Term
|
Definition
Increased Procedural Services:
When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. Documentation must support the substantial additional work and the reason for the additional work (increased intensity, time, technical difficulty of procedure, severity of pt condition, physical and mental effort required.
this modifier should NOT be appended to an E/M service. |
|
|
Term
|
Definition
Unusual Anesthesia
Occasionally, a procedure, which usually requires either no anesthesia or local anesthesia, because of unusual circumstances must be done under general anesthesia. This circumstance may be reported by adding modifier 23 to the procedure code of the basic service. |
|
|
Term
|
Definition
Unrelated E/M Service by the Same Physician During a Post op Period:
The physician may need to indicate that an E/M service was performed during a postop period for a reason(s) unrelated to the original procedure.
this circumstance may be reported by adding modifier 24 to the appropriate level of E/M service. |
|
|
Term
|
Definition
Significant, Separately Identifiable E/M Service by the Same Physician on the Same Day of the Procedure or Other Service
It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the pt condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preop and postop care associated with the procedure that was performed.
This modifier is not used to report an E/M service that resulted in a decision to perform surgery. |
|
|
Term
| Define: Significant, separately identifiable E/M service |
|
Definition
service is defined or substantiated by documentation that satisfies the relevent criteria for the respective E/M service to be reported.
The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. |
|
|
Term
|
Definition
Professional Component
Certain procedures are a combination of a physicican component and a technical component. When the physician component is reported separately, the service may be identified by adding modifier 26 to the usual procedure number. |
|
|
Term
|
Definition
Mandated Services
Services related to mandated consultation and/or related services (3rd party payer, governmental, legislative or regulatory requirement) may be identified by adding modifier 32 to the basic procedure. |
|
|
Term
|
Definition
Anesthesia by Surgeon
Regional or general anesthesia provided by the surgeon may be reported by adding modifier 47 to the basic service.
DOES NOT INCLUDE local anesthesia
Modifier 47 would not be used as a modifier for the anesthesia procedures |
|
|
Term
|
Definition
Bilateral Procedure:
Unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. |
|
|
Term
|
Definition
Multiple Procedures
When multiple procedures, other than E/M services, Physical Medicine and Rehabilitation services or provision of supplies (vaccines) are performed at the same session by the same provider, the primary procedure or service may be reported as listed. The additional procedure or service(s) may be identified by appending modifier 51 to the additional procedure or service code.
This modifier should not be appended to designated "add0on" codes (See Appendix D) |
|
|
Term
|
Definition
Reduced Services
Under certain circumstances a service or procedure is partially reduced or eliminated at the physician's discretion.
Under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced.
This provides a means of reporting reduced services without disturbing the identificaiton of the basic service.
NOTE: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 |
|
|
Term
|
Definition
Discontinued Procedure:
Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances, or those that threaten the well-being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued.
Use of modifier 53 is allowed for all surgical procedures. Modifier 53 is a payment modifier when used with CPT code 45378 and HCPCS codes G0105 and G0121 only. It is “information only” for all other surgical procedures. |
|
|
Term
|
Definition
| 54, 55, 56 – Providers providing less than the global surgical package should use modifiers 54, 55, & 56. These modifiers are designed to ensure that the sum of all allowances for all practitioners who furnished parts of the services included in a global surgery fee do not exceed the total amount of the payment that would have been paid to a single practitioner under the global fee for the procedure. The payment policy pays each physician directly for that portion of the global surgery services provided to the client. The breakdown is as follows: |
|
|
Term
|
Definition
| Surgical Care Only: When one physician performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding modifier 54 to the usual procedure number. A specific percentage of the global surgical payment in the fee schedule is made for the surgical procedure only. |
|
|
Term
|
Definition
| Postoperative Management Only: When one physician performs the postoperative management and another physician has performed the surgical procedure, the postoperative component may be identified by adding the modifier 55 to the usual procedure number. A specific percentage of the global surgical payment in the fee schedule is made for the surgical procedure only. |
|
|
Term
|
Definition
| Preoperative Management Only: When one physician performs the preoperative care and evaluation and another physician performs the surgical procedure, the preoperative component may be identified by adding the modifier 56 to the usual procedure number. A specific percentage of the global surgical payment in the fee schedule is made for the surgical procedure only. |
|
|
Term
|
Definition
| Decision for Surgery: An evaluation and management (E&M) service provided the day before the day of surgery that resulted in the initial decision to perform the surgery, may be identified by adding the modifier 57 to the appropriate level of E&M service. This does not apply to minor surgeries (those with a follow-up period of less than 90 days) |
|
|
Term
|
Definition
| Staged or Related Procedure or Service by the Same Physician During the Postoperative Period: The physician may need to indicate that the performance of a procedure or service during the postoperative period was: a) planned prospectively at the time of the original procedure (staged); b) more extensive than the original procedure; or c) for therapy following a diagnostic surgical procedure. This circumstance may be reported by adding the modifier 58 to the staged or related procedure. NOTE: This modifier is not used to report the treatment of a problem that requires a return to the operating room. See modifier 78. |
|
|
Term
|
Definition
| Distinct Procedural Service: The physician must indicate that a procedure or service was distinct or separate from other services performed on the same day. This may represent a different session or patient encounter, different procedure or surgery, different site, separate lesion, or separate injury (or area of surgery in extensive injuries). This modifier is for informational purchases only; no extra allowance is allowed. |
|
|
Term
|
Definition
| Two Surgeons: Under certain circumstances, the skills of two surgeons (usually with different skills) may be required in the management of a specific surgical procedure. Under such circumstances, separate services may be identified by adding modifier 62 to the procedure code used by each surgeon for reporting his/her services. Payment for this modifier is 125% of the global surgical fee in the fee schedule. The payment is divided equally between the two surgeons. No payment is made for an assistant surgeon. |
|
|
Term
|
Definition
| Team surgery: For informational purposes only; no extra allowance is allowed. |
|
|
Term
|
Definition
| Repeat Procedure by Same Physician: The physician may need to indicate that a procedure or service was repeated. This may be reported by adding the modifier 76 to the repeated service. |
|
|
Term
|
Definition
Repeat Procedure by Another Physician:
It may be necessary to indicate that a basic procedure or service was repeated by another physician or other qualified health care professional subsequent to the original procedure or service. This circumstance may be reported by adding modifier 77 to the repeated procedure or service.
NOTE: This modifier should not be appended to an E/M service
For informational purposes only; no extra allowance is allowed. |
|
|
Term
|
Definition
|
|
