Cpt Modifiers

Front 1

Postoperative follow-up visit, normally included in the surgical package, to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) related to the original procedure.

Back 1

CPT code 99024
(Procedure, page 759, Post-Op-Vist)

Front 2

A patient underwent a total hip replacement 10 days ago. The patient presents to the emergency room after being involved in an automobile accident. The patient sustained a fracture to the left arm. The surgeon who performed the total hip replacement was asked by the emergency room doctor to evaluate the patient’s arm. The surgeon performed a problem focused history and examination with straightforward decision making.

Back 2

CPT code 99024

Front 3

A patient underwent a total hip replacement 7 days ago. The patient presents for a routine followup visit. The surgeon who performed the total hip replacement examined the hip and found the surgical site to be healing appropriately.

Back 3

CPT code 99024

Front 4

Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period in Appendix A.

Back 4

Modifier 24

Front 5

A patient underwent a total hip replacement 10 days ago. The patient presents to the emergency room after being involved in an automobile accident. The patient sustained a fracture to the left arm. The surgeon who performed the total hip replacement was asked by the emergency room doctor to evaluate the patient’s arm. The surgeon performed a problem focused history and examination with straightforward decision making.

Back 5

CPT code 99241-24 because this is unrelated to the hip surgery.
Modifier 24 sends the third-party payer back to the diagnosis code, where they will see the diagnosis is for a different condition even though the patient, surgeon, and surgical time period all indicate the problem is related to the hip.
Evaluation and management fracture left arm. 99241-24

Front 6

For minor surgeries, the postoperative period is up to

Back 6

10 days

Front 7

for major surgery, the postoperative period is up to

Back 7

90 days

Front 8

Reimbursement for the physician (individual provider) portion of surgery services is usually bundled together into

Back 8

into one payment

Front 9

An orthopedic surgeon performs an open reduction and internal fixation of a fracture of the right radius. During the postoperative period the patient returns for a sprain of the opposite arm. The same orthopedic surgeon who performed the surgery performed an expanded problem focused history and an expanded problem focused examination for the left arm sprain with straightforward decision making.

Back 9

The appropriate evaluation and management code for evaluation and management of the sprain is selected: 99213. However, if this is reported without a modifier, the third-party payer will likely “bundle” the E/M visit under the right radial fracture instead of processing it as a separate claim.
Modifier 24 gives the third-party payer the additional information to process the claim as a separately identifiable service.

Front 10

ORIF

Back 10

The internal fixation involves the use of pins, plates, and screws to hold the bones in place. This is done because the bones cannot heal with casting or splinting alone. The internal fixators hold the bones together as they begin to heal. Sometimes they are simply left in place, and in other instances, they may be removed when healing is complete. Healing is monitored with the assistance of medical imaging to confirm that the bones are knitting, healing evenly, and healing correctly.

Front 11

Consider a patient who visits the physician’s office because of a problem with severe headaches. The physician spends quite a bit of time evaluating the patient for the headache problem. The physician does a history, physical, and prescribes medication for the patient’s headaches.

Back 11

The evaluation and management code for the patient’s headache evaluation and management is 99202.
(see page 11 of the E/M)

Front 12

Patient previously mentioned the sever headache.
Now let’s assume the patient mentioned a bothersome skin tag during the physical exam and the physician and patient decide it’s a good idea to remove the skin tag during this same visit. The physician performs the procedure

Back 12

Evaluation and management for headache, skin tag removal. 99202–25, 11200
Modifier 25 alerts the third-party payer of the two separate services:
1. evaluation and management for a condition OTHER than the condition for which the procedure was performed
2. procedure – removal of the skin tag
Evaluation and management for headache, skin tag removal. 99202–25, 11200
(Table of Contents ix, surgery, page 59, see page 57, "Removal of Skin Tags")

Front 13

Modifier blank should only be used when services are provided by the same physician to the same patient on the same day as another procedure/other service. When reporting both an E/M service and a procedure, the physician must appropriately document in the medical record that both of the services are medically necessary.

Back 13

25

Front 14

Consider a new patient who visits the doctor for pain and swelling of the knee. During an evaluation and management of a problem focused history and examination and straightforward medical decision-making, the physician diagnoses the patient with bursitis of the knee. After some discussion about treatment options, the patient and physician agree to inject the knee with steroids, which the physician performs that day.

Back 14

Evaluation and management for pain and swelling of the knee, injection of the knee. 99201-25, 20610

Why: New patient 99201
Why: Injection, Bursa, 20600, (surgery 20600)

99201-25, same patient, same day, same physician, 206010

Front 15

If the patient did not receive the injection, then only cpt code

Back 15

99201 would be listed

Front 16

The day of the steroid injection would be coded

Back 16

20610

Front 17

A patient who goes to the physician’s office and has an x-ray performed in the physician’s office and then has the results read by his or her physician is having both the technical and professional components combined into one service. This is an example of what modifer?

Back 17

26

Front 18

A patient who is referred to the outpatient radiology department of the hospital by his or her primary physician for an x-ray receives the blank component at the hospital

Back 18

technical

Front 19

If the films are sent back to the primary physician to be interpreted, then the primary physician is providing the blank component.

Back 19

professional

Front 20

If the films are sent back to an outside radiologist to be read, then the outside radiologist is providing the blank component

Back 20

professional

Front 21

Samantha was referred for a chest x-ray including the frontal and lateral views. Samantha scheduled an appointment for the x-ray at Mercy Me Hospital. The x-ray was sent to an independent radiologist who read the x-ray and wrote a report of the findings in the x-ray.

Back 21

X-ray: chest 7101
CPT code 71020 w/modifier 26 because Since your provider did not provide both components of the service—technical and professional—you must add the professional component Modifier.
Appendix A: 26 Professional Component
Interpretation of chest x-ray. 71020-26

Front 22

Requests for second and third opinions by an insurance company or government agency are examples that require the addition of modifier blank to the CPT® code. Second opinions may result in different approaches in the management of a patient’s care.

Back 22

32

Front 23

Insurance companies and third-party payers may request consultations for confirmation of a diagnosis, prognosis, or treatment plan for a patient.
A consultation requested in these circumstances is called

Back 23

a confirmatory consultation

Front 24

Richard’s physician recommends he undergo surgery for disc herniation. At the request of Workers’ Compensation, Richard sees Dr. Bartholomew for a second opinion. Dr. Bartholomew does a consultation with Richard and provides documentation to Richard’s physician and Workers’ Compensation.

Back 24

The evaluation and management code for Richard’s visit to Dr. Bartholomew is 99243. The modifier 32 is added to indicate the visit was a mandated service.
Evaluation and management consultation for disc herniation, mandated. 99243-32

Front 25

Examples of preventive services with an A or B rating are screening for high blood pressure, screening for cervical cancer, screening for HIV, screening for cholesterol abnormalities, and more. When assigning a code for these preventive services and when these services are performed for preventive care, assign modifier blank. To see a full list of the preventive services with an A or B rating go to the following webpage: http://www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm

Back 25

33

Front 26

List of preventive care descriptions.

Back 26

http://www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm

Front 27

Modifier blank is appended to the PROCEDURE code and not to any anesthesia code

Back 27

47

Front 28

The administration of a regional or general anesthesia by a surgeon instead of by an anesthesiologist is reported by adding the modifier blank to the procedure code to indicate the surgeon administered the anesthesia.

Back 28

47

Front 29

Blank is a surgical procedure used to diagnose and often treat disorders, diseases, or problems due to injury of a joint. This literally means visual examination of the joint. Most often, arthroscopy is a procedure performed in an outpatient setting by an orthopedic physician.

Back 29

Arthroscopy

Front 30

Blank surgery is a procedure carried out on a knee which has sustained an injury called a medial or lateral meniscus tear. The meniscus is a crescent-shaped piece of cartilage structure which helps cushion the knee joint and absorb shock; there are two of these structures in each knee joint. Damage to the meniscus causes pain, inflammation, and reduced mobility.

Back 30

Meniscectomy

Front 31

A blank system usually consists of a chamber and some kind of tube for gently rinsing cavities in the body, most often the sinuses. A doctor may also use a lavage system to examine the lungs. In these cases, the fluid is added to the lungs, then extracted and examined to discover what kind of infection may be there. Nasal lavage, also called nasal irrigation, usually involves passing water through the sinuses to relieve allergies or help clear away a sinus infection. Typically, the look and style of a lavage system depends largely on what part of the body it is being used to irrigate.

Back 31

lavage

Front 32

Franklin had an arthroscopic medial meniscectomy of the knee performed under general anesthesia at Smallville Hospital. Smallville has no anesthesiologist available to provide the anesthesia, so the surgeon administered the anesthesia and performed the procedure.

Back 32

1. Arthroscopy/ Surgical
2. Knee 29871-29889
3. Surgery 29871 (look for meniscectomy)
29881-47

Front 33

blank modifers are used with E/M codes

Back 33

24 and 25

Front 34

blank modifiers are used with procedure codes only

Back 34

22 and 23

Front 35

When a patient has a procedure performed and subsequently visits the physician who performed the procedure in the time period following the procedure, most often the visit is related to the original procedure.
Modifier blank is the exception for times when a visit is made during the time period following surgery NOT for post-surgical care.

Back 35

24

Front 36

Modifier 24 is used in those cases where a patient has a procedure by a physician and is seen in the postoperative timeframe by the same physician for a different reason.

Back 36

24

Front 37

When an Evaluation and Management visit falls within the postoperative period of a surgery, modifier blank is appended to the E/M code to indicate that the visit is unrelated to the surgery. To report this modifier documentation must be submitted indicating the service provided is not related to the post-op care of the procedure.

Back 37

24

Front 38

A patient underwent a total hip replacement 7 days ago. The patient presents for a routine followup visit. The surgeon who performed the total hip replacement examined the hip and found the surgical site to be healing appropriately.
"CPT® Index":

Back 38

Post-op visit 99024

Front 39

A patient underwent a total hip replacement 10 days ago. The patient presents to the emergency room after being involved in an automobile accident. The patient sustained a fracture to the left arm. The surgeon who performed the total hip replacement was asked by the emergency room doctor to evaluate the patient’s arm. The surgeon performed a problem focused history and examination with straightforward decision making.

Back 39

The patient receives evaluation and management during the hip replacement postoperative period by the same surgeon for a condition unrelated to the total hip replacement (fracture left arm). Turn to the E/M Numeric Section and find code 99241. Remember you will learn how to determine the appropriate E/M code in a future unit.
E/M code describes a physician E/M visit. If the surgeon codes and bills 99241 without a modifier, the third-party payer will reject the claim under the assumption the E/M service is related to the hip replacement. Modifier 24 sends the third-party payer back to the diagnosis code, where they will see the diagnosis is for a different condition even though the patient, surgeon, and surgical time period all indicate the problem is related to the hip.
Evaluation and management fracture left arm. 99241-24

Front 40

Consider a patient who visits the physician’s office because of a problem with severe headaches. The physician spends quite a bit of time evaluating the patient for the headache problem. The physician does a history, physical, and prescribes medication for the patient’s headaches.

Back 40

The evaluation and management code for the patient’s headache evaluation and management is 99202

Front 41

Now let’s assume the patient mentioned a bothersome skin tag during the physical exam and the physician and patient decide it’s a good idea to remove the skin tag during this same visit. The physician performs the procedure (skin tag removal).

Back 41

Now let’s assume the patient mentioned a bothersome skin tag during the physical exam and the physician and patient decide it’s a good idea to remove the skin tag during this same visit. The physician performs the procedure (skin tag removal). The code for the procedure is 11200.

Front 42

When the claim is prepared, if the codes show evaluation and management and skin tag removal, it is not clear that evaluation and management was for a condition separate from the procedure performed (skin tag removal). Payment would be limited to evaluation, management, and care of a skin tag only instead of for evaluation and management of headache, skin tag and removal of a skin tag.

Back 42

Modifier 25 alerts the third-party payer of the two separate services:
1. evaluation and management for a condition OTHER than the condition for which the procedure was performed
2. procedure – removal of the skin tag
Evaluation and management for headache, skin tag removal. 99202–25, 11200

Front 43

Consider a new patient who visits the doctor for pain and swelling of the knee. During an evaluation and management of a problem focused history and examination and straightforward medical decision-making, the physician diagnoses the patient with bursitis of the knee. After some discussion about treatment options, the patient and physician agree to inject the knee with steroids, which the physician performs that day.

Back 43

Clearly the physician should be paid for more than just an injection of the knee. Significant time was spent evaluating and managing the problem, as well as injecting the knee. Evaluation and management was performed by the same physician on the same patient on the same day as a procedure (injection of the knee with steroids). The evaluation and management code (99201) and procedure code (20610) should both be reported AND Modifier 25 should be appended to the E/M code to indicate the patient received evaluation and management services in addition to the procedure performed.
Evaluation and management for pain and swelling of the knee, injection of the knee. 99201-25, 20610

Front 44

A patient who is referred to the outpatient radiology department of the hospital by his or her primary physician for an x-ray receives the blank at the hospital.
If the films are sent back to the primary physician to be interpreted, then the primary physician is providing the blank.

Back 44

technical component
professional component

Front 45

Henry hit his finger with a hammer. He went to see his primary physician who did a physical exam and two view x-ray of the hand. His primary physician read the x-ray as no fractures.

Back 45

Certain procedures are a combination of a physician component and a technical component. When the physician’s component is reported separately, the service may be identified by adding modifier 26 to the usual procedure number.
"CPT® Index":
X-ray
hand 73120-73130
"Numeric Section":
73120
Radiologic examination, hand; two views
X-ray of the hand, technical and professional components. 73120

Front 46

Samantha was referred for a chest x-ray including the frontal and lateral views. Samantha scheduled an appointment for the x-ray at Mercy Me Hospital. The x-ray was sent to an independent radiologist who read the x-ray and wrote a report of the findings in the x-ray.

Back 46

X-ray
chest 71010-71035
"Numeric Section":
71020
Radiologic examination, chest, two views, frontal and lateral
Since your provider did not provide both components of the service—technical and professional—you must add the professional component Modifier.
Appendix A: 26 Professional Component
Interpretation of chest x-ray. 71020-26

Front 47

blank means “two” and blank means “side.”

Back 47

bi and lateral

Front 48

procedures performed on both sides of the body are called

Back 48

bilateral procedures

Front 49

When bilateral procedures are done during the same session, the modifier blank is appended to the procedure code

Back 49

50

Front 50

The modifier 50 is not applicable to procedures that are bilateral by definition or procedures where the descriptions include the terminology

Back 50

"bilateral or unilateral"
see page 299, cpt code 58900.

Front 51

PROCEDURE: Bilateral upper eyelid blepharoplasty with excision of excessive skin weighing down the lid.

Back 51

Blepharoplasty 15820–15823
"Numeric Section":
15822
Blepharoplasty, upper eyelid;
15823
with excess skin weighing down lid

PROCEDURE: Bilateral upper eyelid blepharoplasty with excision of excessive skin weighing down the lid. 15823–50 (There is no description regarding bilateral or unilateral in the cpt book)

Front 52

PROCEDURE: Bilateral tympanostomy with ventilation tube placement under general anesthesia.

Back 52

69436-50

Front 53

During an operative session more than one procedure may be performed. When this occurs, it’s described as multiple procedures. You have to be careful when coding multiple procedures because CPT® codes may include many different procedures bundled together as one code. However, if one code does not describe all the procedures performed, then each secondary procedure code may be reported with the modifier blank.

Back 53

51 appended

Front 54

Add-on codes and codes exempt from modifier 51 are exceptions to the multiple procedures modifier. Appendix D in the CPT codebook lists the add-on codes and Appendix E lists the codes exempt from modifier 51.

Back 54

Appendix D in the CPT codebook lists the add-on codes and Appendix E lists the codes exempt from modifier 51.

Front 55

blank procedure in which the organ is returned to its proper location

Back 55

colporrhaphy

Front 56

PROCEDURES PERFORMED: Total abdominal hysterectomy and anterior and posterior colporrhaphy

Back 56

Hysterectomy
abdominal
total 58150-58200, 58956
"Numeric Section":
58150
Total abdominal hysterectomy (corpus and cervix), with or without removal of tube(s), with or without removal of ovary(s)
"CPT Index":
Colporrhaphy
anteroposterior (sub-term) 57260-57265
"Numeric Section":
57260
Combined anteroposterior colporrhaphy
Go back and carefully read the descriptions for your two procedure codes: 58150 and 57260. Do you see any indication these codes are “bundled” together? Any add-on code symbols? Double check Appendix D—are either of these procedure codes exempt from Modifier 51?
Looks like a true case of multiple procedures.
Appendix A: 51 Multiple Procedures
PROCEDURES PERFORMED: Total abdominal hysterectomy and anterior and posterior colporrhaphy. 58150, 57260-51

Front 57

blank is a surgical procedure that helps to realign a crooked septum. The septum, which is the bony portion that separates the two nostrils, may be crooked due to some type of malformation of the cartilage and the bone itself. This condition adversely affects the ability to breathe through the nose. A simple nasal septoplasty can straighten the bone and repair the cartilage, allowing a normal flow of air through the nostrils.

Back 57

Septoplasty

Front 58

An blank is an intranasal procedure that is used to treat these conditions. Intranasal means that this procedure is performed with tools that enter the body through the nose. An endoscope, which is tube with a camera and light connected to it, is used to help guide the surgeon in this task.

Back 58

etmoidectomy

Front 59

An blank is a surgical procedure that is used to treat infections in these sinus cavities. During this procedure, matter that blocks drainage of the ethmoid sinuses is removed.

Back 59

ethmoidectomy

Front 60

PROCEDURE: Septoplasty and unilateral anterior ethmoidectomy

Back 60

"CPT® Index":
Septoplasty 30520
"Numeric Section":
30520
Septoplasty or submucous resection, with or without cartilage scoring, contouring or replacement with graft
(Read all pertinent notes, symbols).
PROCEDURE: Septoplasty and unilateral anterior ethmoidectomy.
"CPT® Index":
Ethmoidectomy 31200-31205
"Numeric Section":
31200
Ethmoidectomy; intranasal, anterior
Once again, there is no indication these procedures are bundled. Double check Appendices D and E to make sure neither of these procedure codes are add-on codes or exempt from modifier 51.
Appendix A: 51 Multiple Procedures
PROCEDURE: Septoplasty and unilateral anterior ethmoidectomy. 30520, 31200-51