Most used modifier of E & M code 99201, 99499

Modifiers Available in the DoD for E&M in the range 99201-99499.  

Coders should be in the habit of using appropriate modifiers.  At this time, not all modifiers are accepted in the Ambulatory Data Module.  There will be times when modifiers will not be accepted. In this instance, discontinue entering the code until it is announced that codes are available.  For all other modifiers, enter them.  

At this time, the SADR, a feed from your server to a central database, does not have a field for modifiers.  The Third Party Collection Program (TPCP) feed does transmit the modifiers listed below to the billing system.  The modifiers listed below are also available from your server.

-21 Prolonged E&M services (use only on highest level of E&M)

-24 Unrelated E&M by same physician during a postoperative period

-25 Significant, separately identifiable E&M by same physician on same day

-57 Decision for Surgery

Top 20 - Most commonly used Modifier

Modifier Description

22 Increased Procedural Service: When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. Documentation must support the substantial additional work and the reason for the additional work (eg, increased intensity, time, technical difficulty of procedure, severity of patient’s condition, physical and mental effort required). Note: This modifier should not be appended to an E/M service.

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: It  may be necessary to indicate that on the day a procedure or service 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 that was performed. 

A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported. The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date.

26 Professional Component: Certain procedures are a combination of a physician or other qualified health care professional component and a technical component . When the physician or other qualified health care professional component is reported separately, the service may be identified by adding modifier 26 to the usual procedure number. 50 Bilateral Procedure: Unless otherwise identified in the listings, bilateral procedures that are performed at the same session should be identified by adding modifier 50 to the appropriate 5 digit code.

51 Multiple Procedures: When multiple procedures, other than E/M services, Physical Medicine and Rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same individual, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by appending modifier 51 to the additional procedure or service code(s).

Note: This modifier should not be appended to designated “add-on” codes

52 Reduced Services: Under certain circumstances a service or procedure is partially reduced or eliminated at the discretion of the physician or other qualified health care professional. This provides a means of reporting reduced services without disturbing the identification of the basic service.

53 Discontinued Procedure: Under certain circumstances, the physician or other qualified health care professional may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued.

57 Decision for Surgery: An evaluation and management service that resulted in the initial decision to perform the surgery may be identified by adding modifier 57 to the appropriate level of E/M care.

58 Staged or Related Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period: It may be necessary to indicate that the performance of a procedure or service during the postoperative period was: a) planned or anticipated (staged); b) more extensive than the original procedure; or c) for therapy following a surgical procedure. This circumstance may be reported by adding modifier 58 to the staged or related procedure. Note: For treatment of a problem that requires a return to the operating/procedure room (eg, unanticipated clinical condition), see modifier 78.

59 Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures or services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. 

Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than modifier 59. 

Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25.

73 Discontinued Outpatient Hospital / Ambulatory Surgery Center (ASC) Procedure Prior to the Administration of Anesthesia: Due to extenuating circumstances or those that threaten the well being of the patient, the physician may cancel a surgical or diagnostic procedure subsequent to the patient’s surgical preparation (including sedation when provided, and being taken to the room where the procedure is to be performed), but prior to the administration of anesthesia (local, regional block(s) or general). Under these circumstances, the intended service that is prepared for but cancelled can be reported by its usual procedure number and the addition of modifier 73.

74 Discontinued Outpatient Hospital / Ambulatory Surgery Center (ASC) Procedure After Administration of Anesthesia: Due to extenuating circumstances or those that threaten the well being of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia (local, regional block(s) or general) or after the procedure was started (incision made, intubation started, scope inserted, etc.). Under these circumstances, the procedure started but terminated can be reported by its usual procedure number and the addition of modifier 74.

78 Unplanned Return to the Operating / Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period: It may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). When this procedure is related to the first, and requires the use of an operating/procedure room, it may be reported by adding modifier 78 to the related procedure.

79 Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period: The individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. This circumstance may be reported by using modifier -79. (For repeat procedures on the same day, see modifier -76.)

CA Procedure payable only in the inpatient setting when performed emergently on an outpatient who expires prior to admission

FB Item provided without cost to provider, supplier or practitioner, or full credit received for replaced device

FC Partial credit received for replaced device

LC Left circumflex coronary artery

LD Left anterior descending coronary artery

LT Left side (used to identify procedures performed on the left side of the body)

LM Left main coronary artery

RC Right coronary artery

RI Ramus intermedius coronary artery

RT Right side (used to identify procedures performed on the left side of the body)

TC Technical component

Why we using modifier - Most used modifiers

Why use a modifier? 

•    to indicate that a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code. 

•    may use a modifier to report — 

* a service or procedure has either a professional or a technical component

*  a service or procedure was provided more than once

*  a service or procedure has been increased or reduced

* only part of a service was performed

*  unusual events occurred

*  a bilateral procedure was performed

Some modifiers affect reimbursement and others are for documentation purposes. 

CPT Modifiers: 

21 Prolonged E/M Services 

Add to E/M code number 

22 Unusual Procedural Services 

Service greater than that usually required for the procedure 

23 Unusual anesthesia 

Procedure that usually requires no anesthesia or local anesthesia must be done under general anesthesia. 

24 Unrelated E/M Service by Same Physician During a Postoperative Period 

E/M service performed during a postoperative period for a reason unrelated to the original procedure 

25  Significant, Separately identifiable E/M Service by the Same Physician on the Same Day of the 

Procedure or Other Service 

E/M services required above and beyond the other service provided or beyond the usual pre and postoperative care associated with the proce-dure performed. Different diagnoses not required. 

ws26 Professional Component When physician component reported separately from technical component 

32 Mandated Services 

Services related to mandated consultation or related services 

47 Anesthesia by Surgeon Regional or general anesthesia provided by the surgeon (does not include local anesthesia) 

50 Bilateral Procedure - Bilateral procedures performed at the same operative session 

51 Multiple Procedures Multiple procedures, other than E/M*, performed at the same session by the same provider. Report the primary procedure as listed and add -51 to the additional code(s). 

52 Reduced Services 

Procedure partially reduced or eliminated at the physician's discretion 

53 Discontinued Procedure Physician elects to terminate procedure that was started but discontinued. Not used for elective cancellation of a procedure prior to patient's anesthesia induction and/or surgical preparation in the operating suite. 

54 Surgical Care Only One physician performs surgical procedure and another the pre and/or postoperative care. Add -54 to the surgical procedure code. 

55 Postoperative Management Only Used when one physician performed preoperative care and another performed the surgical procedure. 

56 Preoperative Management Only Used when one physician performed preoperative care and another performed the surgical procedure. 

57 

Decision for Surgery 

An E/M service that resulted in decision to perform surgery. 

58 Staged or Related Procedure or Service by the Same Physician During the Postoperative Period 

Physician should indicate that procedure was 1) planned prospectively (staged); b) more extensive than original procedure; or 3) for therapy following a surgical procedure. Not used to report treatment of problem requiring return to operating room. 

59    Distinct Procedural Service 

Service is distinct or independent from other services performed on same day. Identifies procedures not normally reported together. 

62    Two Surgeons 

When two surgeons work together as co-surgeons performing distinct parts of a single reportable procedure, each adds -62 to the surgery code, and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. 

63    Procedure Performed on Infants less than 4 kg 

To allow for increased complexity of procedures performed on neonates and infants up to 4 kg. May be appended to codes in 20000 - 69999 range only; not used with E/M, Anesthesia, Radiology, 

Pathology/Labora tory, or Medicine 

66    Surgical Team 

Highly complex procedures may require concomitant services of several physicians. Each physician adds -66 to surgery code. 

76    Repeat Procedure by Same Physician 

Procedure or service repeated subsequent to the original. 

77    Repeat Procedure by Another Physician 

Basic procedure done by another physician had to be repeated. 

78    Return to the Operating Room for a Related Procedure During the Postoperative Period 

Another procedure was performed during the postoperative period of the original procedure that was related to the first. 

79    Unrelated Procedure or Service by the Same Physician During the Postoperative Period 

Performance of procedure during postoperative period was unrelated to the original procedure. 

80    Assistant Surgeon 

Use -80 modifier to identify surgical assistant services. 

81 Minimum Assistant Surgeon 

Use -81 modifier to identify minimal surgical assistant services. 

82 Assistant Surgeon (when qualified resident surgeon not available) Unavailability of qualified resident surgeon is a prerequisite for use of modifier -82. 

90 Reference (Outside) Laboratory Laboratory procedures performed by a party other than the treating or reporting physician. 

91 Repeat Clinical Diagnostic Laboratory Test Repeat same lab test on same day to obtain multiple test results.  99 Multiple Modifiers Two or more modifiers may be necessary to completely delineate a service. 

NOTE: Anesthesia Physical Status Modifiers P1 - P6 are included in Appendix A, as well as the Anesthsia Guidelines. 

The rules of 25 Modifier usage

25 Modifier

Significant separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service

Indicates on the day of a procedure or other service, the patient's condition required a significant, separately identifiable Evaluation and Management (E/M) service above and beyond the other service provided or beyond the usual pre-operative and post-operative care associated with the procedure that was performed. This modifier should only be used if an E/M is being billed on the same day as a procedure.

Correct Use

This modifier may be used to indicate that an E/M service or eye exam, which is performed on the same day as a minor surgery (000 or 010 global days) and which is performed by the surgeon, is significant and separately identifiable from the usual work associated with the surgery.

Documentation in the patient's medical record must support the use of this modifier.

This modifier should not be submitted with E/M codes that are explicitly for new patients only: CPT codes 92002, 92004, 99201-99205, 99321-99323 and 99341-99345. These codes are listed as new patient codes and are automatically excluded from the global surgery package. They are reimbursed separately from surgical procedure and no modifier is required. 

New patient CPT codes required CPT modifier 25 when a separately identifiable E/M service is performed the same day as chemotherapy or non-chemotherapy infusions or injections as these are not considered surgery.

No supporting documentation is required with the claim when this modifier is submitted.

A different ICD-10 code from the one submitted with the minor surgery is not required with the E/M code. The diagnosis for the E/M service and the other procedure may be the same or different.

This modifier may be used to indicate that an E/M service was provided on the same day as another procedure that would normally bundle under the National Correct Coding Initiative (NCCI). In this situation, CPT modifier 25 signifies that the E/M service was performed for a reason unrelated to the other procedure.

Incorrect Use

A physician other than the physician performing the procedure. Documentation shows the amount of work performed is consistent with that normally performed with the procedure.

The following conditions must be met to report modifier 25:

*  The patient’s condition required a significant, identifiable E/M service above and beyond the other service provided or services beyond the usual preoperative and postoperative care associated with the procedure that was performed.

*  These circumstances may be reported by adding the 25 modifier to the appropriate level of the E/M service.

1. The phrase, “the patient’s condition required” is extremely important. In other words, it was medically necessary for the patient to have these extra services on the same day that another procedure or service was performed.

2. The phrase, “a significant, separately identifiable E/M service above and beyond” the other service provided indicates that this extra service was clearly different from the other procedure or service that was performed.

3. The phrase, “services beyond the usual preoperative and postoperative care” associated with the procedure emphasizes the fact that all procedures as defined in the Resource-Based Relative Value Scale (RBRVS) system of reimbursement that Medicare uses include a certain amount of preoperative and postoperative care in the reimbursement package. The 25 modifier should be used if extra work beyond the usual is performed. A good standard for judging whether the 25 modifier should be used is: 

If a physician in the same specialty area would agree after reading the clinical record that extra preoperative and/or postoperative work beyond what is usually performed with that service was performed, then it is proper to use the 25 modifier to indicate that extra work. To document the extra work performed, the clinical record should clearly indicate that extra or unusual work.