What does the modifier in CPT coding do?
Asked by: Melissa Schultz V | Last update: March 22, 2025Score: 5/5 (43 votes)
What does a modifier do for a CPT code?
A medical coding modifier is two characters (letters or numbers) appended to a CPT® or HCPCS Level II code. The modifier provides additional information about the medical procedure, service, or supply involved without changing the meaning of the code.
What is the purpose of a modifier in coding?
Modifiers indicate that a service or procedure performed has been altered by some specific circumstance, but not changed in its definition or code. They are used to add information or change the description of service to improve accuracy or specificity.
What is the E1, E2, E3, and E4 modifier?
CPT® provides one modifier for each eyelid: E1 for upper left, E2 for lower left, E3 for upper right, and E4 for lower right. The general rule is to use the E modifiers when a procedure can be performed on any one of the four eyelids -- but real-world coding and billing don't always allow you to.
When to use 59 or 51 modifier?
Modifier -51 would be attached because the biopsy is the lesser-valued procedure done at the same session, and modifier -59 would be attached to indicate that the biopsy, which is normally bundled with excision of the same lesion, was done on a separate lesion from the one that was excised.
What is a Modifier in Medical Coding? CPT and HCPCS Modifiers for Beginners
What is modifier 50 used for?
Use modifier 50 to report bilateral procedures performed during the same operative session by the same physician in either separate operative areas (e.g., hands, feet, legs, arms, ears) or in the same operative area (e.g., nose, eyes, breasts).
What CPT codes need a 59 modifier?
Another common use of modifiers 59 or XE is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures performed during different patient encounters on the same day that can't be described by 1 of the more specific NCCI PTP-associated modifiers – in other words, 24, 25, 27, 57, 58, 78, 79, ...
What is a 58 modifier used for?
Modifier 58 is defined as a staged or related procedure performed during the postoperative period of the first procedure by the same physician. A new postoperative period begins when the staged procedure is billed.
What is modifier 73 and 53?
Modifier 53 has the caveat that the procedure was discontinued due to the well-being of the patient after the induction of general anesthesia. Whereas modifiers 73 and 74 have no requirement that the patient's well being be tied to the procedure's discontinuance.
What is the correct order for modifiers?
In medical coding, modifiers are used to give additional information about a procedure, service, or supply, and modifiers that will have the biggest impact on reimbursement are normally sequenced first. These modifiers typically fall into one of three categories: (1) Pricing, (2) Payment, or (3) Location.
How do I know if a CPT code needs a modifier?
According to CPT, the situations when the use of a modifier may be appropriate are: The service or procedure has both professional and technical components. More than one provider performed the service or procedure.
What is 57 modifier?
CPT modifier 57 may be used to report the decision for surgery for certain codes. This modifier may be used to indicate that an evaluation and management (E/M) service performed on the same day or the day before a major surgery (090 global days) by the surgeon resulted in the decision to perform the procedure.
What are the most used modifiers in medical billing?
Understanding commonly used modifiers in medical billing is crucial for accurate reimbursement and avoiding claim denials. Modifiers such as 22, 25, 26, 33, 50, 51, and 59 play a significant role in communicating additional information about the services provided.
What is modifier used for?
Modifiers provide additional information to payers to make sure your provider gets paid correctly for services rendered. If appropriate, more than one modifier may be used with a single procedure code; however, are not applicable for every category of the CPT codes.
How do you know which modifier to use?
The correct modifier to use is determined by payor preference. There can be instances where a CPT code is further defined by an HCPCS modifier, for example, to describe the side of the body the procedure is performed on, such as left (modifier -LT) or right (modifier -RT).
When not to use modifier 25?
Modifier 25 should not be used when: ❌ The sole purpose of the encounter is for the procedure (e.g., lesion removal), and there is no documented medical necessity for a separate E/M service.
What is modifier 51 used for?
Modifier 51 Multiple Procedures indicates that multiple procedures were performed at the same session. It applies to: Different procedures performed at the same session. A single procedure performed multiple times at different sites.
What is modifier 56 used for?
Modifier 56 is used for preoperative management only when a qualified health care professional performed the preoperative care and evaluation and another performed the surgical procedure.
What is the 55 modifier for?
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 OR BY USE OF THE SEPARATE FIVE DIGIT MODIFIER CODE 09955.
What is modifier 60 used for?
The CPT manual introduced modifier -60 in 2001 to allow providers to indicate when a procedure was more complex than normal due to an altered surgical field.
What is modifier 24 used for?
Use CPT modifier 24 for unrelated evaluation and management service during a postoperative (global) period. The global period of a major surgery is the day prior to, day of and 90 days after the surgery.
What is modifier 58?
To start, modifier 58 is a surgical-specific modifier, used to indicate a staged or related procedure or service by the same physician during the postoperative period.
When to use modifier 90?
Independent laboratories shall use modifier 90 to identify all referred laboratory services. A claim for a referred laboratory service that does not contain the modifier 90 is returned as unprocessable if the claim can otherwise be identified as being for a referred service.
What is modifier 62 used for?
Two surgeons. Under some circumstances, the individual skills of two or more surgeons are required to perform surgery on the same patient during the same operative session.