Modifiers are generally twodigit or five-digit numeric or alphanumeric characters. However, for hospital reporting only the two-digit character code is appended to the Health Care Financing Administration’s Common Procedure Classification System (HCPCS) Level I (CPT) and HCPCS Level II codes.
The reporting of modifiers with CPT and HCPCS Level II codes identify altered services that were provided to the patient. These altered services unfortunately cannot be easily identified on a claim. Therefore, modifiers were established to permit claims of such nature to bypass the Correct Coding Initiative (CCI) edits and supply additional information regarding the specific service provided. It is important to note however that the appendage of a modifier after a CPT or HCPCS code does not ensure reimbursement.
The use of modifiers is an integral part of the Outpatient Hospital Prospective Payment System (OPPS), and is crucial for the approval and optimal reimbursement of reported services. Therefore, clear and precise documentation in the health record is a major factor for appropriate reimbursement.
General guidelines for modifier usage must be followed to avoid rejections of submitted claims. When appending modifiers to a CPT or HCPCS code, always remember:
- Not all HCPCS require modifiers.
- Modifiers 73 & 74 do not apply to radiology services.
- These modifiers should be appended to surgical procedures only:
-50 bilateral procedures
-52 reduced services
-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
- Modifiers should not be appended when the narrative description indicates multiple occurrences
Let’s address a few issues regarding the use of a couple of modifiers:
Cancelled surgical procedures
When appending modifiers to cancelled surgical procedures HCFA allows full and partial payments for procedures with a status indicator of “T” when a modifier is appended to the code assignment.
In the instance where a surgical procedure is started but discontinued after the induction of anesthe- 8 sia (e.g. local, regional block, or general anesthesia) Medicare will pay the full amount of the planned procedure if the CPT code for the planned procedure is reported with a -74 modifier.
When a surgical procedure is terminated after preparation for surgery, including sedation and taken to the procedure room, but before induction of anesthesia, Medicare will allow payment of 50% of the planned procedure and beneficiary amount if the CPT code for the planned procedure is reported with a -73 modifier.
The appending of the modifier -50 indicates a bilateral procedure was performed on both sides at the same operative session.
Bilateral procedures are reported with one procedure code appended with modifier -50.
Certain surgical procedures will be rejected if reported with modifier -50, such as:
— procedures identified by their narrative description as bilateral
— procedures listed as unilateral or bilateral Modifier -25
A significant, separately identifiable evaluation and management (E/M) service by the same physician, on the same day of the procedure, or other service is identified, by reporting the modifier-25 to the appropriate level of E/M service.
The guidelines specifically state that should a separate distinct E/M service be provided on the same date that a diagnostic and/or therapeutic procedure(s) is performed, and information substantiating the E/M service is clearly documented in the health record, modifier -25 may be appended.
Medicare requires that modifier -25 always be appended to the emergency department (ED) E/M code (99281-99285) when services are provided on the same date as a diagnostic medical/surgical and/or therapeutic medical/surgical procedure( s).
FOR EXAMPLE:A patient is brought to the emergency department following a fall. The patient’s lacerations sustained from the fall are repaired and radiological xrays are performed for suspicion of fracture.
The appropriate code(s) from the following code ranges can be reported:
Here is a listing of modifiers approved for proper reporting of services under OPPS:
LEVEL I (CPT): -25, -50, -52, -58, -59, -73, -74, -76, -77, -78, - 79, -91
LEVEL II (HCPCS/NATIONAL): -LT, -RT, -E1, -E3, -E4, -FA, -F1, - F2, -F3, -F4, -F5, -F6, -F7, -F8, - F9, -LC, -LD, -RD, -QM, -QN, - TA, -T1, -T2, -T3, -T4, -T5, -T6, -T7, -T8, -T9
The definitions for the modifiers listed above can be found in your Current Procedural Terminology (CPT) guide, under Appendix A.
Remember that modifiers should always be reported when appropriate. Accurate usage of modifiers will assist in the timely processing of claims and the avoidance of fraud and abuse or noncompliance issues. ♦