Procedure Code Modifiers

As defined by the Physicians’ Current Procedural Terminology/Healthcare Common Procedure Coding System (CPT/HCPCS), a modifier is a two-character (alpha and/or numeric) code that is appended to the CPT/HCPCS procedure code to clarify the services being billed.

The modifier indicates that the service or procedure performed has been altered by some specific circumstance but not changed in its definition or code.

Modifiers are grouped into two levels described below:
Level I:  Modifiers and descriptors that are copyrighted by the American Medical Association
Level II: Modifiers and descriptors approved and maintained by CMS’ Alpha-Numeric Editorial Panel

Understanding how and when to use a CPT/HCPCS modifier is vital for proper reporting of medical services and procedures.

Blue Cross and Blue Shield of Alabama will accept modifiers that comply with the Health Insurance Portability and Accountability Act (HIPAA) legislation. Many modifiers are considered “informational only” and do not affect the processing of the claim or reimbursement. The lack of modifiers or the improper use of modifiers can result in claims delays or claims denials. Following are some of the modifiers that Blue Cross recognizes or requires:

• Modifier 24 – Unrelated Evaluation and Management (E&M) service by the same physician during a postoperative period.
  
• Modifier 25 – Significant, separately identifiable E&M service by the same physician on the same day of the procedure or other service. (Modifier 25 Exception Listing)
   
• Modifier 26 (Professional Component) – Certain procedures are a combination of a physician component and a technical component. When the physician component is reported separately, the service may be identified by adding to the procedure code.

• Modifier 50 (Bilateral Surgery) – When billing for bilateral surgery, the procedure code should be listed on two lines with modifier 50 (bilateral procedure) placed to the right of the procedure code on the second line. The first surgical procedure pays at 100 percent of the allowance and the bilateral procedure will be processed at 50 percent of the unilateral allowance.
• Modifiers 53, 73 and 74 – These modifiers indicate that a surgical or diagnostic procedure was terminated due to extenuating circumstances.
  
• Modifiers 54, 55 and 56 (Optometrist and Ophthalmologist only) – These modifiers may be utilized by optometrists and ophthalmologists to allow for separate billing of postoperative care only (modifier 55), surgery only (modifier 54) and preoperative care only (modifier 56).
  
• Modifier 57 (Decision for Surgery) – An E&M service that resulted in the initial decision to perform the surgery may be identified by this modifier.
  
• Modifier 59 (Distinct Procedural Service) – Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E&M services performed on the same day. (Modifier 59 Exception Listing)
  
• Modifier 62 (Two Surgeons) – When two surgeons work together as primary surgeons performing distinct parts of a procedure, each surgeon should file his/her distinctive work by adding modifier 62 to the procedure code and any associated add-on codes for that procedure as long as both surgeons continue to work together as primary surgeons. Each surgeon should file the co-surgery once using the same procedure codes. If additional procedures are performed during the same surgical session, separate codes may be filed with modifier 62 attached.
  
• Modifier 66 (Surgical Team) – Under some circumstances, highly complex procedures (requiring the concomitant services of several physicians, often of different specialties, plus other highly skilled, specialty trained personnel, various types of complex equipment) are carried out under the “surgical team” concept. Such circumstances may be identified by each participating physician filing the addition of modifier 66 to the basic procedure code used for filing the services.
  
• Modifiers 80, 81, 82 and AS - All charges for assistant surgery services must contain one of these modifiers. 
  
• Modifier 90 - When sending laboratory work to an outside laboratory to be analyzed, there is reimbursement available for the venipuncture to draw the specimen. Use modifier 90 following the venipuncture. Laboratory work that is performed in the physician’s office includes reimbursement for the drawing of blood.
  
• Modifiers AA, P1 – P6 – Modifiers used for anesthesia services only.
  
• Modifiers RT and LT – The right (RT) and left (LT) modifiers should always be the initial modifier listed when multiple modifiers are reported.

Last Updated March 2010