LIST OF MODIFIERS - CPT AND HCPCS


A Modifier Provides the means to report or indicate that a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code


Modifier is used to give additional Information of service and also used for Payment/Reimbursement purposes.

There are two types of categories in Modifiers

  • Level I Modifiers – It consists of two numeric digits, also known as CPT Modifiers and updated by AMA(American Medical Association) annually
  • Level II Modifiers - It consists of (Alpha / Alphanumeric characters) in the sequence AA through VP, also known as HCPCS Modifiers and Updated by CMS (Centers for Medicare and Medicaid Services)

Find the Below List of Level one Modifiers:



Mod
Description
Usage
Definition
22
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 (ie, increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). Note: This modifier should not be appended to an E/M service.
23
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.
24
Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period

The physician or other qualified health care professional may need to indicate that an evaluation and management service was performed during a postoperative 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.
25
Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service
(Under OPPS, modifier may be used only with E/M visit codes (with status indicator V) within the following code ranges: 0359T, 0360T, 0362T, 90945, 92002-92004, 99201, 992014, 95250,99281-99285, 99460, 99463, 99495-99496, G0101, G0175, G0245, G0246, G0248, G0249, G0379, G0380-G0384, G0402, G0463 ~~Modifier used on an E/M code when it is reported with a procedure code that has a outpatient payment status indicator (OPSI) of "S" or "T." However, this does not preclude the provider from reporting this modifier with E/M codes that are assigned to an OPSI other than the "S" or "T" as long as the procedure meets the definition of "significant, separately identifiable E/M service" (Medicare Claims Processing Manual, chapter 4, section 20.6, Integrated Outpatient Code Editor, v17.1.)
It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). 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 of 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. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59.
26
Professional Component

Certain procedures are a combination of a physician or other qualified health care professional component and a technical component. When the physician or other qualified health care professional component is reported separately, the service may be identified by adding modifier 26 to the usual procedure number.
27
Multiple Outpatient Hospital E/M Encounters on the Same Date
(Modifier 27 does not replace condition code (FLs 24-30) G0. Continue to report condition code G0 for multiple medical visits that occur on the same day in the same revenue center ~Modifier should be used with E/M codes (with status indicator V) within the ranges of 90945, 92002-92014, 99201-99285, 99431, G0101, G0175, G0245, G0246, G0248, G0249, G0379 G0380-G0384, G0402, and G0463~Hospitals use this modifier on the second and subsequent E/M code when more than one E/M service is provided to indicate that the E/M service is a separate and distinct E/M encounter from the service previously provided on the same day in the same or different hospital setting. (Medicare Claims Processing Manual, chapter 4, section 20.6, Integrated OCE (IOCE) CMS Specifications V17.1)
For hospital outpatient reporting purposes, utilization of hospital resources related to separate and distinct E/M encounters performed in multiple outpatient hospital settings on the same date may be reported by adding modifier 27 to each appropriate level outpatient and/or emergency department E/M code(s). This modifier provides a means of reporting circumstances involving evaluation and management services provided by physician(s) in more than one (multiple) outpatient hospital setting(s) (eg, hospital emergency department, clinic). Note: This modifier is not to be used for physician reporting of multiple E/M services performed by the same physician on the same date. For physician reporting of all outpatient evaluation and management services provided by the same physician on the same date and performed in multiple outpatient setting(s) (eg, hospital emergency department, clinic), see Evaluation and Management, Emergency Department, or Preventive Medicine Services codes.
32
Mandated Services

Services related to mandated consultation and/or related services (eg, third party payer, governmental, legislative or regulatory requirement) may be identified by adding modifier 32 to the basic procedure.
33
Preventive Services

When the primary purpose of the service is the delivery of an evidence based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be identified by adding 33 to the procedure. For separately reported services specifically identified as preventive, the modifier should not be used.
47
Anesthesia by Surgeon

Regional or general anesthesia provided by the surgeon may be reported by adding modifier 47 to the basic service. (This does not include local anesthesia.) Note: Modifier 47 would not be used as a modifier for the anesthesia procedures.
50
Bilateral Procedure
(Modifier applies to surgical procedures (CPT codes 10040-69990) and to radiology procedures performed bilaterally.~Used to report bilateral procedures performed in the same operative session. Identify that a second (bilateral) procedure has been performed by adding modifier 50 to the procedure code. Do not report two line items to indicate a bilateral procedure.~Do not use modifier with surgical procedures identified by their terminology as "bilateral" (e.g., 27395, lengthening of hamstring tendon, multiple, bilateral), or as "unilateral or bilateral" (e.g., 52290, cystourethroscopy, with meatotomy, unilateral or bilateral).~Applies to any bilateral procedure performed on both sides at the same session.~Report only one unit of service in FL 46 when modifier 50 is reported)
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.

CPT 93000, 93005, 93010 (EKG) Lists of Payable/Covered Diagnosis and Applicable Modifiers


93000  Electrocardiogram, routine ECG with at least 12 leads; with interpretation and report
93010  Electrocardiogram, routine ECG with at least 12 leads; interpretation and report only
93005  Electrocardiogram, routine ECG with at least 12 leads; tracing only, without interpretation and report

Code Description

Multiple electrodes are placed on a patient's chest to record the electrical activity of the heart. A physician interprets the findings. Report 93000 for the combined technical and professional components of an ECG; 93005 for the technical component only; and 93010 for the professional component only.

Instructions and coding tips

Add a 25 modifier to your E&M service when billing in conjunction with an EKG 93000, 93005, 93010 CPT.

Use Modifier XS for 93000 when billed with 93015.
  • Excludes Acoustic cardiography (93799)
  • Excludes ECG monitoring (99354-99360 [99415, 99416])
  • Excludes ECG with 64 or more leads, graphic presentation, and analysis (0178T-0180T)
  • Excludes Echocardiography (93303-93350)
  • Excludes Use of these codes for the review of telemetry monitoring strips
  • Includes Specific order for the service, a separate written and signed report, and documentation of medical necessity
List of Payable/Covered Diagnosis:

A02.1 Salmonella sepsis
A18.84 Tuberculosis of heart
A22.7 Anthrax sepsis
A26.7 Erysipelothrix sepsis
A32.7 Listerial sepsis
A40.0 Sepsis due to streptococcus, group A
A40.9 Streptococcal sepsis, unspecified
A41.01 Sepsis due to Methicillin susceptible Staphylococcus aureus
A41.9 Sepsis, unspecified organism
A42.7 Actinomycotic sepsis
A54.86 Gonococcal sepsis
A74.81 Chlamydial peritonitis
A74.9 Chlamydial infection, unspecified
B33.3 Retrovirus infections, not elsewhere classified
B34.8 Other viral infections of unspecified site
B37.7 Candidal sepsis
B97.0 Adenovirus as the cause of diseases classified elsewhere
B97.89 Other viral agents as the cause of diseases classified elsewhere
E00.0 Congenital iodine-deficiency syndrome, neurological type
E03.4 Atrophy of thyroid (acquired)
E03.8 Other specified hypothyroidism
E07.1 Dyshormogenetic goiter
E07.89 Other specified disorders of thyroid
E07.9 Disorder of thyroid, unspecified
E08.51 Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy without gangrene
E08.52 Diabetes mellitus due to underlying condition with diabetic peripheral angiopathy with gangrene
E09.51 Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy without gangrene
E09.52 Drug or chemical induced diabetes mellitus with diabetic peripheral angiopathy with gangrene
E10.10 Type 1 diabetes mellitus with ketoacidosis without coma
E13.9 Other specified diabetes mellitus without complications
E35 Disorders of endocrine glands in diseases classified elsewhere
E84.0 Cystic fibrosis with pulmonary manifestations

CO97 Medicare/Commercial denial reason, Reason for CO97 denial and Avoid/action CO97 Denial (The benefit for this service is included in the payment)

CO97 Medicare/Commercial denial reason, Reason for CO97 denial and Avoid/action CO97 Denial (The benefit for this service is included in the payment)

Denial Reason CO97 Benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated.

Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present. This change effective September 1, 2017: The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Usage: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

Reason for CO97 denial code

You will receive claim adjustment reason code (CARC) CO50 Denial code when the benefit for this service is included in the payment for the same date of service. Separate payment is never made for routinely bundled services and supplies.

Some services may always be bundled into other services provided or not separately payable. For instance:
  • E/M services conducted during the post-op period of a surgery that are related to the surgery are considered not separately payable.
  • Collection of a blood specimen is usually conducted during a patient encounter, and therefore is not separately payable.
  • Extended hours codes (common after-hour codes) are not separately payable in a facility which operates 24-hours a day.
  • Special handling, conveyance or transfer of a specimen to a laboratory from a physician's office is not usually separately payable, as this type of "extra" care is considered within the payment fee schedules.
So only possibilities to get reimbursed by using Modifier or ICD which is not related to Global Surgery procedure:

Global Periods for Minor Procedures
  • Total global period is either one or eleven days
  • Count the day of the surgery and the appropriate number of days (either 0 or 10) immediately following the day of surgery
 Global Periods for Major Procedures
  • Total global period is ninety-two days
  • Count one day immediately before the day of surgery, the day of surgery, and the 90 days immediately following the day of surgery
Included Components
  • Pre-operative visits
  • Intra-operative services
  • Complications following surgery
  • Post-surgery pain management
  • Anesthesia by surgeon
  • Supplies
  • Miscellaneous services
  • Post-operative visits
Excluded Services
  • Initial Evaluation & Management (E/M) service
  • Other physicians’ care
  • Unrelated visits/surgeries
  • Complications with return to operating room
  • Return to operating room
  • Unrelated Critical care
  • Staged/distinct procedures
  • Diagnostic tests/procedures
Few Steps to Avoid CO97 denial code/ Action for CO97 denial
  • Make sure you have reviewed the whole medical record properly and coded the updated diagnosis and CPT with appropriate modifier if needed.
  • Review the CPT guidelines for that particular service
  • If CPT is not included in any other service for the same date of service, Use Appropriate Modifier as per NCCI guidelines.
  • And Resubmit the claim
  • If CPT is Inclusive with any other service for the same date of service then adjust the CPT.
Note:
  • Before you submit a claim for post-surgical E/M services, verify the post-operative period by checking the surgery date and number of follow-up days associated with the surgical procedure
  • Refer to CPT modifiers 24 and 25
  • When a visit occurs on the same day as a surgery with '0' global days and within the global period of another surgery and the visit is unrelated to both surgeries, CPT modifiers 24 and 25 must be submitted.
Example for CO97 Denial claim

Example 1:

The below example G0101 CPT inclusive with 99396, so the G0101 CPT has been denied and Adjust the G0101 CPT.

DOS CPT Diagnosis Payment Status
4/5/2017 99396-25 Z00.00 Paid
4/5/2017 G0101 Z00.00 CO97 denial
4/5/2017 93000 Z00.00 Paid

Example 2:

The below scenario 99213 CPT has been denied as CO 97 because 25 Modifier is missing as per NCCI.

DOS CPT Diagnosis Payment Status
4/26/2017 99213 M25.561 CO97 denial
4/26/2017 20610 M17.11 Paid
4/26/2017 77002 M17.11 Paid
4/26/2017 J7321 M17.11 Paid

Corrected Claim

Add appropriate Modifier and resubmit the claim

DOS CPT Diagnosis Payment Status
4/26/2017 99213-25 M25.561 Submitted to Insurance
4/26/2017 20610 M17.11 Paid
4/26/2017 77002 M17.11 Paid
4/26/2017 J7321 M17.11 Paid

Denial reason code CO 97 FAQ

Q: We received a denial with claim adjustment reason code (CARC) CO 97. What steps can we take to avoid this denial?


The benefit for this service is included in the payment/allowance for another service/procedure that has already been adjudicated. Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.

A: There are a few scenarios that exist for this denial reason code, as outlined below. Please review the associated remittance advice remark code (RARC) noted on the remittance advice and then refer to the specific resources/tips outlined below to avoid this denial.

M15 – Separately billed services/tests have been bundled as they are considered components of that same procedure. Separate payment is not allowed.

The service billed was paid as part of another service/procedure for the same date of service. Separate payment is never made for routinely bundled services and supplies. Bundled services should be billed to Medicare only when a denial is needed for a secondary payer.

The following procedures are examples of bundled services commonly seen with this denial.

94760: Noninvasive oximetry
97010: Hot/cold packs
99071: Educational supplies
99080: Special reports or forms
99090: Analysis of clinical data
99100: Special anesthesia services
A4500: Surgical tray
Check the procedure code on the First Coast fee schedule lookup tool. Scroll down to policy indicators and review code status. If status is equal to “b,” the service/procedure is not paid separately, not even with a modifier


http://medicare.fcso.com/Fee_lookup/fee_schedule.asp

M144 – Pre/post-operative care payment is included in the allowance for the surgery provided.

The cost of care before and after the surgery or procedure is included in the approved amount for that service. Evaluation and management (E/M) services related to the surgery, and conducted during the post-op period of a surgery, are considered not separately payable.
 If billing for split care, coordinate split-care billing activities with other provider(s) involved in the patient’s care, and ensure the surgical code is billed before the services for post-operative care are billed.


If a modifier is applicable to the claim, apply the appropriate modifier and resubmit the claim. Submit corrected line(s) only. Resubmitting the entire claim will cause a duplicate claim denial.

Modifier 54: pre-and intra-operative services performed
Modifier 55: post-operative management services only
Modifier 56: pre-operative services only


N70 – Consolidated billing and payment applies.

The claim dates of service fall within the patient’s home health episode’s start and end dates. Before providing services to a Medicare beneficiary, determine if a home health episode exists.

Ask the beneficiary (or his/her authorized representative) if he/she is presently receiving home health services under a home health plan of care.

Always check beneficiary eligibility prior to submitting claims to Medicare.
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