Important Modifiers with definition and when to use

-21 Prolonged Evaluation and Management Services:

When the face-to-face or floor/unit service(s) provided is prolonged or otherwise greater than that usually required for the highest level of E/M service within a given category, it may be identified by adding modifier ‘- 21’ to the E/M code number or by use of the separate five digit modifier code 09921. A report may also be appropriate.

-22 Unusual Procedural Services:

When the service(s) provided is greater than that usually required for the listed procedure, it may be identified by adding modifier ‘-22’ to the usual procedure number or by use of the separate five digit modifier code 09922. A report may also be appropriate.

-23 Unusual Anesthesia:

Occasionally, a procedure which usually requires either no anesthesia or local anesthesia, because of unusual circumstances must be done under general anesthesia. This circumstance may be reported by adding the modifier ‘-23’ to the procedure code of the basic service or by use of the separate five digit modifier code 09923. Note: Modifier

‘-47’, Anesthesia by Surgeon, (See Appendix A) would not be used as a modifier for the anesthesia procedures 00100-01999.

-24 Unrelated Evaluation and Management Service by the Same Physician During a Post-operative Period:

The physician may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. This circumstance may be reported by adding the modifier ‘-24’ to the appropriate level of E/M service, or the separate five digit modifier 09924 may be used.

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

The physician may need to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same day. This circumstance may be reported by adding the modifier ‘-25’ to the appropriate level of E/M service, or the separate five digit modifier 09925 may be used. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier ‘-57’.

-26 Professional Component:

Certain procedures are a combination of a physician component and a technical component. When the physician component is reported separately, the service may be identified by adding the modifier ‘-26’ to the usual procedure number or the service may be reported by use of the five digit modifier code 09926.

-32 Mandated Services: Services related to mandated consultation and/or related services (eg, PRO, 3rd party payer) may be identified by adding the modifier ‘-32’ to the  basic procedure or the service may be reported by use of the five digit modifier 09932.

-47 Anesthesia by Surgeon:

Regional or general anesthesia provided by the surgeon may be reported by adding the modifier ‘-47’ to the basic service or by use of the separate five-digit modifier code 09947. (This does not include local anesthesia) Note: Modifier ‘-47’ or 09947 would not be used as a modifier for the anesthesia procedures 00100-01999.

-50 Bilateral Procedure:

Unless otherwise identified in the listings, bilateral procedures that are performed at the same operative session should be identified by adding the modifier ‘-50’ to the appropriate five digit code or by use of the separate five-digit modifier code 09950.

-51 Multiple Procedures:

When multiple procedures, other than Evaluation and Management Services, are performed on the same day or at the same session by the same provider, the primary procedure or service may be reported as listed. The additional, procedure(s) or service(s) may be identified by appending the modifier ‘-51’ to the secondary procedure or service code(s) or by use of the separate five-digit modifier code 09951. Note: This modifier should not be appended to designated “add-on” codes (eg, 22612, 22614)

-52 Reduced Services:

Under certain circumstances, a service or procedure is partially reduced or eliminated at the physician’s discretion. 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 code 09952 may be used as an alternative to modifier ‘-52’. Note: For hospital outpatients reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers ‘-73’ and ‘-74’ (see modifiers approved

for ASC hospital outpatient use).

-53 Discontinued Procedure:

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 reported by adding the modifier ‘-53’ to the code reported by the physician for the discontinued procedure or by the use of the separate five digit modifier code 09953.

Note: This modifier is not used to report the elective cancellation of a procedure prior to the patient’s anesthesia induction and/or surgical preparation in the operating suite. For outpatient hospital/ambulatory surgery center (ASC) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers ‘-73’ and ‘-74’ (see modifiers approved for ASC hospital outpatient use).

-54 Surgical Care Only:

When one physician performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding the modifier ‘-54’ to the usual procedure number or by use of the separate five digit modifier code 09954.

-55 Postoperative Management Only:

When one physician performs the postoperative management and another physician has performed the surgical procedure, the postoperative component may be identified by adding the modifier ‘-55’ to the usual procedure number or by use of the separate five digit modifier code 09955.

-56 Preoperative Management Only:

When one physician performs the preoperative care and evaluation and another physician performs the surgical procedure, the preoperative component may be identified by adding the modifier ‘-56’ to the usual procedure number or by use of the separate five digit modifier code 09956.

-57 Decision for Surgery:

An evaluation and management service that resulted in the initial decision to perform the surgery may be identified by adding the modifier ‘-57’ to the appropriate level of E/M service, or the separate five-digit modifier 09957 may be used.

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

The physician may need to indicate that the performance of a procedure or service during the postoperative period was: a) planned prospectively at the time of the original  procedure (staged); b) more extensive than the original procedure; or c) for therapy following a diagnostic surgical procedure. This circumstance may be reported by adding the modifier ‘-58’ to the staged or related procedure, or the separate five-digit modifier  09958 may be used. Note: This modifier is not used to report the treatment of a problem that requires a return to the operating room. See modifier ‘-78’.

-59 Distinct Procedural Service:

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 is appropriate it should be used rather than modifier ‘-59’. Only if no more descriptive modifier is available should modifier ‘-59’ be used. Modifier code 09959 may be used as an alternative to modifier ‘- 59’.

-62 Two Surgeons:

When two surgeons work together as primary surgeons performing distinct part(s) of a single procedure, each surgeon should report his/her distinct operative work by adding  the modifier ‘-62’ to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary care surgeons. Each surgeon should report the co-surgery once using the same procedure code. If additional procedure(s) (including add-on procedure(s)) are performed during the same surgical session, separate codes may also be reported with the modifier ‘-62’ added. Modifier code 09962 may be use as an alternative to modifier ‘-62’. Note: If a cosurgeon

acts as an assistant in the performance of additional procedure(s) during the same surgical session, those services may be reported using separate procedure code(s) with the modifier ‘-80’ or modifier ‘-82’ added, as appropriate.

-63 Procedure Performed on Infants Less than 4 kg:

Procedures performed on neonates and infants up to a present body weight of 4 kg may involve significantly increased complexity and physician work commonly associated with these patients. This circumstance may be reported by adding the modifier ‘-63’ to the procedure number. Note: Unless otherwise designated, this modifier may only be appended to procedures/services listed in the 20000…69999 code series. Modifier ‘- 63’n should not be appended to any CPT codes listed in the Evaluation and Management Services, Anesthesia, Radiology, Pathology/Laboratory, or Medicine

sections.

-66 Surgical Team:

Under some circumstances, highly complex procedures (requiring the concomitant  services of several physicians, often of different specialties, plus other highly skilled, specially trained personnel, and various types of complex equipment) are carried out under the “surgical team” concept. Such circumstances may be identified by each participating physician with the addition of the modifier ‘-66’ to the basic procedure number used for reporting services. Modifier code 09966 may be used as an alternative to modifier ‘-66’.

-76 Repeat Procedures by Same Physician:

The physician may need to indicate that a procedure or service was repeated subsequent to the original procedure or service. This circumstance may be reported by adding the modifier ‘-76’ to the repeated procedure/service or the separate five-digit modifier code 09976 may be used.

-77 Repeat Procedure by Another Physician:

The physician may need to indicate that a basic procedure or service performed by another physician had to be repeated. This situation may be reported by adding modifier  ‘-77’ to the repeated procedure/service or the separate five-digit modifier code 09977 may be used.

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

The physician may need to indicate that another procedure was performed during the postoperative period of the initial procedure. When this subsequent procedure is related to the first, and requires the use of the operating room, it may be reported by adding the modifier ‘-78’ to the related procedure, or by using the separate five digit modifier 09978. (For repeat procedures on the same day, see ‘-76’).

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

The physician may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. This circumstance may be reported by using the modifier ‘- 79’ or by using the separate five digit modifier 09979. (For repeat procedures on the same day, see ‘-76’).

-80 Assistant Surgeon:

Surgical assistant services may be identified by adding modifier ‘-80’ to the usual procedure number(s) or by use of the separate five-digit modifier code 09980.

-81 Minimum Assistant Surgeon:

Minimum surgical assistant services are identified by adding the modifier ‘-81’ to the usual procedure number or by use of the separate five-digit modifier code 09981.

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

The unavailability of a qualified resident surgeon is a prerequisite for use of modifier ‘-

82′ appended to the usual procedure code number(s) or by use of the separate five digit

modifier code 09982.

-90 Reference (Outside) Laboratory:

When laboratory procedures are performed by a party other than the treating or reporting physician, the procedure may be identified by adding the modifier ‘-90’ to the  usual procedure number or by using the separate five digit modifier code 09990.

-90 Reference (Outside) Laboratory:

When laboratory procedures are performed by a party other than the treating or reporting physician, the procedure may be identified by adding the modifier ‘-90’ to the usual procedure number or by using the separate five digit modifier code 09990.

-91 Repeat Clinical Diagnostic Laboratory Test:

In the course of treatment of the patient, it may be necessary to repeat the same laboratory test on the same day to obtain subsequent (multiple) test results. Under these circumstances, the laboratory test performed can be identified by its usual procedure number and the addition of the modifier ‘-91’. Note: This modifier may not be used when tests are rerun to confirm initial test results; due to testing problems with specimens or equipment; or for any other reason when a normal, one-time, reportable

result is all that is required, This modifier may not be used when other code(s) describe a series of test results (eg, glucose tolerance tests, evocative/suppression testing). This modifier may only be used for laboratory test(s) performed more than once on the same day on the same patient.

-99 Multiple Modifiers:

Under certain circumstances, two or more modifiers may be necessary to completely delineate a service. In such situations modifier ‘-99’ should be added to the basic procedure, and other applicable modifiers may be listed as part of the description of the service. Modifier code 09999 may be used as an alternative to modifier ‘-99’.

-Physical Status Modifier P1

A normal healthy patient

-Physical Status Modifier P2

A patient with mild systemic disease

-Physical Status Modifier P3

A patient with severe systemic disease

-Physical Status Modifier P4

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

-Physical Status Modifier P5

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

-Physical Status Modifier P6

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