Modifiers

Modifiers

A modifier allows providers to indicate that a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code. For QualChoice claims filing, modifiers, when applicable, should be indicated by placing the appropriate two-digit number in the indicated space in Block 24D after the usual procedure code.

The applicable modifiers are listed by code and defined in each Current Procedural Terminology (CPT) section. Some common modifiers that always should be considered when filing claims include the following:

Modifier Definition
22 Increased procedural services
25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service
26 Professional component
33 Preventive services
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
59 Distinct procedural service
62 Two surgeons
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
76 Repeat procedure or service by same physician or other qualified health care professional
78 Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period
80 Assistant surgeon
81 Minimum assistant surgeon
82 Assistant surgeon (when qualified resident surgeon not available)
90 Reference (outside) laboratory
91 Repeat clinical diagnostic laboratory test
XE Separate encounter, a service that is distinct because it occurred during a separate encounter
XS Separate structure, a service that is distinct because it was performed on a separate organ/structure
XP Separate practitioner, a service that is distinct because it was performed by a different practitioner
XU Unusual nonoverlapping service, the use of a service that is distinct because it does not overlap usual components of the main service


Modifier 22 – Increased procedural services

Each procedure code has an expected range of complexity, length, risk and difficulty. When the service provided exceeds these normal ranges (more complicated, complex, difficult or requiring significantly more time than usual), add modifier 22 to the procedure code.

  • When use of modifier 22 is valid, an additional payment may be allowed:
  • May not apply to every code paid
  • Considered only when the documentation submitted clearly states the exceptional nature of the service provided
  • Modifier 22 always requires code review.
  • Do not append modifier 22 to unlisted codes.
  • This modifier should not be appended to an E/M service.

Validity of modifier 22 requires two or more of the following factors, OR one of the following factors in addition to extended anesthesia:

  • Extreme obesity that significantly complicates surgery
  • Co-morbidities that cause complications during the surgery
  • Trauma extensive enough to complicate the particular procedure and not billed as additional procedure codes
  • Other pathologies, tumors, malformations (genetic, traumatic, surgical) that directly interfere with the procedure but are not billed separately
  • Services rendered are significantly more complex than described for the CPT code in question
  • Excessive blood loss for the particular procedure
  • Difficult surgical approach
  • Revisions or removals of prior operative work that are unusually complex or difficult

Individual consideration for modifier 22 may also be given in other situations. For example, if access to the primary operative site is difficult and time-consuming, additional payment may be warranted for the primary procedure. However:

  • Secondary procedures performed through the same incision may not meet the same criteria.
  • Reductions for multiple procedures will still apply.

This process does not exempt claims from clinical code edits relative to bundled services and other code edits.

Modifier 25 – Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service

Modifier 25 is used when, on the day a procedure or service 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.

All surgical procedures and some procedural services include a certain degree of physician involvement or supervision which is integral to that service. For those procedures and services, a separate E&M service is not normally reimbursed. However, a separate E&M service may be considered for reimbursement if the patient’s condition required services above and beyond the usual care associated with the procedure or service provided. To identify these circumstances, modifier 25 is attached to the E&M code.

The submission of modifier 25 appended to an E&M code indicates that documentation is available in the patient’s records for review upon request and will support the significant and separately identifiable nature of the E&M service.

QualChoice performs periodic retrospective reviews of modifier 25 billing patterns. Providers who are statistical outliers will have all claims with modifier 25 pended for medical record review to confirm the appropriate modifier use. The requirement for prepayment submissions of medical records will continue until proper code use has been adequately demonstrated or repeat periodic analysis shows the provider is no longer a statistical outlier.

Modifier 26 – Professional component and Modifier TC – Technical component

Certain procedures and services have both a professional and a technical component:

  • Use modifier 26 when only the professional (physician) component is being billed.
  • Use modifier TC when only the technical component is being billed.

Example of using modifiers 26 and TC: 

Polysomnography, CPT code 95811, is performed at a Certified Sleep Center. A physician not associated with the sleep center interprets the findings. The providers report:

  • Both providers report on a CMS 1500 form.
  • The physician reports the polysomnography interpretation as 95811-26, the professional component.
  • The sleep center reports 95811-TC, the technical component.

Modifier 33 – Preventive health service or a diagnostic test for treatment or monitoring of a health condition

Some CPT codes can be used to report either a preventive health service (as identified by US Preventive Services Task Force or QualChoice designation per our Provider Manual) or a diagnostic test for treatment or monitoring of a health condition.

Modifier 33 identifies these services as preventive. Use of this modifier allows us to apply and reimburse the appropriate benefits to member claims with the first claim submission.

CPT defines modifier 33 as:

“When the primary purpose of the service is the delivery of an evidence based service in accordance with the US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (Legislative or regulatory), the service may be identified by adding 33 to the procedure. (Current Procedural Terminology, American Medical Association, 2015).”

Preventive Care Benefits

Use modifier 33 with codes for services that could be either preventive or diagnostic, to identify that the service rendered or ordered was for preventive health purposes. Examples:

  • 88141 – Cytopathology, cervical or vaginal
  • 45378 – Colonoscopy
  • 80061 – Lipid panel
  • 77080 – Dual energy X-ray absorptiometry, bone density study
  • 97802 – Medical nutrition therapy

Do not use modifier 33 when the service is already specifically identified as preventive within the definition. Examples:

  • 99395 – Periodic comprehensive preventive medicine E&M
  • 77057 – Screening mammography, bilateral
  • 92551 – Screening test, pure tone air only
  • 99412 – Preventive medicine counseling and/or risk factor reduction intervention(s)
  • G0102 – Prostate cancer screening

Modifier 50 – Bilateral procedure

This modifier is used to report bilateral procedures that are performed during the same session. Bilateral procedures should be billed to allow the first procedure at 100% and the second procedure at 50%.
  • Bilateral procedures should be billed on two claim lines.
  • Claim lines should include procedure code and descriptive modifier (right or left).
    For Example:
    Line 1 64483 LT
    Line 2 64483 RT

Modifier 51 – Multiple procedures

Reporting multiple procedures:

  • Modifier 51 is not required on claim lines when multiple procedures are performed on the same day. QualChoice applies multiple same-day surgical logic based on our fee schedule amounts.
  • QualChoice does not use Medicare’s multiple endoscopic procedure methodology, but the services are subject to the same-day multiple surgical reduction.
  • Modifier 51 does not apply to procedures classified as “add-on” or “modifier 51 exempt.”
  • Modifiers such as F- (finger), T- (toe), LT and RT should be used to communicate locations and/or anatomical sites and will be subject to the multiple same-day procedures reduction.
  • The service with the highest allowed fee amount will be priced at the QualChoice fee schedule. Each additional same-day procedure will be priced at 50% of the fee, based on the lesser of billed charges or fee schedule amount.
  • Multiple same-day procedure reduction will be identified as “MSD” on your remittance advice.

Modifier 52 – Reduced services

Report modifier 52 when a component of a CPT code definition is reduced or eliminated. Append modifier 52 to the CPT code that represents the basic service to indicate that the basic service was performed but a component of the service/CPT code definition was not.

Do not use modifier 52 when:

  • There is a CPT code that accurately describes the service(s) performed.
  • To report a discontinued outpatient procedure, use modifier 73 or 74.

Reimbursement under all plans is 50% of the base fee schedule. This does not include MSD reduction, bilateral pricing, etc. that may also be applied.

QualChoice may request notes to determine the extent of services rendered.

Refer to the CPT Manual for additional instruction.

Modifier 53 – Discontinued procedure

Use modifier 53 when a service is terminated due to circumstances beyond the physician or healthcare provider’s control. This may include conditions that threaten the patient’s health.

  • Do not use modifier 53 for an elective cancellation of the procedure.
  • Can be used with diagnostic or surgical CPT codes.
  • To report a discontinued outpatient procedure, use modifier 73 or 74.

Refer to the CPT Manual for additional instruction.

Reimbursement under all plans is 50% of the base fee schedule. This does not include MSD reduction, bilateral pricing, etc. that may also be applied.

Modifier 54 – Surgical care only and Modifier 55 – Postoperative management only

Using modifiers 54 and 55: Co-management of surgery/post-op care

Modifier 54: Surgical care services only

QualChoice global periods are modeled after those of the Centers for Medicare and Medicaid Services (CMS

When a physician performs only surgical services for a member, the appropriate surgical CPT codes should be reported, along with modifier 54, which indicates that only the surgical component of the global package will be performed by this provider.

  • Report modifier 54 when it is known that postoperative care will be performed by or transferred to another healthcare provider.
  • Do not bill the global surgical code when postoperative care is provided by another healthcare provider.
  • QualChoice reviews historical data prior to reimbursing claims submitted with modifiers 54 and 55. If an unmodified surgical code is reported and global payment made, claims submitted with a 54 or 55 will be denied as inclusive or redundant to the global surgical payment.
  • Use modifier 54 when the CPT code has a global surgical period (10 or 90 days); if there is no global period, don't append this modifier.
  • ER and urgent care providers: Review for use with global package CPT codes, as it is unlikely that you provided the preoperative and/or postoperative portions. ER claims without modifier 54 will require supporting documentation to show that a global (10 or 90 day) service was provided.

Modifier 55: Post-operative services only

When a physician provides and/or co-manages postoperative care for a member, report the appropriate surgical CPT code along with modifier 55. Modifier 55 indicates that only postoperative services of the global surgical package were rendered by this provider. Do not use this modifier when there is no global surgical period (10 or 90 days) associated with the CPT code.

  • Reimbursement will be made based on the dates that postoperative care was rendered. The postoperative period begins the day after surgery. Enter the date of surgery as the date of service in box 24. Report the post-op care date span (the “begin” date and “end” date of post-op care) in the notes section of the claim; otherwise, it may be denied due to insufficient information.

Modifier 56 – Preoperative management only

When a physician performs the preoperative care and evaluation only (another physician performs the surgical procedure), identify the preoperative component by adding modifier 56 to the appropriate surgical CPT codes.

Do not bill the global surgical code when pre-operative services are the only services rendered.

Report modifier 56 when:

  • The CPT code has a global surgical package; if there is no global package, the appropriate E&M service may be more appropriate to report.
  • It is known that the surgical services/postoperative care will be performed by or transferred to another healthcare provider.

QualChoice reviews historical data prior to reimbursing claims submitted with modifier 56 to validate that partial services were rendered, to avoid duplicate reimbursement.

If an unmodified surgical code is reported and global payment made, claims submitted with modifier 56 will be denied as inclusive or redundant to the global surgical payment.

Modifier 57 – Decision for surgery

Modifier 57 is used when the initial decision to perform a major surgical procedure is made during an E&M service provided the day before or the day of a major surgery. Major surgery is defined as any code having a 90-day global period.

Modifier 57 appended to an E&M procedure code indicates that documentation is available in the patient’s records, confirming that the E&M service resulted in the initial decision to perform the surgery.

An E&M service provided the day before or the day of a major surgery that resulted in the initial decision to perform surgery may be eligible for reimbursement if modifier 57 is appended to the E&M code. It should not be used when the E&M service is associated with a minor surgical procedure (defined as having a 0- or 10-day global period). Modifier 57 should not be used when the E&M service was for preoperative evaluation.

Excessive use of modifier 57 may result in a request to review medical records prior to claim payment.

Modifier 59 – Distinct procedural service

Modifier 59 is used to identify procedures/services that are commonly bundled together but are appropriate to report separately under some circumstances. A provider may need to use modifier 59 to indicate that a procedure or service was distinct or independent from other services performed on the same day. This commonly means a different location, different anatomical site, and/or a different session.

Providers must maintain adequate documentation in the medical record to support the use of modifier 59 for distinct services. Addenda or amendments to the documentation will not be accepted after a claim has been denied. If a claim line is denied due to a clinical edit and you submit a corrected claim using modifier 59 for that claim line, we will require medical records in order to process the corrected claim. Different diagnoses are not adequate criteria for use of modifier 59.

Using modifier 59 with physical therapy codes:

When appending modifier 59 to physical therapy codes, the documentation must show that distinct services (different session/patient encounter or different procedure/service) were rendered. Appending this modifier should be the exception, not the rule. Overusing this modifier may trigger a review of medical records or an audit of your claims.

Inappropriate use of modifier 59

Modifier 59 should only be used if no other modifier more appropriately describes the relationship(s) of the two or more procedure codes. For example, when commonly bundled procedures are performed on different fingers or toes, the use of finger (F1, F2, F3, etc.) or toe (T1, T2, T3, etc.) modifiers would be more appropriate than the 59 modifier to show that these are distinct services and create a clearer picture for the claim examiner as to why the services were unbundled. This may reduce the need for operative notes or medical office notes.

Other examples when modifier 59 is not appropriate include unlisted codes or with some HCPSC or CPT codes, such as J codes or L codes.

QualChoice performs periodic retrospective reviews of modifier 59 billing. Providers who are statistical outliers will have all claims with modifier 59 pended for medical record review to confirm appropriate modifier use. The requirement for prepayment submission of medical records will continue until proper code use has been demonstrated or repeat periodic analysis shows the provider is no longer a statistical outlier.

Modifier 62 – Two surgeons

When two surgeons work together as primary surgeons performing distinct parts of a procedure, each surgeon should report the co-surgery once using the same procedure code and report his/her distinct operative work by adding modifier 62 and any associated add-on code(s) for that procedure.

Per the AMA CPT rules for modifier 62, two surgeons may only be co-surgeons on one primary procedure and any associated add-on codes or additional procedures if the two surgeons continue to act as co-surgeons performing distinct, separate parts of the same procedure.

  • If additional procedure(s), including add-on procedures, are performed during the same surgical session, separate codes may also be reported with modifier 62 added.
  • Per the AMA rules, you cannot append modifier 62 to the instrumentation or grafting codes.
  • If a co-surgeon acts as an assistant in performing additional procedure(s) during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or 82 added.
  • Do not report an 80 modifier with a 62 modifier when two surgeons are working together on co-surgery. It is implied within the description of the 62 modifier that each surgeon will be “assisting” with the procedure.
  • Report both the 62 modifier and the 50 modifier (bilateral procedure) when co-surgery is done by surgeons of the same specialty.
  • Append the 62 modifier to add-on codes the same way you would with any other co-surgery service.
  • Communicate with the staff of the other surgeon billing co-surgery so claims are submitted in the same time frame.

Documentation requirements for modifier 62

Additional reimbursement will be considered only when the documentation submitted clearly states the medical necessity of the co-surgery:

  • Each surgeon must document the separate procedures they are performing, or portions of procedures in individual op reports.
  • If multiple procedures are performed not all will necessarily meet the standard for co-surgery.
  • Billing must include the supporting documentation for use of modifier 62 versus modifier 80.

Modifier 73 – Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure prior to the administration of anesthesia
and Modifier 74 – Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure after administration of anesthesia

Modifiers 73 and 74 indicate a procedure in an outpatient hospital/ambulatory surgery center (ASC) setting that was cancelled after the patient’s surgical preparation.

  • Modifier 73 indicates the cancellation happened before the administration of anesthesia.
  • Modifier 74 indicates the cancellation happened after the administration of anesthesia and/or the initiation of the procedure.
  • QualChoice may request notes to determine the extent of services rendered.

For physician reporting of a discontinued procedure, see modifier 53.

Please refer to the CPT Manual for additional instruction.

Acceptable reasons for cancellation:

  • Due to extenuating circumstances; or,
  • Due to circumstances that threaten the life of the patient.

Do not use these modifiers to report an elective cancellation of the procedure.

Reimbursement for modifier 73 for all products is 50% of the base fee schedule. No reduction to reimbursement for modifier 74.

Modifier 76 – Repeat procedure or service by same physician or other qualified health care professional

To use this modifier, the repeated procedure must be exactly the same as the first and be performed on the same day.

If you are not sure who ordered the second procedure, or whether the same physician ordered both procedures, code them based on the physician who performed the procedures.

Modifier 76 indicates that a procedure or service was repeated in a separate session on the same day by the same physician.

  • May be reported for services ordered by physicians but performed by technicians
  • The procedure code is listed once, and then listed again with modifier 76 added (two line items)
  • The number of times that the procedure was repeated is reported on separate lines.

Example of modifier 76 use:

A physician orders an EKG 93000 (routine EKG with at least 12 leads; with interpretation and report). It is performed at 8:00 a.m. It is repeated at 1:00 p.m. Later, the patient’s condition requires a third EKG 93000, the same physician orders it and it is repeated at 10:00 p.m.

This is billed as 93000, one unit (first line) and 9300076, two units (next line).

Modifier 78 – Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period

Per the American Medical Association, modifier 78 is used when an unplanned return to the operating room occurs during the post-operative period of the initial or related procedure performed by the same physician or other qualified healthcare professional. A new global period does not begin for services reported with modifier 78.

Appropriate uses of modifier 78:

  • For complications of the original service that require a return to the operating or procedure room.
  • Appended to services with global surgery indicators of 000, 010, 090, YYY, or ZZZ if the service occurs on the same date of service or within the post-operative period of the initial or related service. 

Inappropriate uses of modifier 78:

  • Repeated or unrelated services
  • Staged or related procedure requiring a return to operating room
  • Different rendering provider 
  • Service falls outside of the global period of the original or initial service
  • Services without global period (indicators other than 000, 010, 090, YYY, or ZZZ)

Modifier 80 – Assistant surgeon
Modifier 81 – Minimum assistant surgeon
Modifier 82 – Assistant surgeon when qualified resident surgeon is not available

QualChoice follows CMS guidelines when determining if CPT code is eligible for reimbursement for an assistant at surgery:

  • Some services are not reimbursed for assistant surgeon services (identified by co-surgeon indicator
  • Documentation may be requested to support the need for an assistant surgeon.
  • The multiple procedure fee reduction applies the same way to an assistant at surgery as it would apply to the primary surgeon.
  • Indicating that a resident was not available is not sufficient support for reimbursing some assistant surgeon services.

Modifier uses:

  • CPT modifier 80, assistant at surgery. Includes MD, DO, and DPM provider types and is an assistant surgeon providing full assist to the primary surgeon.
  • CPT modifier 81, minimal assistant at surgery. Includes MD, DO, and DPM provider types and is an assistant surgeon providing minimal assistance to the primary surgeon. May be used when more than one assistant is involved or if one person assists during a portion of the surgery. Not intended for use by non-physician assistants (e.g., RN, PA).
  • CPT modifier 82, assistant at surgery when a qualified resident surgeon is not available to assist the primary surgeon. Includes MD, DO, and DPM provider types.
  • HCPCS Level II modifier AS, a non-physician assistant at surgery. Includes PA, CNS, CRNFA, RNFA, NP, LPN, DDS, DMD, and surgical technician provider types, subject to contract eligibility.

Modifier 90 – Reference (outside) laboratory

Modifier 90 is used when laboratory procedures are performed by a party other than the treating or reporting physician or other qualified health care professional, the procedure may be identified by adding modifier 90 to the CPT code. This modifier is used to indicate that although the physician is reporting the performance of a laboratory test, the actual testing component was performed by a laboratory. 

In general, payment for clinical laboratory tests subject to fee schedules is only made to the person or entity that performed the test. An exception to this policy allows payment to be made to one independent or hospital laboratory for tests performed by another lab under one of the following exceptions:

  • The referring laboratory is located in or is part of a rural hospital
  • The referring laboratory and the reference laboratory are subsidiary related
  • Not more than 30 percent of the clinical laboratory tests billed annually by the referring laboratory are performed in another laboratory, other than a subsidiary related lab.

QualChoice will only reimburse services submitted with CPT modifier 90 to the independent laboratory if one of the above exceptions applies. Physicians may not submit claims on behalf of laboratories for tests referred to these laboratories. QualChoice will not reimburse physicians for pass through laboratory billing when using modifier 90. 

Modifier 91 – Repeat clinical diagnostic laboratory test

Modifier 91 is used to report repeat laboratory tests or studies performed on the same day on the same patient. This modifier is added only when additional test results are to be obtained subsequent to the initial administration or performance of the test(s) on the same day, or when two different tests done on the same day are described by the same code. It is not used when laboratory tests or studies are simply rerun because of specimen or equipment error or malfunction. Nor is it to be used when a test is repeated to confirm initial test results. Further, based on the definition of modifier 91, it should not be reported when the basic procedure code(s) indicate that a series of tests are to be obtained. CPT codes for use with modifier 91 are in the laboratory code range 80047-89398.

Appropriate use of modifier 91

  • The appropriate use of modifier 91 is to identify a subsequent medically necessary laboratory test on the same day of the same previous laboratory test.

Inappropriate uses of modifier 91

Do not use modifier 91:

  • For a rerun of a laboratory test to confirm results
  • Due to testing problems for the specimen
  • Due to testing problems of the equipment
  • When another procedure code describes a series test
  • When the procedure code describes a series of test
  • For any reason when a normal one-time result is required

Modifier 95 – Synchronous telemedicine service

Rendered via real-time interactive audio and video telecommunication system. Please see Telemedicine Payment Policy in the Special CPT Coding section for proper use of Modifier 95.

Modifier XE – Separate encounter, a service that is distinct because it occurred during a separate encounter

Modifier XP – Separate practitioner, a service that is distinct because it was performed by a different practitioner

Modifier XS – Separate structure, a service that is distinct because it was performed on a separate organ/structure

Modifier XU – Unusual nonoverlapping service, the use of a service that is distinct because it does not overlap usual components of the main service

Use of X {ESPU} modifiers to replace modifier 59

The Centers for Medicare & Medicaid Services (CMS) has added four new modifiers to further define modifier 59—modifiers XE, XP, XS and XU. They are collectively known as X {ESPU} and are accepted for all lines of business on both professional and facility claims. They can be used instead of modifier 59, assuming the requirements for modifier 59 are met. These modifiers more effectively identify distinct services that are typically considered inclusive to another service. Using them ensures accurate coding that better describes the procedural encounter.

X {ESPU} modifiers are appropriate for National Correct Coding Initiative (NCCI) procedure-to-procedure edits only.

Do not use one of these modifiers on the same claim line with modifier 59. According to CPT guidelines, modifier 59 should be used only when no other descriptive modifier explains why distinct procedural circumstances exist. Therefore, the X {ESPU} modifiers should be used instead of modifier 59 to describe why a service is distinct.

Modifier Definition Description
XE Separate encounter Service that is distinct because it occurred during a separate encounter.
XP Separate practitioner Service that is distinct because it was performed by a different practitioner.
XS Separate structure Service that is distinct because it was performed on a different organ/structure.
XU Unusual non-overlapping service The use of a service that is distinct because it does not overlap usual components or the main service.