2. Coding with Modifiers
A Guide to Correct CPT®
and HCPCS Level II Modifier Usage
F O U R T H E D I T I O N
DEBORAH J. GRIDER
cpc,cpc-h, cpc-i, cpc-p, cpma, cemc, cpcd, cobgc, ccs-p
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3. Executive Vice President, Chief Executive Officer: James L. Madara, MD
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Copyright 2011 by the American Medical Association. All rights reserved.
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shall be responsible for, and expressly disclaims liability for, damages of any kind arising out of the use of,
reference to, or reliance on, the content of this publication. This publication is for informational purposes only.
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consult a professional advisor for such advice.
The contents of this publication represent the views of the author[s] and should not be construed to be the views
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Please visit www.ama-assn.org/go/Modifiers for potential updates.
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Literature code: BP03:11-P-077:12/11
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12. xi
Preface
A Current Procedural Terminology (CPT®) code set modifier is a two-digit code
reported in addition to the CPT service or procedure code that indicates that the
service or procedure was modified in some way. A modifier provides the means
by which a rendering physician may indicate that a service or procedure has been
performed, or has been altered by some specific circumstances, but not changed in
its definition or code. Understanding how and when to use CPT modifiers is vital
for proper reporting of medical services and procedures. The lack of modifiers or
the improper use of modifiers can result in claims delays or denials.
Modifiers are essential tools in the coding process. The American Medical
Association (AMA) developed modifiers to be used with its CPT code set to
explain various aspects of coding. Modifiers are used to enhance a code narrative
to describe the circumstances of each procedure or service and how it individually
applies to the patient. They are essential ingredients to effectively communicate
between providers and payers. Modifiers are also used as a method to accomplish
the following:
• Record a service or procedure that has been modified but not changed in its
identification or definition
• Explain special circumstances or conditions of patient care
• Indicate repeat or multiple procedures
• Show cause for higher or lower costs while protecting charge history data
• Report assistant surgeon services
• Report a professional component of a procedure or service
The ability of all users to recognize and accept CPT modifiers is important
for the implementation of the CPT coding system. While acceptance of CPT
modifiers is important, the subsequent step involving interpretation of modifiers
in a manner that is consistent with established CPT guidelines is also critical.
Modifiers can help the provider code for services more accurately and get paid for
the work performed.
Coding with Modifiers: A Guide to Correct CPT® and HCPCS Level II Modifiers
Usage, Fourth Edition, introduces the principles of correct CPT and HCPCS mod-
ifier usage and prepares the reader to accomplish the following objectives:
• Understand the purpose of modifiers
• Understand the relationship to the reimbursement process
• Understand logic trees related to modifier usage
• Understand how Medicare carriers and intermediaries vary on the use and
acceptance of modifiers
Coding with Modifiers is divided into 10 chapters organized by modifier. Each
chapter provides step-by-step guidance as to proper and improper use of CPT and
HCPCS modifiers through the use of clinical examples. Coding tips, checkpoint
exercises, and end-of-chapter exercises are also included to help the reader gain a
full understanding of a modifier’s correct usage. Mid-term and final examinations,
as well as PowerPoint slides and an answer key to the text’s exercises, appear on
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13. xii CODING WITH MODIFIERS
the CD that accompanies this text for educators or readers who want to apply and
build knowledge related to the material.
The text is designed to be used by community colleges, career colleges, and
vocational school programs for training medical assistants, medical insurance
specialists, and other health care providers. It can also be used as an independent
study training tool for new medical office personnel, physicians, independent
billing personnel, and any others in the health care field who want to learn
additional skills.
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14. xiii
About the Author
Deborah J. Grider is a Certified Professional Coder (CPC), a Certified Professional
Coder—Hospital (CPC-H), a Certified Professional Coder—Payer (CPC-P),
a Certified Professional Medical Auditor (CPMA), an E/M Specialist (CEMS), a
Certified OB/GYN Coding Specialist (COBGC), a Certified Dermatology Coding
Specialist (CPCD) with the American Academy of Professional Coders (AAPC),
and a Certified Coding Specialist—Physicians (CCS-P) with the American Health
Information Management Association (AHIMA). Her background includes many
years of practical experience in reimbursement issues, procedural and diagnostic
coding, and medical practice management.
Ms Grider teaches and consults with private practices, physician networks, and
hospital-based educational programs. Under a federal retraining grant, she helped
develop and implement a Medical Assisting Program for Methodist Hospital of
Indiana. She conducts many seminars throughout the year on coding and reim-
bursement issues and teaches several insurance courses and coding courses for
various organizations.
Ms Grider is a well-known national speaker on coding and revenue cycle issues
for physicians and hospitals. She was a national advisory board member for the
AAPC and past president of the National Advisory Board. Prior to becoming a
consultant, Grider worked as a billing manager for 6 years, and a practice manager
in a specialty practice for 12 years.
Deborah previously owned her own consulting firm and currently works with
Blue and Company, LLC, as a Senior Manager in the Revenue Cycle Advisory
Division. She continues to provide consulting and educational services to medical
groups, physician practices, and hospital organizations and provides coding train-
ing education to various organizations and medical societies.
Her professional affiliations include AAPC, AAPC National Advisory Board
member 2002–2005; President-Elect of the AAPC National Advisory Board 2005–
2007; President of the AAPC Advisory Board 2007–2009; member of AHIMA; and
member of the Indiana Medical Group Management Association (IMGMA) and
the Healthcare Financial Management Association (HFMA).
Grider has authored, among other titles, Principles of ICD-10-CM Coding
(AMA, 2012); Principles of ICD-10-CM Coding Workbook (AMA, 2012); Medical
Record Auditor, Third Edition (AMA, 2011); and Preparing for ICD-10-CM (AMA,
2010).
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16. xv
Acknowledgments
As I have authored multiple publications for the AMA, I want to specifically
acknowledge everyone at AMA who helped turn this book into reality. Thanks
to Grace Kotowicz, Contributing Coding Consultant, who lent her expertise and
helped me with the outpatient modifier chapter, and to Karen O’Hara, Senior
Coding Consultant, who helped me make changes along the way with her positive
and constructive comments.
Thanks also to my husband Jerry; my son Jerry; my daughter Robyn; and my
grandchildren—Tristan, Cassidy, and Delaney—who endured canceled appoint-
ments and outings and my late nights spent researching and writing. Without their
continued love and support, I could not have completed this project.
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18. 1
CHAPTER 1
Introduction to
CPT Modifiers
The American Medical Association (AMA) works to promote quality and correct
coding of health care services through its maintenance of the Current Procedural
Terminology (CPT
®) code set. The CPT code set is a listing of descriptive terms,
guidelines, and identifying codes for reporting medical services and procedures.
The purpose of the CPT code set is to provide a uniform language that accurately
describes medical, surgical, and diagnostic services and serves as an effective
means for reliable nationwide communication among physicians, patients, and
third parties.
The descriptive terms and identifying codes of the CPT code set serve a wide
variety of important functions. This system of terminology is the most widely
accepted nomenclature used to report medical procedures and services under
public and private health insurance programs. The CPT code set is also used for
administrative management purposes such as claims processing and developing
guidelines for medical care review.
CPT Code Set Development
The AMA first developed and published the CPT code set in 1966. The first
edition encouraged use of standard terms and descriptors to document proce-
dures in medical records, communicated accurate information on procedures
and services to agencies concerned with insurance claims, was the basis for a
computer-oriented system to evaluate operative procedures, and contributed basic
information for actuarial and statistical purposes.
The first edition of the CPT codebook published in 1966 contained primarily
surgical procedures with limited sections on medicine, radiology, and laboratory
procedures. The second edition in 1970 expanded to include diagnostic and thera-
peutic procedures in surgery, medicine, internal medicine, and the specialties. A
5-digit coding system replaced the former 4-digit classification. In 1977 the fourth
edition added significant updates in medical technology and a system of periodic
updating was introduced to keep pace with rapid changes in medicine. In 1983, the
CPT code set was adopted as part of the Healthcare Common Procedure Coding
System (HCPCS) developed by the Health Care Financing Administration (HCFA;
now the Centers for Medicare and Medicaid Services [CMS]). With this adoption,
CMS mandated the use of HCPCS to report services for Part B of the Medicare
program and in the Medicaid Management Information System. In July 1987, as
part of the Omnibus Budget Reconciliation Act (OBRA), the CMS mandated use
of the CPT code set for reporting outpatient hospital surgical procedures.
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19. 2 CODING WITH MODIFIERS
Today, in addition to use in federal programs (Medicare and Medicaid), the
CPT code set is used extensively throughout the United States as the preferred sys-
tem of coding and describing health care services.
HIPAA and CPT
The Administrative Simplification Section of the Health Insurance Portability and
Accountability Act (HIPAA) of 1996 mandated the Department of Health and
Human Services (HHS) adopt national standards for electronic transmission of
health care information, including code sets, national provider identifier, national
employer identifier, security, and privacy. The Final Rule for transmissions and
code sets was issued August 17, 2000. The rule names the CPT code set (including
codes and modifiers) and HCPCS as the procedure code set for the following:
• Physician services
• Physical and occupational therapy services
• Radiological procedures
• Clinical laboratory tests
• Other medical diagnostic procedures
• Hearing and vision services
• Transportation services including ambulance
The Final Rule also adopted the International Classification of Diseases, Ninth
Revision, Clinical Modification (ICD-9-CM) volumes 1 and 2 as the code set for
diagnosis codes; ICD-9-CM volume 3 for inpatient hospital services which will
be used until October 1, 2013. In 2013 the Final Rule (January 2009) adopted the
International Classification of Diseases, Tenth Revision, Clinical Modifications
(ICD-10-CM) as the code set for diagnosis codes and ICD-10-PCS for inpatient
hospital services; Current Dental Terminology for dental services; and the National
Drug Code directory for drugs.
All health care plans and providers who transmit information electronically
must use the established national standards. This Final Rule was implemented
October 16, 2003. The Final Rule mandated elimination of local codes for transi-
tion to national standard code sets. Information regarding elimination of local
code sets (HCPCS Level III) was published in a Program Memorandum by the
HHS and CMS January 18, 2002 (Transmittal AB-02-005), which is discussed later
in this chapter.
Who Maintains the CPT Code Set Nomenclature?
The AMA’s CPT Editorial Panel is responsible for maintaining CPT code sets. This
panel is authorized to revise, update, and modify CPT codes. The panel is com-
posed of 17 members as follows:
• Eleven members nominated by the AMA
• One member is representative of the Performance Measures
development organization
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20. 3
CHAPTER 1 ~ INTRODUCTION TO CPT MODIFIERS
• Two representatives from the Health Care Professionals Advisory
Committee (HCPAC)
• One physician nominated from the Blue Cross and Blue Shield Association
• One representative nominated by the Health Insurance Association
of America
• One representative nominated by the CMS
• One representative nominated by the American Hospital Association
The AMA’s Board of Trustees appoints the panel members. Of the 11 AMA
seats on the panel, 7 are regular seats, which have a maximum tenure of 2
4-year terms, or a total of 8 years for any one individual. The 4 remaining seats,
referred to as rotating seats, have 1 4-year term. The rotating seats allow more
multidisciplinary input.
The panel’s executive committee includes the chairperson, the vice chairperson,
and 3 other members elected by the entire panel. One of the 3 members-at-large of
the executive committee must be a third-party payer representative.
The AMA provides staff support for the CPT Editorial Panel and appoints a
staff secretary who records minutes of the meetings and keeps records.
Supporting the CPT Editorial Panel in its work is the CPT Advisory
Committee. Committee members are primarily physicians nominated by the
national medical specialty societies represented in the AMA House of Delegates.
The committee’s primary objectives are to:
• Serve as a resource to the CPT Editorial Panel by giving advice on procedure
coding and appropriate nomenclature as relevant to the member’s specialty
• Provide documentation to staff and the CPT Editorial Panel regarding the
medical appropriateness of various medical and surgical procedures under
consideration for inclusion in the CPT code set
• Suggest revisions to the CPT code set (The Advisory Committee meets
annually to discuss items of mutual concern and to keep abreast of current
issues in coding and nomenclature.)
• Assist in review and further development of relevant coding issues and prep-
aration of technical educational material and articles pertaining to the CPT
code set
• Promote and educate its membership on the use and benefits of the CPT
code set
The HCPAC was formed by the CPT Editorial Panel to allow for participation
of organizations representing limited license practitioners and allied health profes-
sionals in the CPT process. The co-chairperson of the HCPAC is a voting member
of the CPT Editorial Panel.
How Suggestions for Changes to the
CPT Code Set Are Reviewed
There are specific procedures for suggestions to revise the CPT code set by add-
ing or deleting a code or modifying existing nomenclature. AMA staff reviews
all correspondence to evaluate coding suggestions. If the AMA staff determines
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21. 4 CODING WITH MODIFIERS
the panel has previously addressed the question, the requestor is informed of the
panel’s interpretation.
If the request is a new issue or significant new information is received on an
item the panel has previously reviewed, the request is referred to the appropriate
member of the CPT Advisory Committee. If all advisors agree no new code or
revision is needed, the AMA staff informs the requestor on how to use the exist-
ing codes to report the procedure. If all advisors concur that a change should be
made, or if 2 or more advisors disagree or give conflicting information, the issue is
referred to the CPT Editorial Panel for resolution.
Current medical periodicals and textbooks are used to provide up-to-date
information about the procedure or service. Further data about its efficacy and
clinical usefulness are found in other sources, such as the AMA’s Diagnostic and
Therapeutic Technology Assessment Program and other technology assessment
panels. The AMA staff prepares agenda material for each CPT Editorial Panel
meeting. Medical specialty societies, physicians, hospitals, third-party payers, and
other interested parties may submit material for consideration by the Editorial
Panel. Panel members receive agenda material at least 30 days before each meeting,
allowing them time to review and confer with experts.
The CPT Editorial Panel meets each quarter and addresses complex problems
associated with new and emerging technology and the difficulties encountered
with outmoded procedures. The panel addresses nearly 350 major topics a year.
Panel actions may result in any of 3 outcomes:
• A new code is added or nomenclature is revised and appears in a forthcom-
ing volume of the CPT codebook
• An item is tabled to obtain further information, or
• The item is rejected
Because this is a multistep process, deadlines are important. The deadlines for
change requests and for Advisory Committee comments allows at least 3 months
of preparation and processing time before the issue is ready for review by the CPT
Editorial Panel. The initial step, including staff and specialty advisor review, is
completed when all appropriate advisors have been contacted and have responded
and all information requested of a specialty society or an individual requestor has
been provided to the AMA staff.
The requestor must have completed and submitted a coding change request
form. If the advisors’ comments indicate action by the CPT Editorial Panel is war-
ranted, a second step is taken by the AMA staff to prepare an agenda item that
includes a ballot for the request to be acted on by the CPT Editorial Panel. Once
the panel has taken action and minutes of the meeting are approved, the AMA
staff informs the requestor of the outcome. The requestor may appeal the panel’s
decision if the appeals process is followed:
• A written request for reconsideration is sent to the AMA staff within 10 days
of receipt of notice of the CPT Editorial Panel action.
• The request must address the reasons and/or instructions given in the notice
for the CPT Editorial Panel’s action.
• Requests for reconsideration are referred to the CPT Executive Committee
for an initial determination followed by referral (with or without recommen-
dation) to the CPT Editorial Panel for reconsideration.
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22. 5
CHAPTER 1 ~ INTRODUCTION TO CPT MODIFIERS
The CPT Process
No
Staff review
New issue or
significant
new information
received
Category II code
proposal to PMAG
PMAG agrees code
is necessary
PMAG agrees code
is not necessary
Editorial panel
action
Panel has already
addressed the issue
Letter to requestor
informing him or her
of correct coding
interpretation
Letter to requestor
informing him or her
of correct coding
interpretation
Advisors say give
consideration or
two specialty
advisors disagree
on code assignment
or nomenclature
Advisor(s) agree
no new code
or revision needed
Specialty advisors
Staff letter to
requestor informing
him or her of correct
coding interpretation
or action taken by
the panel
Postpone
for further
study
Reject
proposal
change
Add new code,
delete existing code,
or revise current
terminology
Published in CPT
codebook and on the Web
See editorial panel
action
Staff letter to
requestor
Rejected
Category II code
proposal
Measure suggestions
Measure developed
(input from specialty
societies)
Staff review
Coding suggestion
for Category I or
III codes
Request
information
Appeal
submission
Process
terminated
No
Yes
Executive committee
considers appeal
Process
terminated
Reconsidered
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23. 6 CODING WITH MODIFIERS
Category I CPT Codes
Category I CPT codes describe a procedure or service identified with a 5-digit
numeric CPT code and descriptor nomenclature. The inclusion of a descriptor
and its associated, specific 5-digit identifying code number in this category of
CPT codes is generally based on the procedure being consistent with contempo-
rary medical practice and performed by many physicians in clinical practice in
multiple locations.
When developing new and revised codes, the Advisory Committee and the
Editorial Panel require that the:
• Service or procedure has received approval from the Food and Drug
Administration (FDA) for the specific use of devices or drugs
• Suggested procedure or service is a distinct service performed by many phy-
sicians and practitioners across the United States
• Clinical efficacy of the service or procedure is well established and docu-
mented in US peer-reviewed literature
• Suggested service or procedure is neither a fragmentation of an existing pro-
cedure or service nor currently reportable by 1 or more existing codes, and
• Suggested service or procedure is not requested as a means to report extraor-
dinary circumstances related to the performance of a service or procedure
already having a specific CPT code
Category II CPT Codes: Performance Measurement
Category II CPT codes are intended to facilitate data collection by coding certain
services and/or test results that are agreed on as contributing to positive health
outcomes and quality patient care. This category of CPT codes is a set of track-
ing codes for performance measurement. These codes may be services typically
included in an evaluation and management (E/M) service or other component
part of a service and are not appropriate for Category I CPT codes. Consequently,
the Category II codes do not have relative values associated with them. The use
of tracking codes for performance measures will decrease the need for record
abstraction and chart review and minimize administrative burdens on physicians
and survey costs for health plans.
Category II codes are reviewed by the Performance Measures Advisory Group
(PMAG), an advisory body to the CPT Editorial Panel and the CPT/HCPAC
Advisory Committee. The PMAG is composed of performance measurement
experts representing the Agency for Healthcare Research and Quality (AHRQ),
the AMA, the CMS, the Joint Commission on Accreditation of Healthcare
Organizations (JCAHO), the National Committee for Quality Assurance (NCQA),
and the Physician Consortium for Performance Improvement (PCPI). The PMAG
may seek additional expertise and/or input from other national health care orga-
nizations, as necessary, for the development of tracking codes. These organizations
may include national medical specialty societies, other national health care profes-
sional associations, accrediting bodies, and federal regulatory agencies.
The CPT Performance Measurement codes are assigned an alphanumeric
identifier with the letter F in the last field (eg, 0514F). These codes are located
in a separate section of the CPT codebook, following the Medicine section.
Introductory language is placed in this code section to explain the purpose of the
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24. 7
CHAPTER 1 ~ INTRODUCTION TO CPT MODIFIERS
codes. The use of these codes is optional and not required for correct coding. The
following are examples:*
• 1002F Anginal symptoms and level of activity assessed (NMA – No
Measure Assessed)
• 1070F Alarm symptoms (involuntary weight loss, dysphagia, or gastrointes-
tinal bleeding) assessed; none present (GERD)5
• 2000F Blood pressure measured (CKD)1
(DM)2, 4
• 3017F Colorectal cancer screening results documented and reviewed (PV)1, 2
• 3125F Esophageal biopsy report with statement about dysplasia (present,
absent, or indefinite) (PATH)9
• 4005F Pharmacologic therapy (other than minerals/vitamins) for osteoporo-
sis prescribed (OP)5
• 5015F Documentation of communication that a fracture occurred and that
the patient was or should be tested or treated for osteoporosis (OP)5
• 6020F NPO (nothing by mouth) ordered (STR)5
• 7025F Patient information entered into a reminder system with a target due
date for the next mammogram (RAD)5
Requests for Category II codes are forwarded to the CPT/HCPAC Advisory
Committee, just as requests for Category I CPT codes are reviewed. The interests
of the PMAG are as follows:
• Measurement that is developed and tested by a national organization
• Evidence-based measurements with established ties to health outcomes
• Measurement that addresses clinical conditions of high prevalence, high
risk, or high cost
• Well-established measurements that are currently being used by large seg-
ments of the health care industry across the country
To expedite reporting Category II codes once they have been approved by the
CPT Editorial Panel, the newly added codes are made available on a semiannual
basis via electronic distribution on the AMA Web site (www.ama-assn.org/go/cpt).
The AMA’s CPT Web site features updates of the Category II codes in July and
January in a given CPT nomenclature cycle.
Category III CPT Codes: Emerging Technology
This section of the CPT codebook contains a temporary set of tracking codes
for emerging technologies, services, and procedures. Category III CPT codes
are intended to facilitate data collection on and assessment of these services and
procedures. These codes are used for data collection purposes to substantiate
widespread use or in the FDA approval process. Category III CPT codes need not
conform to the following usual CPT coding requirements for a Category I code:
• Services or procedures be performed by many health care professionals
across the country
• FDA approval be documented or imminent within a given CPT cycle
• The service or procedure has proven clinical efficacy
* Please note that the superscript footnote numbers in the above list correspond to sources
cited in CPT®
2012, Category II Codes.
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25. 8 CODING WITH MODIFIERS
The service or procedure must have relevance for ongoing or planned research.
These codes have an alphanumeric identifier with the letter T in the last field
(eg, 0078T). These codes are located in a separate section of the CPT codebook
following the Category II code section. Introductory language is placed in this
code section to explain the purpose of these codes. The following are examples of
Category III codes:
• 0078T Endovascular repair using prosthesis of abdominal aortic aneurysm,
pseudoaneurysm or dissection, abdominal aorta involving visceral branches
(superior mesenteric, celiac, and/or renal artery[s])
• 0099T Implantation of intrastromal corneal ring segments
• 0101T Extracorporeal shock wave involving musculoskeletal system, not oth-
erwise specified, high energy
• 0199T Physiologic recording of tremor using accelerometer(s) and/or
gyroscope(s) (including frequency and amplitude), including interpretation
and report
• 0207T Evacuation of meibomian glands, automated, using heat and inter-
mittent pressure, unilateral
• 0240T Esophageal motility (manometric study of the esophagus and/or
gastroesophageal junction) study with interpretation and report; with high
resolution esophageal pressure topography
Once approved by the Editorial Panel, the newly added Category III CPT codes
are made available twice a year via electronic distribution on the CPT page of the
AMA Web site (www.ama-assn.org/go/cpt). The full set of Category III CPT codes
is included in the next published edition for the CPT cycle.
Category III CPT codes are not referred to the AMA/Specialty RVS Update
Committee for evaluation because no relative value units are assigned. Payment
for these services and procedures is based on the policies of payment and not on a
yearly fee schedule.
These codes are archived after 5 years if the code has not been accepted for
placement in the Category I section of the CPT codebook, unless it is dem-
onstrated that a Category III code is still needed. These archived codes are
not reused.
The HCPCS Coding System
The CMS developed this system in 1983 to standardize the coding systems used
to process Medicare claims on a national basis. The HCPCS coding system is
structured in 2 levels: CPT nomenclature and national codes. (Level III local
codes were eliminated under HIPAA regulations.) Each level has its own unique
coding system.
Level I: CPT Nomenclature
Level I is the AMA’s CPT nomenclature. The CPT nomenclature makes up the
majority of the HCPCS. Most of the procedures and services performed by physi-
cians, physician extenders, and other health care professionals, even with respect
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26. 9
CHAPTER 1 ~ INTRODUCTION TO CPT MODIFIERS
to Medicare recipients, are reported with CPT code sets. The CPT code set nomen-
clature includes the following:
• Each procedure or service identified with a 5-digit numeric code or a
5-character alphanumeric code
• Two-digit numeric modifiers used (except for the Physical Status modifiers,
Genetic Testing modifiers, and Performance Measures modifiers)
• Codes revised and updated annually
• Updates and revisions become effective each January
• Revisions, additions, and deletions are prepared by the AMA’s CPT
Editorial Panel
Level II: National Codes
Level II national codes are assigned, updated, and maintained by CMS. Codes in
this level identify services and supplies not found in the CPT code set. Examples
of HCPCS Level II codes are durable medical equipment, ambulance services,
medical and surgical supplies, drugs, orthotics, prosthetics, dental procedures, and
vision services. The HCPCS Level II national codes are made up of the following:
• Five-character alphanumeric codes. The first character is a letter A through
V (except I) followed by 4 numeric digits (eg, J3488). (Note: The HCPCS “I”
codes are reserved for use by the Health Insurance Association of America
to fulfill member companies’ unique coding needs. The HCPSC “S” codes
are created and maintained by the Blue Cross Blue Shield Association for its
needs. The HCPCS “C” codes are used for reporting drugs and biologicals
for outpatient hospital services and not used in professional settings.)
• Alphabetic (eg, RT) and alphanumeric (eg, E2) modifiers.
Codes are updated annually by CMS and are required for reporting most medi-
cal services and supplies provided to Medicare and Medicaid recipients.
Level III: Local Codes
The HCPCS Level III codes have been eliminated. CMS eliminated local codes and
their descriptors developed by Medicare contractors for use by physicians, practi-
tioners, providers, and suppliers. The Level III HCPCS codes were alphanumeric
codes of 5 digits, in the W, X, Y, or Z series, that were not representative of HCPCS
Level I or II codes. The HCPCS Level III codes also contained 2-digit alphabetic
modifiers and were represented by WA through ZZ. The elimination of these codes
was necessary to prepare for full implementation of HIPAA. These codes were
eliminated effective October 16, 2003, because the local codes did not support the
objectives of HIPAA, which calls for an efficient coding system that meets uni-
form standards and requirements. The Consolidation Appropriations Act of 2001
(Public Law 106-554), enacted December 21, 2000, extended the maintenance and
use of the official HCPCS Level III codes and modifiers until December 31, 2003
(CMS Program Memorandum Transmittal AG-02-005). A copy of the transmittal
may be found at www.cms.hhs.gov. The local codes are no longer in use.
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27. 10 CODING WITH MODIFIERS
Modifiers
The CPT code set nomenclature uses modifiers as an integral part of its structure.
A modifier provides a means by which a practitioner can indicate a service or
procedure was altered by specific circumstances but not changed in its definition
or code.
Modifiers are essential tools in the coding process. The AMA developed
HCPCS Level I modifiers, which are numeric. The CMS developed HCPCS Level
II alphabetic modifiers to be used with codes to explain various circumstances
of procedures and/or services. Modifiers are used to enhance a code narrative to
describe the circumstances of each procedure or service and how it individually
applies to the patient. They are essential ingredients to effectively communicate
between providers and payers. Modifiers do not ensure reimbursement. Some
modifiers may increase reimbursement, whereas some are only informational.
Not only are there dozens of modifiers, but the rules for using them vary. For
example, a modifier may be used one way for physician services and another way
for hospital services.
A modifier provides the means to report that a service or procedure that was
performed was altered by some specific circumstance but not changed in its defini-
tion or code. Modifiers also enable health care professionals to effectively respond
to payment policy requirements established by other entities.
In the CPT code set nomenclature, modifiers may be used in many cases, such
as to report the following:
• Only the professional component of a procedure or service
• A service mandated by a third-party payer
• A service or procedure was performed bilaterally
• Multiple procedures were performed at the same session by the
same provider
• A portion of a service or procedure was reduced or eliminated at the
physician’s discretion
• Assistant surgeon services
• A service or procedure was performed by more than one physician, or
• A repeat clinical diagnostic laboratory test was performed
Example 1 shows when a modifier would be applicable.
Example 1
A chest X ray with 2 views was performed on a patient with suspected pneu-
monia. This service was performed in the outpatient radiology department of
the hospital. The radiologist is not employed by the hospital.
CPT Code(s) Billed: 71020 26 Radiologic examination, chest, 2 views,
frontal and lateral
Appending modifier 26 in Example 1 indicates the radiologist performed only
the professional component (reading the chest X ray and dictating the formal
report). Appending modifier 26 at the end of the code does not change the original
definition, but it indicates the total procedure was not performed by the physician,
only the reading of the film(s) and the interpretation and report.
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CHAPTER 1 ~ INTRODUCTION TO CPT MODIFIERS
Two surgeons might be required to perform a specific surgical procedure
together. When two surgeons work together as primary surgeons and perform dis-
tinct part(s) of a procedure, each surgeon should report his or her surgical work by
adding modifier 62 to the procedure code and any associated code(s) for that pro-
cedure as long as both surgeons continue to work together as primary surgeons.
Each surgeon reports the co-surgery once using the same procedure code. If addi-
tional procedure(s), including add-on procedure(s), are performed during the same
surgical session, separate code(s) may also be reported with modifier 62 added.
Example 2
Two general surgeons were performing a complete cystectomy with intesti-
nal anastomosis with a bilateral lymphadenectomy. One physician performed
the radical cystoprostatectomy, and the second surgeon performed the
bowel loop.
51595 Cystectomy, complete, with ureteroileal conduit or sigmoid
bladder, including intestine anastomosis; with bilateral pelvic
lymphadenectomy, including external iliac, hypogastric, and
obturator nodes
51595 62 Surgeon 1
51595 62 Surgeon 2
Each surgeon will report 51595 with modifier 62 (Two surgeons). Both physicians
are acting as primary surgeons. The total fee for 51595 is 125% of the fee schedule.
Each surgeon files on a separate CMS 1500 form with 51595-62, and each receives
a total of 62.5% of the fee schedule.
Example 3
A neurosurgeon and an otolaryngologist work together to perform a trans-
sphenoidal excision of a pituitary neoplasm. Each physician performs a distinct
part of the procedure.
CPT Code(s) Billed: 61548 62 Hypophysectomy or excision of pituitary
tumor, transnasal or transseptal approach, nonstereotactic
In this example, modifier 62 indicates to the insurance carrier that 2 surgeons
performed specific parts of the procedure, but it does not change the original defi-
nition of the code.
When billing the surgical procedure, each surgeon would bill by using the CPT
code 61548 with modifier 62.
61548 62 Neurosurgeon
61548 62 Otolaryngologist
THIRD-PARTY
PAYER CODING TIP
Keep in mind that
each insurance carrier
determines the amount
of reimbursement and
whether 2 surgeons
are allowed for a
particular procedure.
NOTE
If a co-surgeon acts as
an assistant in the per-
formance of additional
procedure(s) during the
same surgical session,
those services may be
reported by using sepa-
rate procedure code(s)
with modifier 80 or 82
added as appropriate.
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29. 12 CODING WITH MODIFIERS
Types of Modifiers Used in the Reimbursement Process
There are 2 levels of modifiers within the HCPCS coding system:
• HCPCS Level I (CPT modifiers)
• Category II modifiers
• Genetic testing modifiers
• HCPCS Level II (HCPCS modifiers)
HCPCS Level I (CPT Modifiers)
The CPT modifiers are 2-digit numeric and/or alphanumeric (as in the physical
status modifiers in anesthesia, the genetic testing modifiers, and the Category
II modifiers) designations that explain to an insurance carrier a change in the
description of the code without changing its meaning. The CPT Editorial Panel
determines the definition and guidelines for CPT modifier use on the basis of
input from the Advisory Committee. A complete listing of CPT modifiers and
their descriptors are in Appendix A.
Examples 4 and 5 show clinical cases that use HCPCS Level I (CPT modifiers).
Example 4
Modifier 24 Unrelated Evaluation and Management Service by the Same
Physician During a Postoperative Period
Definition: The physician may need to indicate that an evaluation and manage-
ment (E/M) 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.
A 35-year-old recreational skier injured his right knee, with peripheral longitu-
dinal tears of both medial and lateral menisci, and underwent an arthroscopic
meniscus repair using a suture technique. The CPT code used for this proce-
dure is 29883, and the global period in which the physician provides typical
follow-up care is usually 90 days with many insurance carriers.
The physician submitted a claim to the insurance carrier with the following
CPT code:
29883 Arthroscopy, knee, surgical; with meniscus repair (medial
AND lateral)
The patient returned to his orthopedic surgeon 3 weeks later for follow-up and
indicated that he was experiencing pain in the right shoulder. He told the sur-
geon he had gone to his garage to get a hammer and slipped and fell on the
floor, and he had been experiencing pain in the right shoulder since that time.
After an expanded problem-focused history and examination, the physician
determined the patient had sprained his right shoulder and provided the appro-
priate medication and treatment. The physician also examined the knee and
determined it was healing appropriately. The patient was advised to limit activi-
ties that would cause further injury.
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CHAPTER 1 ~ INTRODUCTION TO CPT MODIFIERS
The physician could bill for an E/M service in this example, because the reason
for the visit procedure (shoulder pain) was unrelated to the surgical procedure.
99213 Office or other outpatient visit for the evaluation and management
of an established patient, which requires at least 2 of these 3 key
components: An expanded problem focused history; An expanded
problem focused examination; Medical decision making of
low complexity
However, without a modifier, the carrier would consider the visit part of the
surgical global (package) procedure and might deny the visit. When modifier 24
is appended to the encounter with an unrelated diagnosis, the claim would be
reviewed and, in most cases, paid by the carrier. The visit should be submitted
with the use of modifier 24 (99213 24).
Example 5
Modifier 58 Staged or Related Procedure or Service by the Same
Physician During the Postoperative Period
A surgeon performed a radical mastectomy on the right breast with removal of
the pectoral muscles and axillary lymph notes on a 67-year-old female patient.
The patient preferred a permanent prosthesis after the surgical wound healed.
The surgeon took the patient back to the operating room during the postopera-
tive global period and inserted a permanent prosthesis.
The physician submitted a claim to the insurance carrier with the following
CPT codes:
19305 RT Mastectomy, radical, including pectoral muscles, axillary
lymph nodes
11970 58 RT Replacement of tissue expander with permanent prosthesis
The surgeon in this case reported the code for the permanent prosthesis inser-
tion 11970 with modifier 58 to indicate the service was related to the mastectomy
(staged to occur at a time after the initial surgery). Because the procedure was per-
formed on the right breast, a HCPCS modifier would be required to identify which
side of the body the procedure was performed on. The original procedure was
coded with modifier RT to identify the right breast.
Physical Status Modifiers
Physical status modifiers are consistent with the American Society of
Anesthesiologists ranking of the patient’s physical status; they distinguish at vari-
ous levels of complexity the anesthesia service provided. Appendix A and the
Anesthesia guidelines list the physical status modifiers used in anesthesia to con-
vey to the carrier the health and condition of a patient who is undergoing surgery
in relation to anesthesia.
Example 6 demonstrates when a physical status modifier might be appropriate.
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31. 14 CODING WITH MODIFIERS
Example 6
A 72-year-old woman with hypertension, type 1 diabetes mellitus, uncontrolled
chronic obstructive pulmonary disease, and a history of severe claudication in
both lower extremities was scheduled for diagnostic femoral arteriography and
venography under general anesthesia.
CPT Code Billed: 01916 P3 Anesthesia for diagnostic arteriography/
venography
Note that adding the physical status modifier P3 does not change the definition
of the code, but the modifier explains the complexity or risk involved with anes-
thesia because the P3 modifier indicates the patient has a severe systemic disease,
which puts the patient at higher risk than a patient who is healthy.
Example 7
A 45-year-old patient in good physical condition underwent a lumbar and ven-
tral (incisional) hernia repair under general anesthesia in the outpatient surgery
department of a local hospital.
CPT Code Billed: 00752 P1 Anesthesia for hernia repairs in upper
abdomen; lumbar and ventral (incisional) hernias and/or
wound dehiscence
In Example 7, adding the physical status modifier P1 indicates the patient is a
healthy patient with little risk.
The question always arises whether CPT modifiers can be used when Medicare,
Medicaid, and private health plans are billed. Medicare administrative contrac-
tors and fiscal intermediaries vary on the use and acceptance of modifiers listed in
the CPT codebook. Other commercial payers may accept only some CPT modi-
fiers. The same is true for private health care plans and managed care plans. It is
important to check with individual payers regarding their billing requirements.
Good sources for this information are the insurance carrier’s provider manual or
Web site.
HCPCS Level II (HCPCS Modifiers)
The HCPCS modifiers were developed by the former HCFA (now CMS) for use
in the Medicare program. Many carriers now accept HCPCS modifiers. However,
before HCPCS national modifiers (Level II) are used, providers should determine
whether specific carriers accept these codes. The HCPCS data set is updated and
published yearly and may be purchased from various publishers and bookstores
across the country. Because HCPCS codes and modifiers may change and be
added to throughout the year, it is prudent to check the CMS Web site regularly
(http://www.cms.gov/center/physician.asp). The complete listing of HCPCS modi-
fiers is provided in Appendix B of this book.
Each year in the United States, health care insurers process more than 5 bil-
lion claims for payment. For Medicare and other health insurance programs to
ensure that claims are processed in a consistent manner, HCPCS Level II codes
were developed. Level II is a standardized coding system used primarily to identify
NOTE
Not all carriers accept
the use of physical
status modifiers.
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CHAPTER 1 ~ INTRODUCTION TO CPT MODIFIERS
products, supplies, and services that are not included in the CPT code set. Level
II HCPCS codes were established for submitting claims for these services. The
development and use of Level II HCPCS began in the 1980s. The HCPCS Level II
codes are considered alphanumeric because they consist of a single alphabetic let-
ter followed by a numeric 4-digit code. In some cases, insurance carriers require
an HCPCS code of Level I or Level II be accompanied by a modifier to provide
additional information regarding the service, item, and/or procedure. Modifiers
are used when the information provided by the code descriptor needs to be supple-
mented to identify any special or unusual circumstances that may apply to the
item or service. These modifiers are alphanumeric or 2 letters.
Some HCPCS modifiers are located in Appendix A of the CPT codebook, but
a complete listing is found in the HCPCS Manual. It is strongly recommended
that an updated HCPCS coding manual be purchased each year because codes are
added and deleted yearly. The HCPCS modifiers are discussed in more detail in
Chapter 8.
Many carriers accept a combination of CPT and HCPCS modifiers. For exam-
ple, radiology services have a professional component and a technical component,
which are components of the CPT code, unless indicated in the code definition.
These modifiers split out the service provided by the physician (professional, 26)
and the facility, which includes the technician, supplies, equipment, and so on
(technical, TC).
When the provider bills the global component technical and professional, a
modifier is not required. Modifier TC is an HCPCS modifier, and modifier 26 is a
CPT modifier.
Level III Modifiers: Local Codes
The CMS eliminated local codes and their descriptors developed by
Medicare contractors for use by physicians, practitioners, providers, and
suppliers. These codes were eliminated effective October 16, 2003, and
providers were given 12 months to prepare for the discontinued use of the
codes. They were eliminated because the local codes did not support the
objectives of HIPAA, which calls for an efficient coding system that meets
uniform standards and requirements.
Level III modifiers were phased out December 31, 2003. These modifiers
and their guidelines were unique to each Medicare Part B contracted car-
rier. The Medicare contracted carrier is sometimes referred to as a fiscal
intermediary who defines use of a local modifier. Some examples of local
modifiers are W, X, Y, and Z. They are not described in this text.
Why Use Modifiers?
Modifiers explain to insurance carriers that the description of the code is the
same but something about the procedure or service was changed without chang-
ing the definition of the CPT code set. Some modifiers impact reimbursement,
whereas others are informational and help get the claim paid without costly delay.
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33. 16 CODING WITH MODIFIERS
Modifiers can be appended to a CPT code, further defining the service and, there-
fore, increasing the likelihood of accurate payment.
Using a modifier—a CPT or an HCPCS modifier—does not guarantee reim-
bursement. In some cases, the provider might be asked to provide a report and/
or documentation to support the service(s) billed. The report or documentation
should be complete, describing in detail the complexity of the patient’s problems
and/or physical findings with any therapeutic or diagnostic procedures. An accu-
rate diagnosis and any associated conditions and/or signs and symptoms should be
evident to the carrier.
If the medical record documentation does not support the modifier billed
by the provider, the provider risks denial of the claim and possible penalties for
submitting an incorrect claim. It is not necessary to become an expert in coding
modifiers; however, it is important to understand how to use modifiers correctly
along with which modifiers should be appended to the claim appropriately. Each
modifier will be explored individually with correct use, documentation require-
ments, carrier guidelines, clinical examples, and tips.
Surgical Procedures
When surgical procedures are billed, every procedure is connected to a global
period, which is 0 to 90 days and defined by each carrier individually.
The global period includes preoperative management, the surgical procedure,
certain types of anesthesia, and all typical follow-up care up to and including the
global period, sometimes referred to as global days.
If the patient requires care related to the surgery, routine follow-up care, dress-
ing changes, and so on, during the required postoperative period, the provider
cannot bill additional charges. They are included in the procedure. However, when
the service or procedure performed by the same practitioner and/or group is unre-
lated or is significantly separately identifiable, a modifier would indicate that the
service is not included in the procedure and/or service.
Example 8
A 30-year-old male, who was an established patient, came in for a follow-up
office visit for a 3-month history of fatigue, weight loss, and intermittent fever
and showing diffuse adenopathy and splenomegaly. A detailed history was
taken, including complaints and possible exposures such as sexual and travels
abroad. A comprehensive examination, including lymphatic and abdominal
examination, was performed. Medical decision making of moderate complexity
included discussion of possible diagnoses, possible diagnostic testing needed,
and importance of follow-up. During the encounter, the patient mentioned he
had a lesion on the right arm. The physician evaluated the 2.3-cm lesion, deter-
mined it was benign, and excised it.
Two separate encounters occurred during the visit: The patient came in with
multiple medical problems to be addressed, including fatigue, weight loss, inter-
mittent fever, and diffuse adenopathy and splenomegaly. The physician also
evaluated a lesion, determining it was benign but needed removal. The E/M
service and the lesion removal are significantly and separately identifiable, and
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CHAPTER 1 ~ INTRODUCTION TO CPT MODIFIERS
both services may be reported on the same day. Here is the correct way to submit
the claim:
99214 25 Office visit
11403 Benign lesion excision
The descriptions of the codes selected are as follows:
99214 Office or other outpatient visit for the evaluation and management
of an established patient, which requires at least 2 of these 3 key
components: A detailed history; A detailed examination; Medical
decision making of moderate complexity
11403 Excision, benign lesion including margins, except skin tag (unless
listed elsewhere), trunk, arms or legs; excised diameter 2.1 to
3.0 cm
The CPT modifier 25 is appended only to the E/M service when the physician
needs to indicate an E/M service was performed and it was a significant, sepa-
rately identifiable E/M service performed on the same day as another procedure
or service. The physician may need to indicate that on the day a procedure or ser-
vice 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 performed. A significant, separately identifiable service is defined or
substantiated by documentation that satisfies the relevant criteria for the respective
E/M service to be reported.
Without modifier 25 (Significant, Separately Identifiable Evaluation and
Management Service by the Same Physician on the Same Day of the Procedure or
Other Service), the claim would most likely be denied on the basis of the initial
claim submitted, even with a different diagnosis. Modifier 25 will be discussed in
further detail in Chapter 3.
Modifiers and Reimbursement
Coding has become an integral part of any hospital or medical practice. It is com-
plex and constantly changing, and there are stiff penalties for incorrect coding.
Accurate coding is the antidote to the decline in the reimbursement rate.
Using modifiers does not always mean payers will recognize or accept them.
Reimbursement policy has been developed through consideration of the AMA’s
CPT code set and instructions with many insurance carriers. Many payers develop
their own payment policies that differ from CPT guidelines. Before submitting
claims, it is beneficial to discuss modifier use with the payer to determine if the
individual carrier has developed a separate policy from CPT guidelines.
The CMS uses the resource-based relative value scale (RBRVS) and recommen-
dations from the National Correct Coding Initiative (NCCI). With rare exceptions,
reimbursement policy may also be developed on the basis of input from external
provider consultants, contract language, and benefits.
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35. 18 CODING WITH MODIFIERS
RBRVS Payment Rules and Policies
The RBRVS payment system required the development of national payment poli-
cies and their uniform implementation by Medicare carriers. Under customary,
prevailing, and reasonable payment, each Medicare carrier established its own
policies, including issues such as which services were included in the payment for
a surgical procedure. As with the elimination of specialty differentials and cus-
tomary charges, there was no transition period for standardizing carrier payment
policies under the RBRVS payment system. Standardization of payment policies
became effective January 1, 1992.
One of the most significant standardization provisions included in the OBRA of
1989 was the requirement that CMS adopt a uniform coding system for Medicare.
In the June 1991 Notice of Proposed Rulemaking, CMS stated the AMA’s CPT
code set would serve as that uniform system. The CPT code set includes more
than 8000 codes to describe physicians’ services, including codes for E/M services
that became effective January 1, 1992. These codes are used to describe visit and
consultation services and were developed for use under Medicare’s RBRVS-based
payment system.
In addition to the 5-digit CPT codes, CMS recognizes other alphanumeric
codes for some nonphysician services and supplier services, such as ambulance
services. Together, the CPT code set and the alphanumeric codes compose
the HCPCS.
In addition to coding, CMS established a multitude of national policies as part
of the revisions to the payment system, including uniform national policies on
payment for the following:
• Global surgical packages
• Medicare Physician Fee Schedule
• Assistants at surgery
• Assistants at surgery in a teaching hospital
• Incident-to services
• Modifier usage
• Supplies and drugs
• Technical component-only services
• Diagnostic tests
• Nonphysicians’ services
• Several other aspects of Medicare Part B
It is important for physicians to understand that the carriers are required to
implement these policies in a nationally uniform manner. Carriers do not have an
option to develop a different policy for their local areas.
The CMS sets national guidelines, but individual insurance carriers may inter-
pret guidelines for their own organizations or regional offices. The CPT and/or
HCPCS modifiers accepted for use by one insurance company may not be accepted
by another company. Also, their interpretations of a modifier may differ. Local
carrier guidelines should be reviewed before a modifier is used.
Nonrecognition of modifiers is an important issue and significantly impacts
physician reimbursement and the administrative burden for physicians. Because
the modifier list is published, physicians justifiably presume modifiers will be
recognized and they will be reimbursed for medically necessary and appropriate
services. When claims are not paid appropriately, the physician must endure time-
consuming, costly, and often futile efforts through the appeals process.
THIRD-PARTY
PAYER CODING TIP
Not all modifiers will
increase reimbursement,
but they may explain
to a carrier that the
claim being submitted
is different.
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CHAPTER 1 ~ INTRODUCTION TO CPT MODIFIERS
Third-party payers define their own policy for the acceptance of modifiers,
and the coder and/or practitioner must review each carrier’s acceptance of a
particular modifier.
The CPT modifiers are used to describe special circumstances under which the
basic service was provided. With implementation of the Medicare RBRVS, the use
of modifiers was standardized to establish national payment policies.
The instructional notes pertaining to reporting 5-digit modifiers have been
deleted from the CPT code set to coincide with the CMS-1500 claim form report-
ing instructions because the instructional notes conflicted with the previous
instructions in the CPT code set regarding use of a separate 5-digit modifier.
According to the National Uniform Claim Committee, the electronic claim
format for the CMS-1500 claim form, in compliance with regulations that apply to
HIPAA, will not accommodate a 5-digit modifier. The current field length of the
electronic format that holds a modifier is limited to 2 characters.
The Proper Use of Modifiers: Step by Step
To appropriately code with modifiers, the health care organization should include
commonly used modifiers on charge tickets, superbills, encounter forms, and
the electronic health record. Even though they may be listed appropriately, not
all practitioners will use them correctly without guidance and training. Careful
documentation is the key to supporting the use of modifiers. Every claim with
modifiers should be reviewed to make sure the documentation, if requested by the
insurance carrier, will support the claim. Practitioners should take a preventive,
proactive approach rather than wait until a claim is denied to take action. The fol-
lowing is a checklist of steps to take when coding modifiers:
• Review CPT (AMA) guidelines.
• Review HCPCS guidelines.
• Review individual carrier guidelines.
• Refer to the practitioner’s or facility’s patient medical record and/or visit note
before appending modifiers.
• Use only 2 digits when appending modifiers (unless instructed otherwise
by an individual carrier); with implementation of standard code sets with
HIPAA, 5-digit modifiers are no longer accepted.
• Provide training for physicians, staff, clinicians, and others, and update
training regularly.
• Take a proactive approach and find the errors in modifier application before
the claim is submitted to the insurance carrier.
• Understand that insurance carrier interpretations are not always the same as
the interpretations in the CPT codebook.
• Review the NCCI guidelines each quarter for correct modifier use for each
CPT code that your organization uses.
The CMS accepts the use of CPT modifiers, but not all private insurance carri-
ers recognize modifiers. Interpretation of a modifier may be defined by individual
carriers. Practitioners’ offices should develop a system of tracking denials based on
the use of modifiers.
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37. 20 CODING WITH MODIFIERS
Tips for Using Coding Modifiers Correctly
• Always have the most recent edition of the CPT codebook on hand.
• Have billing staff regularly attend coding workshops.
• Remember modifiers are often used differently for physician services
and hospital outpatient services.
• Learn as much as you can about using coding modifiers so you can help
billing staff with coding questions.
• Keep up-to-date on coding changes and modifier interpretations.
• Obtain the NCCI guidelines regarding the policy on correct modifier
use for government payers and other commercial payers who follow
the NCCI.
• Communicate with the individual payer regarding policy and use
of modifiers.
Chapter 1 Review
• Level 1 (CPT) modifiers are 2-digit extenders that are appended to a
CPT code.
• Modifiers explain to a carrier that the descriptor of the CPT code has not
changed but has been modified to explain unusual circumstances.
• Modifiers appended to the CPT code designate the need for
additional consideration.
• Some modifiers are informational, whereas others affect
proper reimbursement.
• To support coding with modifiers, the practitioner’s documentation must
clearly support the circumstance.
• The HCPCS modifiers are used by some carriers to designate specific
information, such as RT for right and LT for left.
• The HCPCS Level I and Level II modifiers may not be recognized by all
insurance carriers.
• Understanding modifiers, updating code manuals, and ongoing training
are the keys to correct coding with modifiers.
References
American Medical Association, Current Procedural Terminology: CPT® 2012 (Chicago:
American Medical Association, 2011).
Medicare Carrier’s Manual Publication 100-4, available at www.cms.hhs.gov/physicians.
National Correct Coding Initiative Guidelines, available at www.cms.hhs.gov/
NationalCorrectCodInitEd/NCCIEP/list.asp.
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38. 21
CHAPTER 1 ~ INTRODUCTION TO CPT MODIFIERS
Test Your Knowledge
1. CPT modifiers are published by the:
a. Centers for Medicare and Medicaid Services (CMS).
b. Centers for Disease Control and Prevention (CDC).
c. American Medical Association (AMA).
d. local fiscal intermediary.
2. Modifiers are:
a. 2-digit extenders.
b. numeric only.
c. used only to track diseases.
d. none of the above.
3. The HCPCS modifiers are Level:
a. II.
b. I.
c. III.
d. IV.
4. Level I modifiers are published by the:
a. CMS.
b. AMA.
c. CDC.
d. Medicare administrative contractors.
5. These Level 1 modifiers were introduced in 2006 to indicate:
a. genetic testing.
b. physical status.
c. performance measures inclusions and exclusions.
d. none of the above.
6. Modifiers explain:
a. that a code has changed in its definition.
b. that a code has not changed in its definition but has
been modified.
c. that reimbursement should be higher.
d. b and c.
7. What is an antidote to an incorrect reimbursement rate?
a. Modifiers
b. Unbundling
c. Billing claims during the global period
d. Accurate coding
8. To append a modifier to a claim, you should:
a. review CPT guidelines only.
b. review CPT and carrier guidelines for interpretation.
c. bill without regard to carrier rules.
d. do none of the above.
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39. 22 CODING WITH MODIFIERS
9. Level II modifiers are:
a. published by the AMA.
b. published by the CMS.
c. published by each individual state.
d. a and b.
10. CPT modifiers are:
a. Level I modifiers.
b. Level II modifiers.
c. Level III modifiers.
d. Level IV modifiers.
True or False
11. Modifiers always affect reimbursement.
12. Category III codes were developed to report emerging technology.
13. HCPCS Level II modifiers are numeric.
14. Level II National codes are maintained by the American
Medical Association.
15. CPT performance measures are assigned an alphanumeric identifier
with the letter F in the last field.
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