Medical Billing and Coding Lesson
8: CPT Actual Modifiers with
questions and answers
CPT Modifiers
Modifiers are used to describe alterations to the 5-digit CPT code
to accommodate special circumstances. Appendix A of the CPT
manual contains a full list of modifiers. You can find a quick
reference list on the manual's inside cover.
Modifiers communicate to third-party payers a situation that may
alter the way in which payment is made. If a service is coded
without use of an appropriate modifier, reimbursement will be
based on the standard service deliverable, which may result in
overpayment or underpayment.
Modifier Functions
When a modifier is added to the 5-digit CPT code, it can change
the CPT code to include the following types of additional
information
Alter the service - for example, more or less service
Bilateral procedure
Multiple procedures
Only portions of service (i.e., professional service only)
More than one surgeon
Unusual service
Example: If a modifier code was not used when a patient received
a service that was performed bilaterally on the same day, the
,third-party payer would assume that the billing for the second
service was a duplicate of the billing for the first service and
would not pay it.
Note that third-party payers often consider surgical procedures as
part of a “package”. The surgical “package” encompasses
components ranging from preoperative work to supplies and
postoperative visits. There is a defined period of time following
each surgery that is referred to as the “global surgery period”.
Some of the modifiers in this lesson refer to that global period,
which typically is 90 days for major surgery and 10 days for more
minor surgeries.
Modifier -22
Modifier -22 indicates that the services performed were
significantly greater than usual. Use of this modifier must be
accompanied by written report and supportive documentation.
The written report describes the increased physician work.
Examples:
Increased risk to the patient caused by complications
Difficulty of the procedure
Excessive blood loss
Other circumstance that significantly altered the delivery of the
service.
Because Modifier -22 is overused, and because it increases
payment by as much as 20 to 30 percent, it is subject to special
scrutiny by third-party payers.
Modifier -23
You should use code modifier -23 when anesthesia is used in a
procedure that normally does not involve either general or local
anesthesia. The modifier is used only with anesthesia codes and
requires a written report with the submission of the modifier.
, Example: A highly agitated senile patient might require the use of
anesthesia for a procedure in which anesthesia is not normally
used.
Modifier -24
Modifier -24 is used when an E/M Service is performed during a
postoperative period that is unrelated to recovery from the
surgery. This E/M service is separately billable. Use -24 only on an
E/M code. If E/M related to the surgical procedure is provided
during the post-op global period, there is no separate payment for
E/M services.
Although the modifier -24 is most often used for surgical services,
it also may be used with the general ophthalmological services
codes 92002-92014, which are used to code medical
examinations for new and established patients.
Example: Patient is in global period for hip surgery and is now
seen for a fractured collarbone.
Modifier -25
Use modifier -25 to report another E/M service on a patient by the
same doctor on the same day. Documentation must support the
additional service to clarify medical necessity.
Examples:
On a patient seen for sinus congestion, the physician performs a
“history and physical” examination (H&P), prescribes a
decongestant, notes a lesion on the patient’s back, and removes
it. Code the procedure (lesion removal) + E/M -25.
A patient seen on consultation for pain management, and
subsequent to rendering an opinion, was given a nerve injection.
Modifier -25 is placed on E/M code.
Modifier -26
8: CPT Actual Modifiers with
questions and answers
CPT Modifiers
Modifiers are used to describe alterations to the 5-digit CPT code
to accommodate special circumstances. Appendix A of the CPT
manual contains a full list of modifiers. You can find a quick
reference list on the manual's inside cover.
Modifiers communicate to third-party payers a situation that may
alter the way in which payment is made. If a service is coded
without use of an appropriate modifier, reimbursement will be
based on the standard service deliverable, which may result in
overpayment or underpayment.
Modifier Functions
When a modifier is added to the 5-digit CPT code, it can change
the CPT code to include the following types of additional
information
Alter the service - for example, more or less service
Bilateral procedure
Multiple procedures
Only portions of service (i.e., professional service only)
More than one surgeon
Unusual service
Example: If a modifier code was not used when a patient received
a service that was performed bilaterally on the same day, the
,third-party payer would assume that the billing for the second
service was a duplicate of the billing for the first service and
would not pay it.
Note that third-party payers often consider surgical procedures as
part of a “package”. The surgical “package” encompasses
components ranging from preoperative work to supplies and
postoperative visits. There is a defined period of time following
each surgery that is referred to as the “global surgery period”.
Some of the modifiers in this lesson refer to that global period,
which typically is 90 days for major surgery and 10 days for more
minor surgeries.
Modifier -22
Modifier -22 indicates that the services performed were
significantly greater than usual. Use of this modifier must be
accompanied by written report and supportive documentation.
The written report describes the increased physician work.
Examples:
Increased risk to the patient caused by complications
Difficulty of the procedure
Excessive blood loss
Other circumstance that significantly altered the delivery of the
service.
Because Modifier -22 is overused, and because it increases
payment by as much as 20 to 30 percent, it is subject to special
scrutiny by third-party payers.
Modifier -23
You should use code modifier -23 when anesthesia is used in a
procedure that normally does not involve either general or local
anesthesia. The modifier is used only with anesthesia codes and
requires a written report with the submission of the modifier.
, Example: A highly agitated senile patient might require the use of
anesthesia for a procedure in which anesthesia is not normally
used.
Modifier -24
Modifier -24 is used when an E/M Service is performed during a
postoperative period that is unrelated to recovery from the
surgery. This E/M service is separately billable. Use -24 only on an
E/M code. If E/M related to the surgical procedure is provided
during the post-op global period, there is no separate payment for
E/M services.
Although the modifier -24 is most often used for surgical services,
it also may be used with the general ophthalmological services
codes 92002-92014, which are used to code medical
examinations for new and established patients.
Example: Patient is in global period for hip surgery and is now
seen for a fractured collarbone.
Modifier -25
Use modifier -25 to report another E/M service on a patient by the
same doctor on the same day. Documentation must support the
additional service to clarify medical necessity.
Examples:
On a patient seen for sinus congestion, the physician performs a
“history and physical” examination (H&P), prescribes a
decongestant, notes a lesion on the patient’s back, and removes
it. Code the procedure (lesion removal) + E/M -25.
A patient seen on consultation for pain management, and
subsequent to rendering an opinion, was given a nerve injection.
Modifier -25 is placed on E/M code.
Modifier -26
