Vol. 13 Issue 11
Assigning CPT and HCPCS Modifiers For Hospital-Based Outpatient Service
When coding outpatient encounters and visits during the certified coding specialist (CCS) examination, you are instructed to assign CPT/HCPCS modifiers for hospital-based facilities, if applicable, regardless of the payer. Modifiers are two digit numeric or alphanumeric characters that are appended to CPT or HCPCS Level II codes. A modifier provides a means to indicate that a service or procedure was altered by specific circumstances, without changing the definition of the code.
Modifier assignment is often confusing to coders. When trying to determine if a modifier is appropriate, coders should ask if any of the following apply. Was the same service performed more than once on the same date? Will a modifier eliminate the appearance of duplicate billing or unbundling? Will a modifier provide more specific information on the anatomical site of the procedure? Will a modifier provide any additional information on the services provided? If any of these circumstances apply, then it may be appropriate to append a modifier to the procedure code.
Two modifiers may be appended to each CPT or HCPCS code. It is important to list first the modifier that will affect reimbursement. For example, modifier -25 is used to indicate separate evaluation and management services. Modifier -50 is used to indicate a bilateral procedure. Both will affect reimbursement.
The CPT modifiers that are currently approved for hospital reporting are: -25, -27, -50, -52, -58, -59, -73, -74, -76, -77, -78, -79 and -91. The HCPCS modifiers that are currently approved for hospital reporting are: -CA, -E1 through -E4, -FA through -F9, -GA, -GG, -GH, -GY, -GZ, -LC, -LD, -RC, -LT, -RT, -QM, -QN, and -TA through -T9. It is very important to understand how to use modifiers because they will often mitigate OCE and CCI edits. Some of the more problematic modifiers are addressed here.
Modifier -25 identifies significant separate evaluation and management (E/M) services provided on the same date as a procedure or other service. Modifier -25 is appended to the E/M code. It is important to determine the intent of the visit before making the decision to assign an E/M code with modifier -25.
If a patient presents specifically for a procedure or service and no separate E/M services are provided beyond those necessary for the procedure being performed, it is not appropriate to assign an E/M code or modifier -25. If a patient is presenting for the evaluation of an injury or illness and just happens to have a procedure or service during the visit, then it is appropriate to assign an E/M code with modifier -25. For example, a patient presents to the ED for evaluation after an automobile accident. It is determined that the patient requires a skin laceration repair. In this instance, code both the laceration repair code and the E/M code with modifier -25 appended.
Modifier -50 is used to report bilateral procedures performed during the same operative session. Modifier -50 is used only if the same procedure is performed on both paired body parts. For example, use modifier -50 with CPT code 64721 when a patient undergoes bilateral open carpal tunnel releases. Report the CPT code once with modifier -50. If the CPT code description includes the word "bilateral," do not use modifier -50. The code itself includes the description, and appending modifier -50 is redundant reporting.
Modifiers -LT and -RT are used to identify the left and right sides of the body and are often confused with modifier -50. Use modifiers -LT or -RT when a procedure is performed on one side of the body and is a paired organ. Modifiers -LT and -RT should also be used when the procedures performed are similar but not identical and are performed on both paired body parts. For example, a patient has a lesion removed from the left breast and a biopsy of a lesion of the right breast. In this instance, assign 19120 with modifier -LT and 19100 with modifier -RT.
Modifier -52 is used to identify reduced services when the intended procedure is partially reduced or not performed. Modifier -52 is used with procedures that do not require anesthesia. In this circumstance, conscious sedation is not considered anesthesia. An example of an appropriate use of modifier -52 is when a patient is scheduled to have an upper GI series performed but could not tolerate the barium. Code 74240 with modifier -52 is assigned in this instance.
Modifiers -73 and -74 are used to report discontinued procedures when extenuating circumstances or those that threaten the well being of the patient cause the physician to cancel a surgical or diagnostic procedure subsequent to the surgery. Modifier -73 identifies procedures discontinued prior to the administration of anesthesia. Modifier -74 identifies procedures discontinued after the administration of anesthesia.
Append modifier -52, -72 or -73 to the code for the intended procedure. If multiple procedures were planned and the surgery is terminated prior to completion, report the completed procedures only without the modifier. Other planned procedures that were not performed are not reported. When none of the planned procedures is completed, report only the first planned procedure with modifier -52, -73 or -74. Do not use modifiers -52, -73 or -74 to report elective cancellations of surgery.
If a procedure is terminated prior to the induction of anesthesia and before the patient is wheeled into the procedure room, the procedure should not be reported. The patient has to be taken to the room where the procedure is to be performed to report modifiers -52 and -73.
Modifier -59 is used to report distinct procedural services. This modifier identifies procedures that are not normally reported together but were performed on a different body site or during a different procedure or surgical session, required a separate incision, were related to separate injuries or were performed during different sessions or encounters.
If there is another modifier that better describes the circumstances, then it should be used instead. Modifier -59 should not be used just to mitigate OCE/CCI edits. One of the circumstances identified above should be present. For example, if simple repairs of the trunk and the nose are performed during the same visit, report codes 12001 and 12011. Modifier -59 should be appended to code 12011 to indicate that the procedure was performed on a different body site.
Modifier -76 is used to report repeat procedures by the same physician. Modifier -77 is used to report repeat procedures by a different physician. These modifiers may be appended to repeat procedures performed by technicians, but ordered by a physician. For example, use modifier -76 or -77 to report repeat EKGs. The code is assigned twice with the modifier appended to the second code. Modifiers -76 and -77 should not be used with laboratory or pathology procedures. Use modifier -91 instead.
Modifier -91 is appended to repeat clinical diagnostic laboratory tests performed on the same date. Modifier -91 is not to be used for procedures repeated to verify results or due to equipment failure or specimen inadequacy. If the same test was performed on different sites, use modifier -59 instead. For example, if two wound cultures were taken from two different wound sites, modifier -59 would be appended to the second wound culture code. However, if a second culture was taken of the same wound site, then it would be appropriate to append modifier -91 to the second wound culture code. If a lab panel is performed and one of the tests within the panel is repeated, modifier -91 is appended to the repeat lab test.
Assigning modifiers can be confusing to coders. In instances where it may appear that more than one modifier fits the circumstances, always use the most specific modifier. If there are a CPT modifier and an HCPCS modifier that fit the circumstances, then generally the HCPCS modifier is the most specific.
Take some time now to review the descriptions for the modifiers not discussed in detail above. After you have completed your review, check yourself with the quiz below.
1. A patient is seen in the clinic for chemotherapy infusion. The physician discusses the procedure with the patient. The nurse takes vital signs and prepares the patient for the chemotherapy. Should an E/M code be assigned with modifier -25 along with the chemotherapy infusion code?
2. A hammer toe correction is performed on both big toes. Which of the following would be the appropriate code selection?
b. 28285LT and 28285RT
c. 28285TA and 28285T5
3. How is a bilateral tubal ligation reported? Which of the following would be the appropriate code selection?
4. A colonoscopy is scheduled. The scope is inserted but could not be passed beyond the splenic flexure. The procedure is discontinued. Which of the following would be the appropriate code selection?
5. An electrolyte panel is performed, and on the same date, the potassium level is repeated. Which of the following would be the appropriate code selection?
a. 80051 and 84132
b. 80051 and 8413259
c. 80051 and 8413291
6. The excisions of two different lesions of the left breast are performed, utilizing two separate incisions. Which of the following would be the appropriate code selection?
a. 19120 units of 2
b. 19120LT and 19120LT
c. 19120LT and 1912059LT
7. A patient presents to radiology for an upper GI series, but because of equipment failure, the procedure is cancelled and rescheduled. Which of the following should be coded?
a. No code is assigned
8. A Medicare patient is seen in the ED after a fall. After examination, the patient was found to have a 2 cm laceration of the thigh and a .5 cm laceration of the wrist. The thigh was repaired with sutures, and the wrist was repaired with Dermabond. Which of the following would be the appropriate code selection?
a. 9928125 and 12001
b. 9928125, 12001 and G016859
c. 12001 and G016859
9. An excision of chalzion left upper eyelid and a biopsy of left lower eyelid are performed during the same operative episode. Which of the following would be the appropriate code selection?
a. 67800 and 67810
b. 67800 and 6781059
c. 67800E1 and 67810E2
d. 67800E1 and 6781059E2
This month's column has been prepared by Cheryl D'Amato, RHIT, CCS, director of HIM, and Melinda Stegman, MBA, CCS, manager of clinical HIM services, HSS Inc. (www.hssweb.com), which specializes in the development and use of software and e-commerce solutions for managing coding, reimbursement, compliance and denial management in the health care marketplace.
Coding Clinic is published quarterly by the American Hospital Association.
CPT is a registered trademark of the American Medical Association.
1. b: In this instance, it is not appropriate to assign the E/M code with modifier -25. The patient presented specifically for the chemotherapy, and no additional E/M services were provided.
2. c: Appending modifiers TA and T5 indicate the most specific anatomic site.
3. a: Code 58600 has bilateral in its definition.
4. b: Code 45330 is assigned because in this instance a procedure, sigmoidoscopy, is completed. The completed procedure is coded instead of the intended procedure with modifier -52.
5. c: Appending modifier -91 to the repeat potassium level indicates a repeat laboratory test.
6. c: Modifier -LT is appended to both procedure codes to identify on which breasts the procedures were performed. Modifier -59 is listed first for the second instance of 19120 because it may affect reimbursement and indicates that the procedure was performed on a different lesion.
7. a: No code is assigned if a procedure is cancelled due to equipment failure or because of the lack of proper equipment. No code is assigned if a procedure is cancelled by the physician because of scheduling or cancelled electively by the patient.
8. b: An E/M code with modifier -25 is assigned because the patient presented for evaluation. Codes 12001 and G016859 are both assigned because they are different types of repair. Modifier -59 is appended to code G0168 to indicate a laceration repair on a different site.
9. c: Modifiers E1 and E2 indicate that the procedures are performed on different eyelids. It is not necessary to assign modifier -59 in this instance to indicate a different site.