Modifiers
are extremely important to medical coding. They
indicate that a service or procedure was altered,
by a specific circumstance, without changing the
intent of the code. For example, to show that
a service was increased or took longer than normal
you might use modifier 22 or 23 depending on the
place of service. Modifiers play an important
role in explaining to payers that additional procedures
or services are in fact justified.
Modifier assignment can be confusing. When trying
to determine if a modifier is appropriate, coders
and billers should ask if any of the following
apply:
1. What is the location of the service?
2. Was the same service performed more than once
on the same date?
3. Was a global service performed by more than
one provider?
4. Will a modifier eliminate the appearance of
duplicate billing or unbundling?
5. Will the modifier add more information regarding
the anatomic site of the procedure?
6. 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. Care should be taken to document
these circumstances in the medical record.
It is important to note that some carriers only
read the first modifier while other carriers can
read up to four modifiers, so modifiers which
affect reimbursement should be listed first.
One frequently misused modifier is -25. Some
offices use the modifier for every office visit.
Modifier -25 should be used with Evaluation and
Management codes to indicate "Significant
separately identifiable E/M service by the same
physician on the same day of the procedure or
other service." In other words, a separate
evaluation and management service was rendered.
For example: Patient presents for a Chiropractic
manipulative treatment (CMT) on their upper back
(98940). During the CMT the patient stated that
they fell off a ladder and hurt their lower back.
An evaluation was performed on the lower back.
(99213-25). The -25 modifier is used to demonstrate
that the evaluation was on an area other than
the one being treated. Without the addition of
modifier -25 on the E/M code the office visit
would not be paid.
Another frequently misused modifier is -59. According
to the CPT, modifier -59 indicates "Distinct
procedural service." Modifier -59 is an important
Correct Coding Initiative (CCI) modifier that
indicates that two or more procedures are performed
on different anatomic sites or during different
patient encounters. Modifier -59 should only be
used if no other modifier can be used which more
appropriately describes the relationships between
the two or more procedure codes.
CCI edits define when two procedure codes may
not be reported together "except under special
circumstances." If an edit allows the use
of a CCI associated modifier, the two procedure
codes may be reported together if the two procedures
are performed on different anatomic sites or at
different patient encounters and the documentation
must be in the patient chart. Modifier -59 and
other CCI associated modifiers should NOT be used
to get around CCI edits. The use of modifier -59
to indicate different procedures/surgeries does
not require a different diagnosis for each HCPCS/CPT
coded procedure or surgery. Additionally, different
diagnoses are not sufficient reason to use modifier
-59.
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