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Coding Consult: Get the most out of modifiers


Get the most out of modifiers


Coding Consult

Get the most out of modifiers

By Fred Chafin, CPC

You've probably heard a lot about how the accurate use of modifiers can increase your income. Fortunately, it takes only a few minutes for you and your staff to learn how to use these valuable coding tools.

To prompt yourself to use modifiers, when appropriate, alter your encounter form by adding a column next to the one for the CPT code. While you're at it, add a column for ICD-9-CM diagnosis codes, as well. So your new encounter form would contain these columns: CPT code/Modifier/Description/ICD-9-CM/Fee.

Here are examples of how to use the most common modifiers:

–25Significant, separately identifiable E&M service on the same day as a procedure or other service. This is primary care's most frequently used modifier. It allows you to bill for a procedure plus an office visit on the same day.

When insurance companies evaluate claims that use this modifier, they review the "separately identifiable" requirement. In other words, they ask whether the E&M service is above and beyond the basic protocol for performing the procedure itself.

They also want proof that the E&M service was "significant." Many carriers require enough documentation to support the equivalent of a 99213. (Of course, this is in addition to documentation related to performance of the procedure.)

Example: You examine a patient and discover prostate nodules, though you can't make a certain diagnosis. So you order a biopsy. How do you bill this visit? Bill for the biopsy, then select the appropriate E&M code for the office visit, and append modifier –25. This modifier allows you to get paid your full fee for both codes.

–26Professional component. Certain procedures are a combination of physician and technical components. When the physician component is claimed separately, you may report the service by adding modifier ­26.

Example: You're called to the emergency room at 3 am to diagnose and treat a patient who is presenting with respiratory problems. You suspect pneumonia. After examining the patient, you order an X-ray. Because a radiologist is not available, you bill for the X-ray interpretation using –26. You'll need to prepare a separate, signed report of your interpretation.

–53Discontinued procedure. Example: You attempt a sigmoidoscopy, but even using your smallest instrument, you're unable to enter the colon. So you stop the procedure.

Submit your bill at your full fee with the addition of modifier –53. Along with your documentation, include a cover letter explaining why you discontinued the procedure.

Another example: You're unable to complete excision of subcutaneous birth control implants. Let's say you're able to remove only three of the six implants before the patient experiences edema and pain. The rest will require anesthesia and surgical removal.

In this situation, you can bill the procedure at your full fee with the addition of modifier –53. Your reimbursement should be between 75 and 100 percent of your normal fee.

If you later complete the procedure, bill for it a second time. You should receive your full fee. If you perform the second attempt under anesthesia on the same day, add modifier –59 to the claim. (More on –59 below.)

–55Postoperative management only. This modifier allows you to share in a surgical fee if you provide the postoperative follow-up.

Example: You refer a patient to a surgeon in another town. It will be difficult for the patient to see the surgeon for follow-up, so the surgeon agrees for you to do it.

To get paid, simply bill the CPT code for the surgery and append modifier –55. The postoperative fee for most surgical procedures is 10 percent of the procedure reimbursement.

The only other requirement is for the surgeon to append modifier –54 to the surgical procedure code. This indicates that he's billing for surgery only, thus allowing you to bill for the postoperative services.

–59 Procedures and services not normally reported together. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or a separate injury not ordinarily encountered on the same day by the same physician.

Example: You treat a patient for an upper respiratory infection. Since the patient is overdue for a breast/pelvic exam, you perform one during the same office visit. Append modifier –59 to the code for the breast/pelvic exam. Expect to be reimbursed at 50 percent of the allowable fee.

–76 Repeat procedure by same physician. Use this modifier if you need to repeat an X-ray, ECG, or other service.

Example: You order an ECG but decide that the results look wrong, so you have the procedure repeated. Add modifier –76 to the second test in order to receive payment for both. You can also use the modifier if you re-order a test to monitor responses to medications or changes in symptoms.

–77Repeat procedure by another physician.Example: Dr. A orders an ECG and leaves at noon. Dr. B, another member of the group, reviews the test results and decides they're not reliable. So he has the test repeated. By adding modifier –77 to the second test, your group stands a better chance of being reimbursed for both attempts.

–91Repeat clinical diagnostic laboratory test. This relatively new modifier is used to report a lab test that's repeated on the same day in order to obtain subsequent results.

Example: Say you need to repeat a test for serum creatinine to diagnose renal insufficiency. Similarly, you may want to order multiple tests on a given day for blood sugar values after administration of medication to lower elevated glucose. Append modifier –91 to claims for the later tests.

The author, a certified professional coder, is a consultant and seminar leader for McVey Associates (mcveyseminars.com), an insurance reimbursement consulting company in Novato, CA. This department answers common coding questions. Since coding rules frequently change and are subject to interpretation by insurance carriers, decisions should be made in light of individual circumstances, local conditions, payer policies, contracts, and new or pending governmental policies. We welcome your questions for future columns. Please submit them to mecode@medec.com. Sorry, but we're not able to answer readers individually.


Fred Chafin. Coding Consult: Get the most out of modifiers. Medical Economics 2001;15:18.

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