CPT modifier may describe whether multiple procedures were performed, why that procedure was necessary, where the procedure was performed on the body, how many surgeons worked on the patient, and lots of other information that may be critical to a claim’s status with the insurance payer.

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What Are CPT Modifiers And Why Medical Billing
Companies Use Them?
Since medical procedures and services are often complex, we sometimes need to supply
additional information when we’re coding. CPT modifier may describe whether multiple
procedures were performed, why that procedure was necessary, where the procedure was
performed on the body, how many surgeons worked on the patient, and lots of other
information that may be critical to a claim’s status with the insurance payer.
Some of the common reasons for using a Modifier are:
 The procedure was more complicated than anticipated
 Another procedure was required during the same procedure
 The same diagnostic test had to be re-run on the same day
 The X-Ray was done in one facility and the results were read in a different facility
Consider this example: while doing surgery for a wrist repair - 25607, during the same
procedure, a carpal tunnel release - 64721 is done. You need to append modifier 51 to show
the secondary procedure was performed.

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CPT Modifiers are always two characters and may be numeric or alphanumeric. Most of the
CPT modifiers you’ll see are numeric, but there are a few alphanumeric Anesthesia modifiers
also. CPT modifiers are added to the end of a CPT code with a hyphen. In the case of more
than one modifier, you code the “functional” modifier first, and the “informational” modifier
second. The distinction between the two is simple: you always want to list the modifiers that
most directly affect the reimbursement process first.
Take, for example, the partial mastectomy of the left breast (code 19302-LT-53). If you were to
swap out the -53 (discontinued procedure) with the functional modifier -52 (for reduced
services), you would then code the whole procedure 19302-52-LT. Note that the functional
modifier (-52) now comes before the informational modifier (-LT). If the informational modifier
is listed first in a claim, an insurance company will deny that claim and return it to the
healthcare provider.
In CMS-1500 and UB-04 forms, the two most common claim forms, have space for four
modifiers, payers don’t always look at modifiers after the first two. Because of this, you always
want the most important modifiers to be visible.
Let’s take a quick look at an example of a CPT modifier in action.
A surgeon performs a procedure to remove a bone cyst in the upper arm of a patient. The
procedure also includes obtaining a graft from elsewhere in the body. Due to minor
complications, the surgeon is unable to fully excise the bone cyst. For the procedure, we’d
code 23140 for “excision or curettage of bone cyst or benign tumor, humerus; with autograft
(includes obtaining the graft).” Since the procedure was completed but not fully successful,
we’d add the -52 modifier, for reduced services, to the code, and we’d end up with 23140-52.
Certain modifiers also have guidelines specific to them. The modifier -51, for multiple
procedures, is one of the more commonly used CPT modifiers. In the instance of multiple
procedures provided by the same specialist or healthcare provider, a coder would list the
initial procedure’s CPT code, then append the modifier -51 to the end of the code for the
additional procedure or procedures. Certain procedures, however, are listed in the CPT book
as “-51 exempt,” and coders must be aware of this distinction.

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Note that some modifiers can be used in conjunction with each other (like -23, unusual
anesthesia, and -47, for anesthesia by the surgeon). Others contradict one another and cannot
be included in the same code, For example, the modifier –LT (procedure on the left of two
paired appendages or organs) cannot be coded with the modifier -50, which describes a
bilateral procedure.
Payers have what is called reimbursement edits for reporting code combinations. If using two
codes are stand-alone codes they may be subject to multiple procedure payment reductions.
You would append modifier 51 to the procedure that has less value than the primary
procedure. You need to be aware of special rules that are applied when using modifiers.
Using the appropriate modifiers can substantially impact reimbursement. If you do not report
a modifier and the procedure allows a modifier you will not be paid for the procedure. There
are industry standards related to the use of modifiers and reimbursement. While some
modifiers change the payment rates some are for informational use only or impacts bundling
edits. It pays to understand and get familiar with modifiers and how they are used. Modifiers
have different pricing, some pay 10% of the fee schedule and some pay 100%.
These are just a few examples to show the impact of modifiers:
Sr.
No.
Modifier
type
Details Reimbursements
1 Modifier
22
Increased
Procedural
services
Maximum of 110% of Fee Schedule
Allowance/Contracted Rate with supporting
documentation
2 Modifier50 Bilateral
Procedure
150% of Fee Schedule Allowance/Contracted Rate Submit
one line with one unit
3 Modifier
51
Multiple
Procedures
50% of Fee Schedule Allowances/Contracted Rate for
each additional procedure unless the procedure is
exempt from multiple procedure logic
4 Modifier
55
Follow up care
only
20% of Fee Schedule Allowance/Contracted Rate
5 Modifier
XE
Separate
encounter,
distinct service
Informational /impacts bundling

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References:
1. Centre of Medicare and Medicaid Services (CMS), Global Surgery Booklet (Sept 2018).
Retrieved from https://www.cms.gov/Outreach-and-Education/Medicare-Learning-
Network-MLN/MLNProducts/downloads/GloballSurgery-ICN907166.pdf
2. Ingenix Coding Lab-Understanding Modifiers. Retrieved from
https://www.optum360coding.com/upload/pdf/3989/ICL-
Understanding%20Modifiers.pdf