• Introduced in 1992 CPT.
• May only be listed with the highest level of E/M service (informational purposes).
• Prolonged E/M service codes (99354-99359) replace use of this modifier in most cases.
• CMS does not allow extra payment for this modifier.

• Used to alert payers to unusual circumstances or complications encountered during a procedure, when the services provided are greater than usually required.
• Payers watch use of this modifier very carefully since it has been widely abused. Do not use with E/M codes.
• These words in an operative report help document unusual circumstances: "increased risk," "difficult," "extended," "complications," "prolonged," "severe respiratory distress," "hemorrhage," "blood loss over 600cc," "unusual findings" or "unusual contamination controls."
• CMS contends that the slight extension of a procedure does not warrant the -22 modifier. The circumstance must involve significant increase in physician work.
• Use modifier -22 when:
  • complications cannot be identified by a separate code and there is a significant increase in physician work.
  • the procedure is lengthy and unusual.
  • work and effort is increased by approximately 30-50% of what would normally be required due to unusual circumstances.
• Send a cover letter and report with the claim documenting unusual circumstances; do not use generalizations. Be specific. For example, it is helpful to state that the procedure took 3 hours and normally only takes 1 hour, then explain how and why the work was increased.
• If transmitting electronically, use a "paper claim" with attached documentation for consideration.
• The Medicare carrier may increase reimbursement if sufficient documentation is submitted.

• This modifier is used to report anesthesia services for procedures which normally would not use general anesthesia, e.g., panicky child, use of local anesthesia is ineffective, or operative site is so awkward that general anesthesia becomes necessary.
• This modifier is used with the code for the primary procedure performed which would not ordinarily require anesthesia. Example: 62270-23.

• Attach to an E/M service provided during a postoperative period performed for reasons unrelated to the original procedure; do not attach to a procedure code. If a different physician admits the patient, modifier -24 is not used.
• Must be linked with a diagnosis code that indicates this service is unrelated to the surgery.
• CMS authorizes payments for in-patient services with modifier -24 for the following special circumstances:
  • Immunotherapy furnished by the transplant surgeon.
  • Critical care for a burn or trauma patient; documentation must accompany the claim.

• Reports a problem or abnormality picked up during a preventative medicine visit that is significant enough to require additional work to perform the key components of a problem or E/M service. Report this "significant and separately identifiable" E/M service with -25. (Do not report additional E/M service if a problem is identified but nothing is done about it.)
• Documentation may be required for instances where the diagnosis code is the same. Different diagnoses are not required for reporting E/M services on the same date as a procedure.
• CMS does not allow additional reimbursement for this modifier.
• If you perform significant, separately identifiable services, you may have a strong argument to support billing the visit. A brief note will not suffice; the medical record needs to indicate your exam was a significant, separately identifiable service beyond the usual preoperative or postoperative care associated with the procedure performed, or above and beyond the other service provided.
• Language was modified in CPT 2000, adding "may be prompted by the symptom or condition for which the procedure and/or service was provided." NOTE: Many times offices are not using modifier -25 because they have been told that they must have a divergently different diagnosis before they can use the -25, and now the AMA and CMS have clarified this.

• Used to denote the professional services of a physician when the service has both a professional and technical component. For example, a physician may provide a cardiac catheterization using a facility's cardiac cath lab. The physician bills his/her service using modifier -26, while the facility bills using modifier -TC (technical component). Example: 76360-26 for computerized axial tomographic guidance for needle biopsy, radiological supervision and interpretation done at a hospital facility with their equipment. -26 denotes the physician's professional component only of the service.
• Also used by physicians to denote interpretation of diagnostic tests.
• CMS indicates that payment is affected by use of this modifier; some procedures have a professional and technical component and the global billing may be divided into these components.

• Attach to mandated consultation and/or other services. These services are flagged because they are required by a third party, e.g., a court of law, agency, or insurance entity.
• Many Medicare carriers will require use of HCPCS Level II modifier SF (second opinion ordered by a PRO or professional review organization) or SM (second opinion) or SN (third opinion).
• CMS has indicated that use of this modifier does not affect payment.

• Do not attach to anesthesia procedure codes, 00100-01999.
• This modifier is not used by an anesthesiologist.
• Denotes use of regional or general (not local) anesthesia administered by physician without benefit of a CRNA (certified registered nurse anesthetist) or anesthesiologist.
• Do not use for conscious sedation - see codes 99143 and 99150.
• CMS does not cover this modifier.
• Most Medicare carriers will not pay anesthesia administered by surgeons. Private insurers' policies vary.

• A bilateral service is defined as the same procedure being performed on both sides of the body.
• Do not attach this modifier to CPT surgical procedures that contain the language, "one or both," e.g., 64776 - Excision of neuroma; digital nerve, one or both, same digit; or "unilateral or bilateral," e.g., 63047 - Laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root(s), (e.g., spinal or lateral recess stenosis), single vertebral segment; lumbar.
• Typically, the allowance for bilateral procedures is 150% of the unilateral allowance. However, there are some payers who will allow 100% for each side.
• Payment by CMS is 150% for procedures that allow this modifier. The bilateral indicator of "1" in the Physician Fee Schedule denotes 150% payment for bilateral procedure.

• Use this modifier to denote more than one medical/surgical procedure (multiple procedures other than E/M) being performed by the same physician on the same day at the same operative session. The major procedure with the highest RVU is listed first and is reimbursed in full. Secondary or lesser procedures may be listed next with modifier -51.
• CMS pays 100% for the first procedure and 50% for the second through fifth procedures. Any other multiple procedure will be paid after carrier review. Attachment of this modifier to an anesthesiology procedure does not affect payment.
• When billing, do not reduce the charge amount; allow the payer to reduce payment.
• Be careful if you use the -51 modifier with procedure codes with phrases like "each additional" or "list in addition to," because use of the -51 modifier may result in an unintended further reduction of the payers' allowance. Add-on procedures, such as 63048 - Each additional segment, are exempt from usage of modifier -51 per CPT.

• Use when the physician reduces or eliminates a portion of the procedure as described within a certain CPT code, at the physician's discretion. Modifier -52 is reported in addition to the procedure code.
• Do not use with E/M codes.
• Examples: Procedures that are normally performed bilaterally but are only performed on one side. Procedure not completed due to patient's condition.
• Use of ICD-9-CM code will identify reason for reduction of service. See code range V64. (Persons encountering health services for specific procedures not carried out.)
• CMS payment is based on the extent of the procedure performed. Submit documentation with the claim.

• A surgical or diagnostic procedure may have been started but discontinued due to extenuating circumstances, or those that threaten the well-being of the patient. This circumstance is reported by adding the modifier -53 to the code for the discontinued procedure.

• Use when one physician provides surgical services and another provides preoperative and/or postoperative care.
• The medical record should contain a written agreement for transfer of care.
• Modifier -54 generally includes the preoperative care that a surgeon renders the day before surgery.
• CMS indicates that payment will be limited to the preoperative and intra-operative services only.

• Physician provides only the postoperative care and is paid the postoperative percentage of the global service, because another physician has performed the surgical procedure.
• Do not attach this to an E/M service code; it is only attached to the surgical or medical procedure code (include the date the surgery was performed).
• May only be billed after the first postoperative visit has been performed.
• CMS indicates that payment is limited to the amount allotted for postoperative services only.

• Attach this modifier to the surgical or medical procedure code.
• Use to report the preoperative component when another physician was responsible for the intra-operative and postoperative care of the patient. This modifier is rarely used.
• Do not use this modifier for Medicare claims. Payment for this component is included in the allowable for the surgery. If another physician performed the surgery, report only an E/M service code for the level of care provided.

• Identifies an E/M service that resulted in the decision for surgery. For Medicare the preoperative global period is the day before or day of surgery.
• Attach to an E/M service code, not the surgical or medical procedure code.
• CMS expects this modifier to be used when the surgery has a 90-day postoperative period. Use of this modifier allows payment of the E/M service in addition to the surgical or medical procedure.

• Use this modifier when a procedure is performed during the postoperative period and was one of the following:
  • planned prospectively at the time of the original procedure
  • more extensive than the original procedure
  • used for therapy following a diagnostic surgical procedure that has a global period
• If a less extensive procedure fails and a more extensive procedure is required, the second procedure should be billed with the -58 modifier.
• CMS has clarified that those surgical procedures that contain the language, "one or more sessions," e.g. codes 67141-67228 should not be modified with -58.
• CMS has indicated that use of this modifier does not affect payment.
• Using this modifier can have a positive impact on Medicare reimbursement. When not used correctly, this could result in a delayed payment or denied claims.

• Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day.
• Modifier -59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. This may represent the following situations not ordinarily encountered or performed on the same day by the same physician:
  • different session or patient encounter
  • different procedure or surgery on the same day
  • different site or organ system
  • separate incision/excision
  • separate lesion, or separate injury (or area of injury in extensive injuries)
• When another already established and more descriptive modifier is available, it should be used rather than -59, unless the use of modifier -59 best explains the circumstances.
• Multiple services provided to a patient in the same day by the same provider may appear to be incorrectly coded, when in fact the services may have been performed as reported. Because you cannot easily identify these circumstances, a modifier was established to permit claims of such a nature to bypass correct coding edits.
• Modifier -59 may be used to identify those circumstances where a procedure designated as a "separate procedure" is carried out independently, or considered unrelated or distinct from other procedures/services provided at that time.

• Used when two surgeons perform a single procedure together. If each surgeon is performing a different procedure during the same operative session, then modifier -62 is not necessary for most carriers. Also, please note that multiple surgery rules apply only if one surgeon does more than one procedure. Co-surgeons agree beforehand to bill for their services using the -62 modifier.
• The -62 modifier should only be appended to a single definitive primary procedure and any associated add-on code(s) as long as both surgeons continue to work together as primary surgeons. Each surgeon should report the co-surgery once using the same procedure code.
• Do not use this modifier to describe the services of an assistant surgeon. If a co-surgeon acts as an assistant during additional procedures in the same operative session, those services should be reported using modifiers -80 or -81 (as appropriate).
• Many payers will deny payment if the surgeons have the same specialty because of the language in this modifier's description "usually with different skills." Submit documentation supporting the medical necessity of two surgeons with the same skills. CMS has expanded the list of specialties and sub-specialties to help avoid this type of claim denial. CPT 1999 clarified that the modifier -62 may be appended by surgeons of the same or differing skills and/or specialty.
• Payment from CMS is increased to 125% of the approved allowable and each surgeon receives 62.5%. Some surgical procedures will allow payment for a co-surgeon if the surgeons have different specialties while other procedures will not allow co-surgery payment at all.
• The modifier -62 may not be reported for procedures involving three or more surgeons at the same surgical session. Modifier -66 should be used to describe this involvement.

• Use this modifier to identify a highly complex or intricate procedure requiring the concomitant services or more than two physicians, often of different specialties, e.g. organ transplant, multi-trauma patients, etc.
• Each surgeon submits his services with modifier -66.

Most payers automatically submit these claims to medical review for determination of payment to each provider. Medicare sends these claims to the carrier's Medical Director for payment decision.

• Use to report a repeat procedure by the same physician performed subsequent to the original procedure with no time limitation.
  • Example: Use to report a repeat fusion code 22612.
• Used to prevent claim denial for duplicate billing.
• CMS has indicated that this modifier does not affect payment; it is for informational purposes only.

• Identical to Modifier -76, except that the physician performing the service is different from the one who performed the original service with no time limitation.
  • Example: 62230 Revision of cerebrospinal fluid shunt by another physician.
• CMS indicates that use of this modifier does not affect payment.

• "Operating room" is defined by CMS as a place of service specifically equipped and staffed for the sole purpose of performing procedures. This includes cardiac catheterization suites, laser suites and endoscopy suites. It does not include a patient room, a minor treatment room, a recovery room or an intensive care unit.
• Use this modifier to report the treatment of a problem that requires a return to the operating room and is related to the original procedure, e.g. medical, surgical or mechanical complications.
• CMS allows 50% of the intra-operative amount and recognizes this modifier when attached to procedures with a 10- or 90-day global period. A new postoperative period does not begin with the use of modifier -78.
• CMS allows full payment for complications treated by another physician if expertise beyond that of the first surgeon is necessary to treat the complications. In this case, no modifier is needed and only the allowance for the intra-operative period will be allowed.
• Under Medicare rules and some other payer rules, such return trips will be paid when performed during the postoperative period, but at a reduced intra-operative rate.

• Similar to modifier -78, except that the return to the operating room is for an unrelated procedure, and this modifier specifies that the physician is the same one who performed the original surgery.
• The diagnosis code should reflect that the procedure is unrelated.
• With -79, a new postoperative period begins and payment should be the full amount.
• Do not use to denote a return to the operating room for complications due to the original surgery.
• CMS has indicated that use of this modifier does not affect the payment amount.

• Used to identify the services of an assistant surgeon or resident surgeon at a teaching facility.
• Payers will reimburse a small portion of the surgical fee to the assistant. (Private payers reimburse approximately 20-25% of the surgical fee to the assistant, while Medicare pays 16% of the Medicare fee allowed amount. Most payers have lists of procedures for which they will allow payment to an assistant.)
• For a few payers, their normal allowance for the CPT code covers the services of PA's or nurse practitioners that are utilized and employed by the surgeon. Many private payers will allow 20% to 30% for assistant surgeons.

• Used to identify those services of a surgical assistant with no "hands on," or a second or third assistant, that falls into the category of minimum service rendered.
• Not covered by CMS except in extreme cases. Check other third-party payers to determine their reimbursement policy.

• Use this modifier when no qualified resident surgeon is available to assist or there is not an appropriate training program for the medical specialty that is required to perform the procedure.
• CMS has strict guidelines regarding the use of an assistant in teaching facilities. A certificate should accompany the claim which states:

  "I understand that section 1842 of the Social Security Act prohibits Medicare Part B payment for the services of assistants-at-surgery in teaching hospitals when qualified residents are available to furnish such services. I certify that the services are subject to post-payment review by the Medicare carrier."

• Indicates that an outside laboratory rendered the services.
• Private payers and HMOs have differing policies on who may bill the patient for lab services.
• CMS only allows the entity that performed the services to bill the services. Reference laboratories would be responsible for billing the patient, not the ordering physician.

• Use when laboratory tests are repeated on the same patient on the same day to obtain subsequent test results.
• Do not use to confirm test results or repeat due to problems with the specimens or equipment. Also do not use with a code describing a series of test results, such as a glucose tolerance test.

• Attach to a service/procedure code when two or more modifiers are necessary to describe the service performed.
• Modifier -99 is rarely used. Payers have different instructions of where to list additional modifiers.