CPT Modifiers: How Was Your Visit to the Doctor?

cpt modifiersCurrent Procedural Terminology modifiers, or CPT modifiers, refer to a code book of medical procedures that contain descriptions and codes of procedures, organized by a body system. In the CPT manual, the first section contains codes of evaluation and management (E/M) used for billing encounters with a physician, whether in a hospital, office or outpatient setting.

There are also sections in the CPT which cover procedures of radiology, medications, lab tests and pathology. Along with the icd-9 code book of conditions and diseases to bill third party payers for medical services reimbursements, this code book is used as well. Here is a course you might be interested in entitled Basics of Health Insurance that consists of an e-learning module to help you understand various health insurance types.

Also called Level 1 modifiers, CPT modifiers are used to adjust the description or supplement information providing additional details that concern a service or a procedure provided by physicians. The CPT system was developed by the American Medical Association or the AMA and the modifiers that can themselves be attached to the codes. In the process of reimbursement, modifiers play a huge role.

Attaching the right modifier helps in ensuring that the claims of reimbursement sent to providers of insurance will go through successfully. In claims forms, modifiers appear in the same box as the codes for CPT. By the way here is a course entitled Jump Start: Primary Medicine for Allied Health Professionals which you might want to check out.

Modifiers

To add more information on the claim, aside from a CPT code, modifiers are used. These modifiers state particular circumstances that affect the amounts the physicians will get reimbursement. Modifiers are used for management and evaluation as well as codes of procedure.

To receive a claim’s full reimbursement, documentation of special circumstances is sometimes required. However, there are varied guidelines from one payer to the next. By the way here is an article you might be interested in entitled Understanding Health Insurance: Are you covered?

Common CPT Modifiers

The modifier -26 means that only the service’s professional component was performed. One example is when a the results of a patient’s x-ray performed at another location was being read to him by a physician. He would thus be billed only for this professional component.

Mandated services such as a worker’s compensation evaluation and pre-employment drug screens would require the use of a modifier -32. A modifier -51 is used for identifying multiple performed procedures while a modifier -52 states that there were reduced services done.

A modifier -53 indicates a discontinued procedure. Surgical care only is referred to by a -54 modifier. A -56 is for pre-operative care only and a -55 is for postoperative care only. A modifier -58 is attached to a related or a staged procedure by the same physician during the period of post-op.

Anesthesia Modifiers

To add information to codes of anesthesia, there are several available modifiers. A modifier -23 notes that what was used was unusual anesthesia. A modifier -47 is used when the physician administers the anesthesia.

E/M Modifiers

E/M modifiers stand for Evaluation and Management modifiers which are used for noting a special circumstance of an encounter that a patient had with a doctor. Common modifiers of E/M include -57, -25, -24 and -21. . The modifier -27 identifies separate evaluations of a physician in the same visit for problems that are unrelated. For instance, if patients are seen for routine checks of blood pressure and complains of pain in his foot, these E/M services would be reported with 2 codes of CPT.

The modifier -57 states that it was during an office visit that the decision for surgery was made while the modifier -25 would be listed on the second code of procedure. Modifiers -24 and -25 refer to medical unrelated visits. The modifier-24 was for an office visit billed during a period that was postoperative not related to the operation. The modifier -25 identifies separate evaluations of physicians for unrelated problems in the same visit.

Bilateral Modifiers

When a bilateral modifier is indicated, or -50, this means that it was on both sides that a procedure was done. Usually, a modifier like this one is used for procedures on limbs, ears and eyes. It can also be used for procedures involving lungs and kidneys.

Other CPT Modifiers

When 2 surgeons perform a procedure, a -62 modifier is used. When physicians are performing procedures on infants that weigh under four kilograms, they use a -63 modifier. When a procedure was performed by a medical team, the modifier -66 is used.

When a procedure has been repeated by a different physician, a -76 modifier is used. When there had been an unplanned return to the operating room after the first procedure, a modifier -78 is used. A modifier -79 identifies performed unrelated procedures done by the same physician during the post-op period. If an assistant surgeon performed the procedure, the -80 modifier is used.

For lab tests and pathology, the modifiers -92, -91 and -90 are used. To show that on the claim there are multiple modifiers being used, this would be indicated by a modifier -99 and is only used on the first code of CPT that the claim lists. Here is a course entitled How to Re-Claim Payment Protection Insurance that will help you avoid the need for expensive claims companies and navigate the process of claims with relative ease.

Code Changes

The CPT AMA panel meet several times a year to discuss changes in health care. Existing codes are revised or new codes are developed for new services. When necessary, there are released addendums to the code book. Each year, the entire CPT code book is reissued and updated.

Considerations

At times, there is a requirement of using two or more modifiers to depict a procedure or service fully. For instance, in the case where an assistant surgeon performed a bilateral procedure on a patient when the resident surgeon was not available. In this case, two modifiers would be used, -50 for bilateral procedures and -82 for assistant surgeon.

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