Medical services and procedures are often complex, so there is a need for additional information when coding.
CPT modifiers serve like modifiers in a language, providing additional information about the procedure.
In a language, a modifier describes the who, or what, or why, or how, or where of a situation.
In a similar way, CPT modifiers describe which procedures were necessary, if several procedures were performed, on which part of the body they were performed, how many providers were engaged, and other information that can be essential for the status of a claim with the insurer.
CPT modifiers always contain two characters and can be numeric or alphanumeric.
Most of them are numeric, but there are some alphanumeric modifiers in the Anesthesia section.
These modifiers are added to the end of code with a hyphen.
If there is more than one modifier, the first one will be “functional”, then “informational”.
The difference between them is simple.
You should always list the modifiers that affect the reimbursement process first.
There is a simple reason for that.
The CMS-1500 and UB-04 forms, which are the most common claim forms, have space for four modifiers.
But payers don’t usually look further than the first two of them.
For this reason, the most essential modifiers should always be visible.
The CPT modifiers we are talking about are copyrighted by the AMA and depend on specific guidelines and factors.
That means that there are certain rules for their use.
You can’t just add a modifier to the code if you think it is appropriate.
For instance, there are modifiers that can’t be used with Evaluation and Management (E&M) codes.
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Here’s an example of a CPT modifier:
A patient gets a procedure for a bone cyst removal in the upper arm by a surgeon.
The procedure also requires getting a graft from another spot on the body.
Because of some complications, the surgeon can’t fully remove the bone cyst.
The procedure code we’d use is 23140 – “excision or curettage of the bone cyst or benign tumor, humerus; with autograft (includes obtaining the graft).”.
Since the procedure wasn’t completed 100% successfully, the modifier -52 (for reduced services) would have to be added to the code.
So the final code would be 23140-52.
Physical Status Modifier (for Anesthesia)
There is a separate set of modifiers for anesthesia procedures.
They are simple and correspond with the patient’s conditions as the anesthesia is administered.
These codes include:
- P1 – a normal, healthy patient.
- P2 – a patient with mild systemic disease.
- P3 – a patient with severe systemic disease.
- P4 – a patient with severe systemic disease that is a constant threat to life.
- P5 – a moribund patient who is not expected to survive without the operation.
- P6 – a declared brain-dead patient whose organs are being removed for donor purposes.
As mentioned before, these are pretty straightforward, but let’s consider another example that will also use some CPT modifiers.
Back to our angioplasty example.
The patient needs anesthesia before the procedure.
So we should turn to the Anesthesia section of the CPT and look for code 00216 for “vascular procedures.”
Our patient is in good health, except for some kidney problems, so we would add the modifier -P1 and end up with code 00216-P1.
Modifiers Approved for Ambulatory Surgery Center (ASC) Hospital Outpatient Use
Ambulatory surgery centers (ASC) also use CPT modifiers.
These are outpatient facilities that specialize in procedures where the patient can go home on the same day.
Some of these modifiers can overlap or contradict with the HCPCS modifiers set.
For instance, the HCPCS codes, which are used to report procedures to Medicaid and Medicare, have modifiers describing the side of the body on which the procedure was performed.
All you need to know at this point is that HCPCS is another code set that has a lot in common with CPT, but comes with its own set of modifiers.
Health insurance payers may require supplemental reports to many CPT modifiers.
For example, if a payer wants to know why the surgery for lesions on the liver repairing was discounted (e.g., there was a complication with one of the proximal organs), a supplementary report stating this would have to be filed.
Coding should be done with the highest level of specificity with as much documentation as possible.
If a modifier needs medical necessity justification but doesn’t have a supplemental report, the claim on the procedure can be rejected.