The session provided an overview of modifiers in medical coding, focusing on their definition, purpose, and practical examples.
Key CPT and HCPCS modifiers such as 22, 25, 58, 59, 62, 78, and 79 were discussed, including scenarios for their appropriate use.
Resources for finding modifier information and best practices for application were highlighted.
Information was geared toward both new and experienced coders, with references to additional learning materials.
Action Items
No specific dated action items were mentioned in the discussion.
Attendees are encouraged to review modifier guidelines and check out the free webinar mentioned for deeper understanding.
Modifier Basics and Definitions
A modifier is a two-digit code appended to a CPT or HCPCS code (not ICD codes) to add clarity or detail to the service provided.
Modifiers never fundamentally change the procedure but clarify aspects such as complexity, anatomical site, or special circumstances.
Commonly used modifiers can be found on the CPT book flap or Appendix A; more comprehensive or insurance-specific modifiers are detailed in the HCPCS book.
Application and Examples of Modifiers
Modifiers are entered in box D of the 1500 form next to the corresponding code.
Example: Modifier 22 (Increased Procedural Service) is used when extraordinary circumstances make a procedure more complex, potentially warranting additional payment contingent on documentation.
Modifier 62 is for co-surgeries (two surgeons performing the same procedure as defined by one CPT code); both get 62.5% of Medicare's fee schedule.
Clarification about clinical versus coding definitions (e.g., “flap” in surgery) and the importance of applying the correct coding definition.
Modifiers Related to Surgical Package/Timing
Modifier 58: Used for planned, staged, or related procedures during the global period, such as staged reconstructive surgeries.
Modifier 78: Indicates an unplanned return to the operating room during the global period for related care.
Modifier 79: Used for procedures during the global period that are entirely unrelated to the original surgery.
Anatomical and Bilateral Modifiers
Modifiers such as RT (right), LT (left), and 50 (bilateral) are used to specify anatomical sites, but only for organs/body parts with pairs (e.g., hands, eyes, kidneys).
Encoders and tools like Codify help suggest appropriate modifiers but may not always align with insurance acceptance.
Evaluation & Management (E/M) Modifiers
Modifier 25: Used only on E/M services when a significant and separately identifiable procedure is performed on the same day as an E/M visit.
Clarification provided for proper scenarios, such as removing impacted cerumen or other procedures performed during routine chronic care management visits.
Emphasis on ensuring the E/M component is significant and not part of the standard pre-procedure evaluation.
Resources and Best Practices
Coders are encouraged to consult Appendix A of CPT, the HCPCS book, and official payer websites for detailed modifier guidance.
Attendees are urged to attend the free webinar on modifiers for additional context and scenarios, especially for office-based coding.
Advised to verify modifier acceptance with specific insurers even when coding guidelines permit their use.
Decisions
No formal decisions were made during this session; the focus was on education and clarification regarding modifiers.
Open Questions / Follow-Ups
Attendees requested information on specific modifiers and expressed interest in a future video about NCCI edits and guidelines for when modifiers are essential to coding multiple procedures together.