The document provides an overview of medical coding modifiers used in healthcare billing, particularly focusing on CPT and HCPCS Level II modifiers. Modifiers convey additional information about procedures or services without altering the original code's meaning and are essential in various billing scenarios. A wide range of specific modifiers are detailed, each with its distinct application and requirements, including documentation necessary for modifiers like KX and 59.

1. Name: Muhammad Aqib Javed
Scholar of MPH
University: Khyber Medical University
Contact email: muhammadaqibjaved05@gmail.com

2. MODIFIERS
Introduction:
A medical coding modifier is two characters (letters or numbers) appended to
a CPT or HCPCS Level II code.
The modifier provides additional information about the medical procedure, service,
or supply involved without changing the meaning of the code.
On the CMS 1500 claim form, the appropriate field is 24D .You enter the modifier
directly to the right of the procedure code on the claim.

3. WHEN OR WHY IS APPROPRIATE TO USE A
MODIFIER?
The service or procedure has both professional and technical components.
More than one provider performed the service or procedure.
More than one location was involved.
A service or procedure was increased or reduced in comparison to what the code
typically requires.
The procedure was bilateral.
The service or procedure was provided to the patient more than once.

4. TYPES OF MODIFIERS:
CPT MODIFIERS(INFORMATIONAL MODIFIERS)
CPT modifiers are generally two digits,
They are not primarily for determining payment, unlike payment modifiers,
These modifiers are added after pricing modifiers on a medical claim,
CPT Category II codes are alphanumeric.
Examples: 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.
59: Distinct procedural service at the same day.

5. HCPCS LEVEL II MODIFIERS
(PRICING MODIFIERS)
HCPCS Level II codes and modifiers are maintained by the Centers for Medicare &
Medicaid Services (CMS). HCPCS Level II modifiers are alphanumeric or have two
letters.
examples
E1: Upper left, eyelid
TC: Technical component
XU: Unusual non-overlapping service, the use of a service that is distinct because it
does not overlap usual components of the main service

6. Modifier KX AND MODIFIER 53
•KX: It indicates that the provider providing a particular service according to the
medical condition and service is met according to the payer's policy.
•Documentation: When using the modifier KX, the provider must have
documentation supporting that the service meets coverage criteria.
•For example, If a physical therapist provides an additional treatment that exceeds
the usual limit, they might use the modifier KX to show that the extra service is
medically necessary and meets the insurer’s criteria.
•53 Indicates the physician elected to terminate a surgical or diagnostic procedure
due to the patient's well-being. Or terminate the procedure due to failed service.

7. MODIFIER 59: DISTINCT
PROCEDURAL SERVICE
1. To be used only on procedure codes, never E/M services.
2. The procedure code was a distinct or separate service from other services
performed on the same day.
3. It is an anatomical modifier (there is no other available anatomical modifier to
show that the procedure was a separate service from other services performed the
same day.
4. It is a multiple procedure modifier.
*IMP… When using modifier 59, append it to the first CPT code.

8. GENERAL MODIFIERS AND
THEIR USE:
59 Distinct Procedural Service identifies procedures/services not normally
reported together, but appropriately billable under the circumstances
63 Procedure Performed on Infants less than 4 kg
66 If a team of surgeons (more than two surgeons of different specialties) is
required to perform a specific procedure, each surgeon bills for the procedure
with a modifier "-66"
74 Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC)
Procedure after administration of anesthesia
76 Repeat Procedure by the *Same Physician; use when it is necessary to report
that repeat procedures performed on the same day

9. CON…
22 Increased Procedural Service requiring work substantially greater than
typically required
24 Unrelated evaluation and management (E/M) service by the same
physician* during a postoperative period
25 Significant, separately identifiable evaluation and management (E/M)
service by the same physician* on the day of a procedure
27 Multiple Outpatient Hospital E/M Encounters on the Same Day (Not
required by CMS and not to be used by physicians for reporting of
multiple E/M services)
52 Reduced Service reports a partially reduced or eliminated service or
procedure.

10. CON…
90 Reference (Outside) Laboratory
99 Multiple Modifiers are required on one line of service
57 Indicates an Evaluation and Management (E/M) service resulted in the initial
decision to perform surgery either the day before a major surgery (90-day
global) or the day of a major surgery
58 Indicates a staged or related procedure or service by the same physician*
during the postoperative period
77 Repeat Procedure by another physician
79 Unrelated procedure by the same physician during the postoperative period

11. CON…
GY Statutorily excluded service - If the service provided is statutorily excluded
from the Medicare Program, the claim will deny whether or not the modifier
is present on the claim
GZ The provider or supplier expects a medical necessity denial; however, did not
provide an Advance Beneficiary Notice of Noncoverage (ABN) to the patient
Q5 Service furnished by a substitute physician under a reciprocal billing
arrangement
Q6 Service furnished by a fee-for-time compensation arrangements physician

12. CON…
AQ Services provided in a Health Professional Shortage Area (HPSA)
CR Emergency health care needs of beneficiaries and providers affected by
Hurricane Katrina and any future disasters
GA The provider or supplier has provided an Advance Beneficiary Notice of
Noncoverage (ABN) to the patient and has a signed copy on file
GO Services delivered under an outpatient occupational therapy plan of care

13. MOSTLY USED FOR LAB BILLING
QW The QW modifier is used in laboratory procedure coding, specifically to
indicate that a test was performed by a Clinical Laboratory Improvement
Amendments (CLIA)-waived laboratory.
GV Used when the service is related to the hospice condition but provided by
an unaffiliated provider. Like consultation from a Cardiologist.
GW Service not related to the hospice patient's terminal condition e.g. A hospice
patient with terminal cancer visits a dermatologist for an unrelated skin
condition. The visit would be billed with a modifier

14. MOSTLY USED FOR DPT
CB When therapy services exceed the annual therapy cap set by Medicare, providers can
request an exception based on medical necessity. If the exception is granted, the CB
modifier is used on the claim to indicate that the services qualify for payment beyond
the cap.
GN Modifier GN is specifically used for Medicare outpatient physical therapy
services to denote services under an outpatient care plan.
GP Services are delivered under an outpatient physical therapy plan of care for
different payer.
25 Significant, separately identifiable evaluation and management (E/M) service by
the same physician* on the day of a procedure.
59 Distinct Procedural Service identifies procedures/services not normally reported
together, but appropriately billable under the circumstances

15. ANESTHESIA DOCUMENTATION
MODIFIERS
AA Anesthesia services performed personally by an anesthesiologist.
QK Medical direction by a physician of two, three, or four concurrent anesthesia
procedures involving qualified individuals.
AD Medical Supervision by a physician, more than four concurrent anesthesia
procedures.
QY Medical direction of one CRNA/AA (Anesthesiologist's Assistant) by an
anesthesiologist.
QX CRNA/AA (Anesthesiologist's Assistant) service with medical direction by a
physician.
QZ CRNA service without medical direction by a physician.