This edition of “Spotlight on CPT” will focus on modifiers. Let’s begin by identifying what a modifier is. A modifier, in CPT, is comprised of two-characters which acts to supply more detail about a procedure without altering the actual definition of the procedure itself. For example, modifier 50 will indicate that the procedure being modified was performed bilaterally. Modifiers are appended to a CPT procedure code with a hyphen. Look at code 64721-50. 64721 indicates a carpal tunnel release procedure was performed; modifier 50 tells that it was performed bilaterally.
Modifiers can be found in the CPT manual in Appendix A and inside the front cover of the AMA publication. Appendix A provides definitions for the modifiers which are only listed inside the cover of the manual. Modifiers are categorized for use by providers or hospital outpatient facilities. Additionally, as they relate to hospital outpatient facilities, there are Level I (CPT) modifiers and Level II (HCPCS) modifiers. The Level II modifiers allow greater specificity when distinguishing between eyelids (E1, E4) or fingers/toes (T4, F5), capturing heart vessels (LD, RC), or establishing laterality (LT, RT).
It’s worth noting that the list of modifiers which apply to providers is different (longer) than the list for hospital outpatient facilities. Most of the modifiers for hospitals overlap with the list for providers. However, there are some modifiers which are specific only to hospital outpatient services. These are modifiers 27, 73, and 74. Modifier 27 indicates that there are multiple outpatient E/M encounters on the same date of service. Modifiers 73 and 74 are used in hospital outpatient settings when a procedure is discontinued. Modifier 73 is assigned if the procedure is discontinued before the patient receives anesthesia, whereas modifier 74 is used once anesthesia has been administered.
One of the trickiest modifiers to apply is modifier 59. This modifier is used to indicate a distinct procedural service. This modifier is often assigned to bypass National Correct Coding Initiative (NCCI) edits. Unfortunately, its indiscriminate use has led to fraud and abuse prompting the Centers for Medicare and Medicaid Services (CMS) to provide new modifiers to be used in place of modifier 59. These X modifiers are not mandatory, leaving facilities and providers to make their own determination on whether or not to implement their usage. The four X modifiers are as follows:
XE-separate encounter
XS-separate structure
XP-separate provider
XU-unusual non-overlapping service
It is valuable to understand what constitutes a distinct
service. CMS published “Modifier 59
Article” to clarify that term and provide relevant examples with rationales to
assist coding professionals in appropriate application of this modifier. The article can be found at https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/downloads/modifier59.pdf
Physical status modifiers (P1-P6) are a specific subset of modifiers for use exclusively with anesthesia codes. These modifiers give an indication of the patient’s overall health before surgery. An example is physical status modifier P1 which means that the procedure is performed on a normal, healthy patient.
Now, light has been shed on modifiers.
Dianna Foley, RHIA, CHPS, CCS is
OHIMA's Coding Education Coordinator. Dianna has been an HIM
professional for 20 years. She progressed through the ranks of coder,
department supervisor, and department director, to her current role as a
coding consultant. She recently served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati subsequently achieving her RHIA, CHPS, and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and a a presenter at regional HIM meetings and the OHIMA Annual Meeting.
