Tucked away in Appendix A of CPT is a series of two-digit modifiers to CPT codes. Attaching modifiers to codes lets you provide additional information about your services, and they can affect whether your claims are paid or denied. Unfortunately, because the modifiers are in the back of the book, you may have overlooked them — and thus overlooked an opportunity to improve your coding and reimbursement.
Get to know them
Here are some of the modifiers that family physicians are likely to use most.
Modifier -25, “Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service,” may be the most important for family doctors. The classic use of this modifier is for an annual preventive-medicine encounter during which the patient says, “Oh, by the way, ...” As a result, you address the “by the way” ailment and perform the preventive service. In this case, you may submit codes for both a preventive service (such as 99396) and a regular office visit (such as 99213) by attaching -25 to the office-visit code. This tells the third-party payer that you did perform two significant, separately identifiable E/M services for the same patient on the same date, and it should keep the payer from bundling the services.
Use modifier -21, “Prolonged Evaluation and Management Services,” when an E/M service takes more time than is usually required for the highest level of service within a given E/M category. For example, you see an established patient with multiple, concurrent problems, spending more than 90 minutes in assessment and counseling with the patient and family. You feel the examination and medical decision making easily qualify the service as a 99215. But in this case, because the service was prolonged (according to CPT, the typical time for a 99215 is 40 minutes) “or otherwise greater than that usually required for the highest level” code in its category, you could append -21 to the 99215 and get credit for the extra time.
Modifier -59, “Distinct Procedural Service,” is similar to modifier -25, but it's applicable to procedural, rather than E/M, services. Attach -59 to a code to indicate that a procedural service is distinct or independent from other services performed the same day, particularly when the services or procedures aren't normally reported together but are appropriate under the circumstances.
For example, you incise and drain two abscesses — one simple and one complicated — for one patient. If you bill for these services using the appropriate CPT codes (10060 and 10061), it may appear as though you're coding twice for the same service. However, by appending -59 to one of the codes, you clarify that the services were distinct and that both should be reimbursed.
Here are several other situations in which modifiers can help you get paid appropriately for what you do:
You provide the professional component of a service for which someone else has provided the technical component (for example, you interpret an X-ray someone else has taken). You can identify your part in this service (unless there's a separate CPT code for the professional component) with modifier -26, “Professional Component.”
You provide postoperative management for a patient following surgery by another physician. You can attach modifier -55, “Postoperative Management Only,” to the procedure code to identify your part in the service.
You want to bill for laboratory services that you purchased from an outside lab. Use modifier -90, “Reference (Outside) Laboratory,” with the appropriate laboratory-service code. Medicare requires labs to bill for such services directly, but not all insurers follow that policy.
Don't stop now
Of course, these are only a handful of the modifiers you'll find in CPT. Appendix A includes a number of others that may be relevant to your practice and are worth reviewing.
You should also know that the two-digit modifiers aren't the only type available. If an insurer's system won't accept the two-digit variety, you may use five-digit modifiers in addition to the E/M or procedure codes you're reporting. The convention for five-digit modifiers is 099XX, where “XX” is the two-digit version of the modifier. For example, rather than attaching -25 to a CPT code, you could submit 09925 as well as the code for the service.
You probably won't be surprised to learn that not all third-party payers recognize modifiers. But in claims to those payers that do, modifiers can be valuable tools to help you get paid appropriately for your work.