Coding With Modifiers

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 iii

Contents

Preface xi
About the Author . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xv

Chapter 1 Introduction to CPT Modifiers 1

CPT Code Set Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
HIPAA and CPT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Who Maintains the CPT Code Set Nomenclature? . . . . . . . . . . . . . . . . 2
How Suggestions for Changes to the CPT Code Set Are Reviewed . . . . . . . 3
The CPT Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
The HCPCS Coding System . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
Modifiers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Types of Modifiers Used in the Reimbursement Process. . . . . . . . . . . . . 12
Why Use Modifiers?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Surgical Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Modifiers and Reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
RBRVS Payment Rules and Policies . . . . . . . . . . . . . . . . . . . . . . . . 18
The Proper Use of Modifiers: Step by Step . . . . . . . . . . . . . . . . . . . . 19
Chapter 1 Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Test Your Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Chapter 2 Modifiers 22 to 24 and the Physical Status Modifiers 23

Modifier 22: Increased Procedural Services. . . . . . . . . . . . . . . . . . . . 23
Modifier 23: Unusual Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . 30
Reporting Anesthesia Services . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Physical Status Modifiers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Modifier 24: Unrelated Evaluation and Management Service by the
Same Physician During a Postoperative Period . . . . . . . . . . . . . . . . . . 38
Test Your Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

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Chapter 3 Modifiers 25 to 47 49
Modifier 25: Significant, Separately Identifiable Evaluation
and Management Service by the Same Physician on the
Same Day of the Procedure or Other Service . . . . . . . . . . . . . . . . . . . 49
The National Correct Coding Initiative and Modifier 25. . . . . . . . . . . . . . 52
Checkpoint Exercises 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68
Modifier 26: Professional Component . . . . . . . . . . . . . . . . . . . . . . . 69
Checkpoint Exercises 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Modifier 27: Multiple Outpatient Hospital E/M Encounters
on the Same Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
Modifier 32: Mandated Services . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Modifier 33 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
Modifier 47: Anesthesia by Surgeon. . . . . . . . . . . . . . . . . . . . . . . . 82
Test Your Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

Chapter 4 Modifiers 50 to 56 91
Modifier 50: Bilateral Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . 91
Modifier 51: Multiple Procedures . . . . . . . . . . . . . . . . . . . . . . . . . 97
Modifier 52: Reduced Services. . . . . . . . . . . . . . . . . . . . . . . . . . 107
Modifier 53: Discontinued Procedure . . . . . . . . . . . . . . . . . . . . . . 111
Checkpoint Exercises 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
Modifiers 54, 55, and 56 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116
Modifier 54: Surgical Care Only . . . . . . . . . . . . . . . . . . . . . . . . . 123
Modifier 55: Postoperative Management Only . . . . . . . . . . . . . . . . . 125
Modifier 56: Preoperative Management Only . . . . . . . . . . . . . . . . . . 128
Checkpoint Exercises 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131
Test Your Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132

Chapter 5 Modifiers 57 to 63 135

Modifier 57: Decision for Surgery . . . . . . . . . . . . . . . . . . . . . . . . 135
Modifier 58: Staged or Related Procedure or Service by the
Same Physician During the Postoperative Period. . . . . . . . . . . . . . . . 140
Checkpoint Exercises 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146
Modifier 59: Distinct Procedural Service . . . . . . . . . . . . . . . . . . . . 147
The National Correct Coding Initiative . . . . . . . . . . . . . . . . . . . . . . 149
Modifier 62: Two Surgeons. . . . . . . . . . . . . . . . . . . . . . . . . . . . 161
Modifier 63: Procedure Performed on Infants Less than 4 kg . . . . . . . . . 169
Checkpoint Exercises 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172
Test Your Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174

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Chapter 6 Modifiers 66 to 82 179

Modifier 66: Surgical Team . . . . . . . . . . . . . . . . . . . . . . . . . . . . 179
Repeat Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
Modifier 76: Repeat Procedure or Service by Same Physician
or Other Qualified Health Care Professional. . . . . . . . . . . . . . . . . . . 183
Modifier 77: Repeat Procedure or Service by Another Physician
or Other Qualified Health Care Professional. . . . . . . . . . . . . . . . . . . 188
Checkpoint Exercises 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191
Modifier 78: Unplanned Return to the Operating/Procedure Room
by the Same Physician or Other Qualified Health Care Professional
Following Initial Procedure for a Related Procedure During the
Postoperative Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192
Modifier 79: Unrelated Procedure or Service by the Same Physician
During the Postoperative Period . . . . . . . . . . . . . . . . . . . . . . . . . 197
Modifiers 80 to 82: Assistant Surgeons . . . . . . . . . . . . . . . . . . . . . 201
Modifier 80: Assistant Surgeon . . . . . . . . . . . . . . . . . . . . . . . . . 201
Modifier 81: Minimum Assistant Surgeon . . . . . . . . . . . . . . . . . . . . 207
Modifier 82: Assistant Surgeon (when qualified resident
surgeon not available) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209
Test Your Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214

Chapter 7 Modifiers 90 to 99 217

Modifier 90: Reference (Outside) Laboratory . . . . . . . . . . . . . . . . . . 217
Modifier 91: Repeat Clinical Diagnostic Laboratory Test . . . . . . . . . . . . 220
Modifier 92: Alternative Laboratory Platform Testing . . . . . . . . . . . . . 225
Modifier 99: Multiple Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . 227
Test Your Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230

Chapter 8 HCPCS Level II Modifiers 233

Reporting HCPCS Modifiers According to HIPAA Rules . . . . . . . . . . . . 234
Modifiers Used for Ambulance Services . . . . . . . . . . . . . . . . . . . . 235
Anesthesia HCPCS Level II Modifiers . . . . . . . . . . . . . . . . . . . . . . 236
Dressings, Wounds, and Supplies . . . . . . . . . . . . . . . . . . . . . . . . 240
Drugs and Enteral/Parenteral Therapy, Supplies, and Infusion . . . . . . . . 241
Glucose Monitoring and Supplies . . . . . . . . . . . . . . . . . . . . . . . . 243
Durable Medical Equipment and Orthotic/Prosthetic Devices . . . . . . . . . 246
Ostomy Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248
Lower-Limb Prostheses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249
Pathology and Laboratory Services . . . . . . . . . . . . . . . . . . . . . . . 251

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Waived and Provider-Performed Microscopy (PPM) Tests . . . . . . . . . . . 253

Radiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254
Dialysis/Hemodialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259
Oxygen and Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261
Vision Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262
Professional Service Modifiers. . . . . . . . . . . . . . . . . . . . . . . . . . 267
Modifiers Used in Mental Health . . . . . . . . . . . . . . . . . . . . . . . . . 268
Miscellaneous Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273
Anatomic Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282
Foot Care Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285
National Modifiers Not Payable by Medicare . . . . . . . . . . . . . . . . . . 286
Test Your Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289

Chapter 9 Ambulatory Surgery Center and Hospital Outpatient Modifiers 293

Status Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293
Ambulatory Payment Classifications . . . . . . . . . . . . . . . . . . . . . . 297
CPT/HCPCS Level II Modifiers Approved for Use in the
Ambulatory Surgery Center . . . . . . . . . . . . . . . . . . . . . . . . . . . 300
When to Use HCPCS Level II Modifiers Approved for
Outpatient Hospital Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . 305
Modifier 25: Significant, Separately Identifiable Evaluation
and Management Service by the Same Physician on the
Same Day of the Procedure or Other Service . . . . . . . . . . . . . . . . . . 307
Modifier 27: Multiple Outpatient Hospital E/M Encounters
on the Same Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311
Modifier 50: Bilateral Procedure . . . . . . . . . . . . . . . . . . . . . . . . . 315
Modifier 52: Reduced Services. . . . . . . . . . . . . . . . . . . . . . . . . . 319
Checkpoint Exercises 1 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323
Modifier 58: Staged or Related Procedure or Service by the
Same Physician During the Postoperative Period. . . . . . . . . . . . . . . . 323
Modifier 59: Distinct Procedural Service . . . . . . . . . . . . . . . . . . . . 326
Modifier 73: Discontinued Outpatient Hospital/Ambulatory
Surgery Center (ASC) Procedure Prior to the Administration
of Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331
Modifier 74: Discontinued Outpatient Hospital/Ambulatory Surgery
Center (ASC) Procedure After Administration of Anesthesia . . . . . . . . . 334
Checkpoint Exercises 2 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 336
Modifiers 76, 77, 78, and 79 . . . . . . . . . . . . . . . . . . . . . . . . . . . 337
Modifier 76: Repeat Procedure or Service by Same Physician or
Other Qualified Health Care Professional . . . . . . . . . . . . . . . . . . . . 337

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Modifier 77: Repeat Procedure or Service by Another Physician or

Other Qualified Health Care Professional . . . . . . . . . . . . . . . . . . . . 339
Modifier 78: Unplanned Return to the Operating Room/Procedure
Room by the Same Physician or Other Qualified Health Care
Professional Following Initial Procedure for a Related Procedure
During the Postoperative Period . . . . . . . . . . . . . . . . . . . . . . . . . 340
Modifier 79: Unrelated Procedure or Service by the Same Physician
During the Postoperative Period . . . . . . . . . . . . . . . . . . . . . . . . . 341
Modifier 91: Repeat Clinical Diagnostic Laboratory Test . . . . . . . . . . . . 343
Checkpoint Exercises 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345
HCPCS Level II (National) Modifiers Approved for the ASC . . . . . . . . . . 345
Test Your Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 348

Chapter 10 Genetic Testing Modifiers and Category II Modifiers 353

Genetic Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 353
Category II Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365
Modifier 1P: Performance Measure Exclusion Modifier due to
Medical Reasons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 366
Modifier 2P: Performance Measure Exclusion Modifier due to
Patient Reasons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367
Modifier 3P: Performance Measure Exclusion Modifier due to
System Reasons. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 368
Modifier 8P: Performance Measure Reporting . . . . . . . . . . . . . . . . . 369
Test Your Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 370

Appendix A HCPCS (Level I) CPT Modifiers 371

CPT Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
Anesthesia Physical Status Modifiers . . . . . . . . . . . . . . . . . . . . . . 377
Modifiers Approved for Ambulatory Surgery Center (ASC)
Hospital Outpatient Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377

Appendix B HCPCS (Level II) Modifiers 383

HCPCS Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383

Appendix C Genetic Testing Modifiers 397

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Appendix D Logic Trees 403

Modifier 22: Increased Procedural Services. . . . . . . . . . . . . . . . . . . 403
Modifier 23: Unusual Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . 404
Modifier 24: Unrelated Evaluation and Management Service
by the Same Physician During a Postoperative Period . . . . . . . . . . . . . 405
Modifier 25: Significant, Separately Identifiable Evaluation and
Management Service by the Same Physician on the Same Day
of the Procedure or Other Service . . . . . . . . . . . . . . . . . . . . . . . . 406
Modifier 26: Professional Component . . . . . . . . . . . . . . . . . . . . . . 407
Modifier 27: Multiple Outpatient Hospital E/M Encounters on the
Same Date . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 408
Modifier 32: Mandated Services . . . . . . . . . . . . . . . . . . . . . . . . . 409
Modifier 47: Anesthesia by Surgeon. . . . . . . . . . . . . . . . . . . . . . . 410
Modifier 50: Bilateral Procedure . . . . . . . . . . . . . . . . . . . . . . . . . 411
Modifier 51: Multiple Procedures . . . . . . . . . . . . . . . . . . . . . . . . 412
Modifier 52: Reduced Services. . . . . . . . . . . . . . . . . . . . . . . . . . 413
Modifier 53: Discontinued Procedure . . . . . . . . . . . . . . . . . . . . . . 414
Modifier 54: Surgical Care Only . . . . . . . . . . . . . . . . . . . . . . . . . 415
Modifier 55: Postoperative Management Only . . . . . . . . . . . . . . . . . 416
Modifier 56: Preoperative Management Only . . . . . . . . . . . . . . . . . . 417
Modifier 57: Decision for Surgery . . . . . . . . . . . . . . . . . . . . . . . . 418
Modifier 58: Staged or Related Procedure or Service by the
Same Physician During the Postoperative Period. . . . . . . . . . . . . . . . 419
Modifier 59: Distinct Procedural Service . . . . . . . . . . . . . . . . . . . . 420
Modifier 62: Two Surgeons. . . . . . . . . . . . . . . . . . . . . . . . . . . . 421
Modifier 63: Procedure Performed on Infants less than 4 kg. . . . . . . . . . 422
Modifier 66: Surgical Team . . . . . . . . . . . . . . . . . . . . . . . . . . . . 423
Modifier 73: Discontinued Out-patient Hospital/Ambulatory
Surgery Center (ASC) Procedure Prior to the Administration
of Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 424
Modifier 74: Discontinued Out-patient Hospital/Ambulatory Surgery
Center (ASC) Procedure After Administration of Anesthesia . . . . . . . . . 425
Modifier 76: Repeat Procedure or Service by Same Physician or
Other Qualified Health Care Professional . . . . . . . . . . . . . . . . . . . . 426
Modifier 77: Repeat Procedure by Another Physician or
Other Qualified Health Care Professional . . . . . . . . . . . . . . . . . . . . 427
Modifier 78: Unplanned Return to the Operating/Procedure Room
by the Same Physician or Other Qualified Health Care Professional
Following Initial Procedure for a Related Procedure During the
Postoperative Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 428
Modifier 79: Unrelated Procedure or Service by the Same Physician
During the Postoperative Period . . . . . . . . . . . . . . . . . . . . . . . . . 429
Modifier 80: Assistant Surgeon . . . . . . . . . . . . . . . . . . . . . . . . . 430

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Modifier 81: Minimum Assistant Surgeon . . . . . . . . . . . . . . . . . . . . 431

Modifier 82: Assistant Surgeon (when qualified resident surgeon
not available) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 432
Modifier 90: Reference (Outside) Laboratory . . . . . . . . . . . . . . . . . . 433
Modifier 91: Repeat Clinical Diagnostic Laboratory Test . . . . . . . . . . . . 434
Modifier 92: Alternative Laboratory Platform Testing . . . . . . . . . . . . . 435
Modifier 99: Multiple Modifiers . . . . . . . . . . . . . . . . . . . . . . . . . 436

Subject Index 437

Code Index 453

Supplementary Materials page 462

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List of Figures
The CPT Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Figure 2-1 Modifier 22 Validation Letter. . . . . . . . . . . . . . . . . . . . . . . 26
Figure 4-1 Example of Modifier 51 Exempt . . . . . . . . . . . . . . . . . . . . . 99
Figure 6-1 Repeat Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . 183
Figure 7-1 Multiple Modifier Example (Modifier 99) . . . . . . . . . . . . . . . 227
Figure 8-1 Advanced Beneficiary Notice of Noncoverage (ABN) . . . . . . . . 276

List of Tables
Table 3-1 Global Surgical Days . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Table 4-1 Excerpt from Medicare Fee Schedule Database
Bilateral Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94
Table 4-2 Global Split Table for CPT Code 43045 . . . . . . . . . . . . . . . . .125
Table 5-1 NCCI Edit Example . . . . . . . . . . . . . . . . . . . . . . . . . . . 153
Table 5-2 CMS Medicare Fee Schedule Database (MFSDB) 2011 . . . . . . . 165
Table 5-3 CMS Medicare Fee Schedule Database Indicators . . . . . . . . . . 167
Table 5-4 CMS Medicare Fee Schedule Database (MFSDB) . . . . . . . . . . 168
Table 6-1 Medicare Fee Schedule Database Excerpt . . . . . . . . . . . . . . 194
Table 6-2 Assistant Surgery Rules (Modifier 80) . . . . . . . . . . . . . . . . 203
Table 6-3 Assistant Surgeon Reduction 2011 . . . . . . . . . . . . . . . . . . 204
Table 6-4 Assistant-at-Surgery Reduction 2011 . . . . . . . . . . . . . . . . . 204
Table 9-1 Payment Status Indicators for the Hospital Outpatient
Prospective Payment System . . . . . . . . . . . . . . . . . . . . . 294
Table 9-2 CPT (HCPCS Level I) Modifiers Approved for
Ambulatory Surgery Centers . . . . . . . . . . . . . . . . . . . . . 302
Table 9-3 Evaluation and Management Services with APC Assignment
for Hospital Clinic and Emergency Department Visits . . . . . . . . 307
Table 10-1 CPT Codes Currently Used with CPT Genetic Modifiers . . . . . . . 354
Table 10-2 Genetic Testing Code Modifiers . . . . . . . . . . . . . . . . . . . . 357
Table A-1 CPT Modifiers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371
Table A-2 Physical Status Modifiers . . . . . . . . . . . . . . . . . . . . . . . 377
Table A-3 CPT (HCPCS Level I) Modifiers Approved for the ASC . . . . . . . . 377
Table B-1 Level II HCPCS Modifiers. . . . . . . . . . . . . . . . . . . . . . . . 383
Table C-1 Genetic Testing Modifiers . . . . . . . . . . . . . . . . . . . . . . . 397

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 xi

Preface

A Current Procedural Terminology (CPT®) code set modifier is a two-digit code

reported in addition to the CPT service or procedure code that indicates that the
service or procedure was modified in some way. A modifier provides the means
by which a rendering physician may indicate that a service or procedure has been
performed, or has been altered by some specific circumstances, but not changed in
its definition or code. Understanding how and when to use CPT modifiers is vital
for proper reporting of medical services and procedures. The lack of modifiers or
the improper use of modifiers can result in claims delays or denials.
Modifiers are essential tools in the coding process. The American Medical
Association (AMA) developed modifiers to be used with its CPT code set to
explain various aspects of coding. Modifiers are used to enhance a code narrative
to describe the circumstances of each procedure or service and how it individually
applies to the patient. They are essential ingredients to effectively communicate
between providers and payers. Modifiers are also used as a method to accomplish
the following:
• Record a service or procedure that has been modified but not changed in its
identification or definition
• Explain special circumstances or conditions of patient care
• Indicate repeat or multiple procedures
• Show cause for higher or lower costs while protecting charge history data
• Report assistant surgeon services
• Report a professional component of a procedure or service

The ability of all users to recognize and accept CPT modifiers is important
for the implementation of the CPT coding system. While acceptance of CPT
modifiers is important, the subsequent step involving interpretation of modifiers
in a manner that is consistent with established CPT guidelines is also critical.
Modifiers can help the provider code for services more accurately and get paid for
the work performed.
Coding with Modifiers: A Guide to Correct CPT ® and HCPCS Level II Modifiers
Usage, Fourth Edition, introduces the principles of correct CPT and HCPCS mod-
ifier usage and prepares the reader to accomplish the following objectives:
• Understand the purpose of modifiers
• Understand the relationship to the reimbursement process
• Understand logic trees related to modifier usage
• Understand how Medicare carriers and intermediaries vary on the use and
acceptance of modifiers

Coding with Modifiers is divided into 10 chapters organized by modifier. Each

chapter provides step-by-step guidance as to proper and improper use of CPT and
HCPCS modifiers through the use of clinical examples. Coding tips, checkpoint
exercises, and end-of-chapter exercises are also included to help the reader gain a
full understanding of a modifier’s correct usage. Mid-term and final examinations,
as well as PowerPoint slides and an answer key to the text’s exercises, appear on

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 xii CODING WITH MODIFIERS

the CD that accompanies this text for educators or readers who want to apply and
build knowledge related to the material.
The text is designed to be used by community colleges, career colleges, and
vocational school programs for training medical assistants, medical insurance
specialists, and other health care providers. It can also be used as an independent
study training tool for new medical office personnel, physicians, independent
billing personnel, and any others in the health care field who want to learn
additional skills.

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 xiii

About the Author

Deborah J. Grider is a Certified Professional Coder (CPC), a Certified Professional

Coder—Hospital (CPC-H), a Certified Professional Coder—Payer (CPC-P),
a Certified Professional Medical Auditor (CPMA), an E/M Specialist (CEMS), a
Certified OB/GYN Coding Specialist (COBGC), a Certified Dermatology Coding
Specialist (CPCD) with the American Academy of Professional Coders (AAPC),
and a Certified Coding Specialist—Physicians (CCS-P) with the American Health
Information Management Association (AHIMA). Her background includes many
years of practical experience in reimbursement issues, procedural and diagnostic
coding, and medical practice management.
Ms Grider teaches and consults with private practices, physician networks, and
hospital-based educational programs. Under a federal retraining grant, she helped
develop and implement a Medical Assisting Program for Methodist Hospital of
Indiana. She conducts many seminars throughout the year on coding and reim-
bursement issues and teaches several insurance courses and coding courses for
various organizations.
Ms Grider is a well-known national speaker on coding and revenue cycle issues
for physicians and hospitals. She was a national advisory board member for the
AAPC and past president of the National Advisory Board. Prior to becoming a
consultant, Grider worked as a billing manager for 6 years, and a practice manager
in a specialty practice for 12 years.
Deborah previously owned her own consulting firm and currently works with
Blue and Company, LLC, as a Senior Manager in the Revenue Cycle Advisory
Division. She continues to provide consulting and educational services to medical
groups, physician practices, and hospital organizations and provides coding train-
ing education to various organizations and medical societies.
Her professional affiliations include AAPC, AAPC National Advisory Board
member 2002–2005; President-Elect of the AAPC National Advisory Board 2005–
2007; President of the AAPC Advisory Board 2007–2009; member of AHIMA; and
member of the Indiana Medical Group Management Association (IMGMA) and
the Healthcare Financial Management Association (HFMA).
Grider has authored, among other titles, Principles of ICD-10-CM Coding
(AMA, 2012); Principles of ICD-10-CM Coding Workbook (AMA, 2012); Medical
Record Auditor, Third Edition (AMA, 2011); and Preparing for ICD-10-CM (AMA,
2010).

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 xv

Acknowledgments

As I have authored multiple publications for the AMA, I want to specifically

acknowledge everyone at AMA who helped turn this book into reality. Thanks
to Grace Kotowicz, Contributing Coding Consultant, who lent her expertise and
helped me with the outpatient modifier chapter, and to Karen O’Hara, Senior
Coding Consultant, who helped me make changes along the way with her positive
and constructive comments.
Thanks also to my husband Jerry; my son Jerry; my daughter Robyn; and my
grandchildren—Tristan, Cassidy, and Delaney—who endured canceled appoint-
ments and outings and my late nights spent researching and writing. Without their
continued love and support, I could not have completed this project.

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 1

CHAPTER 1

Introduction to
CPT Modifiers

The American Medical Association (AMA) works to promote quality and correct
coding of health care services through its maintenance of the Current Procedural
®
Terminology (CPT ) code set. The CPT code set is a listing of descriptive terms,
guidelines, and identifying codes for reporting medical services and procedures.
The purpose of the CPT code set is to provide a uniform language that accurately
describes medical, surgical, and diagnostic services and serves as an effective
means for reliable nationwide communication among physicians, patients, and
third parties.
The descriptive terms and identifying codes of the CPT code set serve a wide
variety of important functions. This system of terminology is the most widely
accepted nomenclature used to report medical procedures and services under
public and private health insurance programs. The CPT code set is also used for
administrative management purposes such as claims processing and developing
guidelines for medical care review.

CPT Code Set Development

The AMA first developed and published the CPT code set in 1966. The first
edition encouraged use of standard terms and descriptors to document proce-
dures in medical records, communicated accurate information on procedures
and services to agencies concerned with insurance claims, was the basis for a
computer-oriented system to evaluate operative procedures, and contributed basic
information for actuarial and statistical purposes.
The first edition of the CPT codebook published in 1966 contained primarily
surgical procedures with limited sections on medicine, radiology, and laboratory
procedures. The second edition in 1970 expanded to include diagnostic and thera-
peutic procedures in surgery, medicine, internal medicine, and the specialties. A
5-digit coding system replaced the former 4-digit classification. In 1977 the fourth
edition added significant updates in medical technology and a system of periodic
updating was introduced to keep pace with rapid changes in medicine. In 1983, the
CPT code set was adopted as part of the Healthcare Common Procedure Coding
System (HCPCS) developed by the Health Care Financing Administration (HCFA;
now the Centers for Medicare and Medicaid Services [CMS]). With this adoption,
CMS mandated the use of HCPCS to report services for Part B of the Medicare
program and in the Medicaid Management Information System. In July 1987, as
part of the Omnibus Budget Reconciliation Act (OBRA), the CMS mandated use
of the CPT code set for reporting outpatient hospital surgical procedures.

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 2 CODING WITH MODIFIERS

Today, in addition to use in federal programs (Medicare and Medicaid), the

CPT code set is used extensively throughout the United States as the preferred sys-
tem of coding and describing health care services.

HIPAA and CPT

The Administrative Simplification Section of the Health Insurance Portability and
Accountability Act (HIPAA) of 1996 mandated the Department of Health and
Human Services (HHS) adopt national standards for electronic transmission of
health care information, including code sets, national provider identifier, national
employer identifier, security, and privacy. The Final Rule for transmissions and
code sets was issued August 17, 2000. The rule names the CPT code set (including
codes and modifiers) and HCPCS as the procedure code set for the following:
• Physician services
• Physical and occupational therapy services
• Radiological procedures
• Clinical laboratory tests
• Other medical diagnostic procedures
• Hearing and vision services
• Transportation services including ambulance

The Final Rule also adopted the International Classification of Diseases, Ninth
Revision, Clinical Modification (ICD-9-CM) volumes 1 and 2 as the code set for
diagnosis codes; ICD-9-CM volume 3 for inpatient hospital services which will
be used until October 1, 2013. In 2013 the Final Rule (January 2009) adopted the
International Classification of Diseases, Tenth Revision, Clinical Modifications
(ICD-10-CM) as the code set for diagnosis codes and ICD-10-PCS for inpatient
hospital services; Current Dental Terminology for dental services; and the National
Drug Code directory for drugs.
All health care plans and providers who transmit information electronically
must use the established national standards. This Final Rule was implemented
October 16, 2003. The Final Rule mandated elimination of local codes for transi-
tion to national standard code sets. Information regarding elimination of local
code sets (HCPCS Level III) was published in a Program Memorandum by the
HHS and CMS January 18, 2002 (Transmittal AB-02-005), which is discussed later
in this chapter.

Who Maintains the CPT Code Set Nomenclature?

The AMA’s CPT Editorial Panel is responsible for maintaining CPT code sets. This
panel is authorized to revise, update, and modify CPT codes. The panel is com-
posed of 17 members as follows:
• Eleven members nominated by the AMA
• One member is representative of the Performance Measures
development organization

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 CHAPTER 1 ~ INTRODUCTION TO CPT MODIFIERS 3

• Two representatives from the Health Care Professionals Advisory

Committee (HCPAC)
• One physician nominated from the Blue Cross and Blue Shield Association
• One representative nominated by the Health Insurance Association
of America
• One representative nominated by the CMS
• One representative nominated by the American Hospital Association

The AMA’s Board of Trustees appoints the panel members. Of the 11 AMA
seats on the panel, 7 are regular seats, which have a maximum tenure of 2
4-year terms, or a total of 8 years for any one individual. The 4 remaining seats,
referred to as rotating seats, have 1 4-year term. The rotating seats allow more
multidisciplinary input.
The panel’s executive committee includes the chairperson, the vice chairperson,
and 3 other members elected by the entire panel. One of the 3 members-at-large of
the executive committee must be a third-party payer representative.
The AMA provides staff support for the CPT Editorial Panel and appoints a
staff secretary who records minutes of the meetings and keeps records.
Supporting the CPT Editorial Panel in its work is the CPT Advisory
Committee. Committee members are primarily physicians nominated by the
national medical specialty societies represented in the AMA House of Delegates.
The committee’s primary objectives are to:
• Serve as a resource to the CPT Editorial Panel by giving advice on procedure
coding and appropriate nomenclature as relevant to the member’s specialty
• Provide documentation to staff and the CPT Editorial Panel regarding the
medical appropriateness of various medical and surgical procedures under
consideration for inclusion in the CPT code set
• Suggest revisions to the CPT code set (The Advisory Committee meets
annually to discuss items of mutual concern and to keep abreast of current
issues in coding and nomenclature.)
• Assist in review and further development of relevant coding issues and prep-
aration of technical educational material and articles pertaining to the CPT
code set
• Promote and educate its membership on the use and benefits of the CPT
code set

The HCPAC was formed by the CPT Editorial Panel to allow for participation
of organizations representing limited license practitioners and allied health profes-
sionals in the CPT process. The co-chairperson of the HCPAC is a voting member
of the CPT Editorial Panel.

How Suggestions for Changes to the

CPT Code Set Are Reviewed
There are specific procedures for suggestions to revise the CPT code set by add-
ing or deleting a code or modifying existing nomenclature. AMA staff reviews
all correspondence to evaluate coding suggestions. If the AMA staff determines

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 4 CODING WITH MODIFIERS

the panel has previously addressed the question, the requestor is informed of the
panel’s interpretation.
If the request is a new issue or significant new information is received on an
item the panel has previously reviewed, the request is referred to the appropriate
member of the CPT Advisory Committee. If all advisors agree no new code or
revision is needed, the AMA staff informs the requestor on how to use the exist-
ing codes to report the procedure. If all advisors concur that a change should be
made, or if 2 or more advisors disagree or give conflicting information, the issue is
referred to the CPT Editorial Panel for resolution.
Current medical periodicals and textbooks are used to provide up-to-date
information about the procedure or service. Further data about its efficacy and
clinical usefulness are found in other sources, such as the AMA’s Diagnostic and
Therapeutic Technology Assessment Program and other technology assessment
panels. The AMA staff prepares agenda material for each CPT Editorial Panel
meeting. Medical specialty societies, physicians, hospitals, third-party payers, and
other interested parties may submit material for consideration by the Editorial
Panel. Panel members receive agenda material at least 30 days before each meeting,
allowing them time to review and confer with experts.
The CPT Editorial Panel meets each quarter and addresses complex problems
associated with new and emerging technology and the difficulties encountered
with outmoded procedures. The panel addresses nearly 350 major topics a year.
Panel actions may result in any of 3 outcomes:
• A new code is added or nomenclature is revised and appears in a forthcom-
ing volume of the CPT codebook
• An item is tabled to obtain further information, or
• The item is rejected

Because this is a multistep process, deadlines are important. The deadlines for
change requests and for Advisory Committee comments allows at least 3 months
of preparation and processing time before the issue is ready for review by the CPT
Editorial Panel. The initial step, including staff and specialty advisor review, is
completed when all appropriate advisors have been contacted and have responded
and all information requested of a specialty society or an individual requestor has
been provided to the AMA staff.
The requestor must have completed and submitted a coding change request
form. If the advisors’ comments indicate action by the CPT Editorial Panel is war-
ranted, a second step is taken by the AMA staff to prepare an agenda item that
includes a ballot for the request to be acted on by the CPT Editorial Panel. Once
the panel has taken action and minutes of the meeting are approved, the AMA
staff informs the requestor of the outcome. The requestor may appeal the panel’s
decision if the appeals process is followed:
• A written request for reconsideration is sent to the AMA staff within 10 days
of receipt of notice of the CPT Editorial Panel action.
• The request must address the reasons and/or instructions given in the notice
for the CPT Editorial Panel’s action.
• Requests for reconsideration are referred to the CPT Executive Committee
for an initial determination followed by referral (with or without recommen-
dation) to the CPT Editorial Panel for reconsideration.

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 CHAPTER 1 ~ INTRODUCTION TO CPT MODIFIERS 5

The CPT Process

Measure suggestions

Measure developed
(input from specialty
societies)

Coding suggestion
for Category I or Category II code
III codes proposal

Staff review Staff review

Category II code PMAG agrees code

Panel has already New issue or
proposal to PMAG is not necessary
addressed the issue significant
new information
received PMAG agrees code
Letter to requestor is necessary
informing him or her
of correct coding Letter to requestor
Specialty advisors See editorial panel
interpretation informing him or her
action
of correct coding
interpretation

Advisors say give Advisor(s) agree

Rejected
consideration or no new code
two specialty or revision needed
advisors disagree
on code assignment
Staff letter to Staff letter to
or nomenclature
requestor informing requestor
him or her of correct
coding interpretation
Editorial panel or action taken by
action the panel

Postpone Reject Add new code,

for further proposal delete existing code,
study change or revise current
terminology

Request
information Published in CPT
codebook and on the Web

Process No Appeal
terminated submission Reconsidered

Yes

Executive committee
considers appeal

Process
terminated

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 6 CODING WITH MODIFIERS

Category I CPT Codes

Category I CPT codes describe a procedure or service identified with a 5-digit
numeric CPT code and descriptor nomenclature. The inclusion of a descriptor
and its associated, specific 5-digit identifying code number in this category of
CPT codes is generally based on the procedure being consistent with contempo-
rary medical practice and performed by many physicians in clinical practice in
multiple locations.
When developing new and revised codes, the Advisory Committee and the
Editorial Panel require that the:
• Service or procedure has received approval from the Food and Drug
Administration (FDA) for the specific use of devices or drugs
• Suggested procedure or service is a distinct service performed by many phy-
sicians and practitioners across the United States
• Clinical efficacy of the service or procedure is well established and docu-
mented in US peer-reviewed literature
• Suggested service or procedure is neither a fragmentation of an existing pro-
cedure or service nor currently reportable by 1 or more existing codes, and
• Suggested service or procedure is not requested as a means to report extraor-
dinary circumstances related to the performance of a service or procedure
already having a specific CPT code

Category II CPT Codes: Performance Measurement

Category II CPT codes are intended to facilitate data collection by coding certain
services and/or test results that are agreed on as contributing to positive health
outcomes and quality patient care. This category of CPT codes is a set of track-
ing codes for performance measurement. These codes may be services typically
included in an evaluation and management (E/M) service or other component
part of a service and are not appropriate for Category I CPT codes. Consequently,
the Category II codes do not have relative values associated with them. The use
of tracking codes for performance measures will decrease the need for record
abstraction and chart review and minimize administrative burdens on physicians
and survey costs for health plans.
Category II codes are reviewed by the Performance Measures Advisory Group
(PMAG), an advisory body to the CPT Editorial Panel and the CPT/HCPAC
Advisory Committee. The PMAG is composed of performance measurement
experts representing the Agency for Healthcare Research and Quality (AHRQ),
the AMA, the CMS, the Joint Commission on Accreditation of Healthcare
Organizations (JCAHO), the National Committee for Quality Assurance (NCQA),
and the Physician Consortium for Performance Improvement (PCPI). The PMAG
may seek additional expertise and/or input from other national health care orga-
nizations, as necessary, for the development of tracking codes. These organizations
may include national medical specialty societies, other national health care profes-
sional associations, accrediting bodies, and federal regulatory agencies.
The CPT Performance Measurement codes are assigned an alphanumeric
identifier with the letter F in the last field (eg, 0514F). These codes are located
in a separate section of the CPT codebook, following the Medicine section.
Introductory language is placed in this code section to explain the purpose of the

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 CHAPTER 1 ~ INTRODUCTION TO CPT MODIFIERS 7

codes. The use of these codes is optional and not required for correct coding. The
following are examples:*
• 1002F Anginal symptoms and level of activity assessed (NMA – No
Measure Assessed)
• 1070F Alarm symptoms (involuntary weight loss, dysphagia, or gastrointes-
tinal bleeding) assessed; none present (GERD)5
• 2000F Blood pressure measured (CKD)1 (DM)2, 4
• 3017F Colorectal cancer screening results documented and reviewed (PV)1, 2
• 3125F Esophageal biopsy report with statement about dysplasia (present,
absent, or indefinite) (PATH)9
• 4005F Pharmacologic therapy (other than minerals/vitamins) for osteoporo-
sis prescribed (OP)5
• 5015F Documentation of communication that a fracture occurred and that
the patient was or should be tested or treated for osteoporosis (OP)5
• 6020F NPO (nothing by mouth) ordered (STR)5
• 7025F Patient information entered into a reminder system with a target due
date for the next mammogram (RAD)5

Requests for Category II codes are forwarded to the CPT/HCPAC Advisory

Committee, just as requests for Category I CPT codes are reviewed. The interests
of the PMAG are as follows:
• Measurement that is developed and tested by a national organization
• Evidence-based measurements with established ties to health outcomes
• Measurement that addresses clinical conditions of high prevalence, high
risk, or high cost
• Well-established measurements that are currently being used by large seg-
ments of the health care industry across the country

To expedite reporting Category II codes once they have been approved by the
CPT Editorial Panel, the newly added codes are made available on a semiannual
basis via electronic distribution on the AMA Web site (www.ama-assn.org/go/cpt).
The AMA’s CPT Web site features updates of the Category II codes in July and
January in a given CPT nomenclature cycle.

Category III CPT Codes: Emerging Technology

This section of the CPT codebook contains a temporary set of tracking codes
for emerging technologies, services, and procedures. Category III CPT codes
are intended to facilitate data collection on and assessment of these services and
procedures. These codes are used for data collection purposes to substantiate
widespread use or in the FDA approval process. Category III CPT codes need not
conform to the following usual CPT coding requirements for a Category I code:
• Services or procedures be performed by many health care professionals
across the country
• FDA approval be documented or imminent within a given CPT cycle
• The service or procedure has proven clinical efficacy

* Please note that the superscript footnote numbers in the above list correspond to sources
cited in CPT® 2012, Category II Codes.

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