign the beneficiary liability.

GY is used in conjunction wth modifier GA to obtain a denial on a non covered service. Use it to tell Medicare that you know the service is not covered.

Below is a list of common modifiers:

20 MICROSURGERY
21 PROLONGED EVALUATION & MANAGEMENT SERVICE
22 UNUSUAL PROCEDURAL SERVICES
23 UNUSUAL ANESTHESIA
24 UNRELATED EVALUATION & MANAGEMENT SERVICE
25 SIGNIFICANT, SEPARATELY IDENTIFIABLE E/M SERVICE
26 PROFESSIONAL COMPONENT
32 MANDATED SERVICES
47 ANESTHESIA BY SURGEON
50 BILATERAL PROCEDURE
51 MULTIPLE PROCEDURES
52 REDUCED SERVICES
53 DISCONTINUED PROCEDURE
54 SURGICAL CARE ONLY
55 POSTOPERATIVE MANAGEMENT ONLY
56 PREOPERATIVE MANAGEMENT ONLY
57 DECISION FOR SURGERY
58 STAGED OR RELATED PROCEDURE OR SERVICE
59 DISTINCT PROCEDURAL SERVICE
62 TWO SURGEONS
66 SURGICAL TEAM
73 DISCONTINUED OUT-PATIENT HOSPITAL/AMBULANCE
74 DISCONTINUED OUT-PATIENT HOSPITAL/AMBULANCE
76 REPEAT PROCEDURE BY SAME PHYSICIAN
77 REPEAT PROCEDURE BY ANOTHER PHYSICIAN
78 RETURN TO THE OPERATING ROOM FOR A RELATED PROCEDURE DURING POSTOP PERIOD
79 UNRELATED PROCEDURE OR SERVICE BY THE SAME PROVIDER DURING THE POSTOP PERIOD
80 ASSISTANT SURGEON
81 MINIMUM ASSISTANT SURGEON
82 ASSISTANT SURGEON
90 REFERENCE (OUTSIDE) LABORATORY
91 REPEAT CLINICAL DIAGNOSTIC LAB TEST
99 MULTIPLE MODIFIERS
E1 UPPER LEFT, EYELID
E2 LOWER LEFT, EYELID
E3 UPPER RIGHT, EYELID
E4 LOWER RIGHT, EYELID
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
FA LEFT HAND, THUMB
LC LEFT CIRCUMFLEX CORONARY ARTERY (HOSPITAL)
LD LEFT ANTERIOR DESCENDING CORONARY ARTERY
LT LEFT SIDE (USED TO IDENTIFY PROCEDURES P
QM AMBULANCE SERVICE PROVIDED UNDER ARRANGEMENT BY HOSPITAL
QN AMBULANCE SERVICE FURNISHED DIRECTLY BY HOSPITAL
RC RIGHT CORONARY ARTERY
RT RIGHT SIDE (USED TO IDENTIFY PROCEDURES)
T1 LEFT FOOT, SECOND DIGIT
T2 LEFT FOOT, THIRD DIGIT
T3 LEFT FOOT, FOURTH DIGIT
T4 LEFT FOOT, FIFTH DIGIT

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