A modifier is a 2-digit code appended to a Current Procedural Terminology (CPT) code to indicate that a service or procedure has been altered by some specific circumstance, but has not changed in its definition or code. Exceptions to the 2-digit code are the anesthesia modifiers and the use of Healthcare Common Procedure Coding System (HCPCS) modifiers for toes and fingers.
In 2008, some modifiers were changed. This column will cover the changes for modifiers 22, 25, and 76. Next month, we’ll look at the changes for modifiers 51, 58, 59, and 78.
When are modifiers used?
A provider may append a modifier to indicate a special circumstance when reporting a service. During the perioperative global period, modifiers are critical to ensuring that the provider receives reimbursement for services that are unrelated to the primary procedure, as well as for staged procedures, multiple procedures, assistant surgeon or co-surgeon services, and evaluation and management (E&M) services. Modifiers may be appended to E&M services, surgical CPT codes, diagnostic tests, laboratory tests, and services from the “Medicine” section of the AMA CPT Manual.
Reporting modifiers to payors
When a provider submits a claim with a CPT code, the appropriate modifier is “linked to the CPT code on the claim form” (Fig. 1). The CPT code is listed on the left side of box 24D, and the modifier is linked on the right side of box 24D.
Changes for modifier 22
Modifier 22 (increased procedural services) underwent both a title and a definition change. When the work required to provide a service is substantially greater than typically required, modifier 22 may be added to the usual procedure code. Documentation must support the additional work and the reason for it (such as increased intensity, time, technical difficulty of procedure, or severity of patient’s condition, physical and mental effort required). This modifier should not be appended to an E&M Service.
For example, because no CPT code exists for a revision of an arthroscopic anterior cruciate ligament (ACL) reconstruction, a physician may report CPT code 29888 (arthroscopically aided anterior cruciate ligament repair/augmentation or reconstruction) with a modifier 22. The documentation must support substantially greater work for the revision, such as increased time and technical difficulty associated with approach through adhesions/scar tissue, removal of hardware, or tendon grafting. In box 19 on the claim form, add a note that the modifier 22 supports a revision ACL with increased complexity.
Caution: If the revision surgery is not “substantially greater” (eg, more physician work), do not append modifier 22. Do not append modifier 22 to unlisted procedure codes.
Changes for modifier 25
The definition of modifier 25—significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service—was clarified in 2008.
Modifier 25 is used 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.
Documentation must define or substantiate the significant, separately identifiable 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 the E&M service on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E&M services.
Modifier 25 should not be used to report an E&M service that resulted in a decision to perform surgery; modifier 57 should be used in this specific setting. Modifier 59, which will be discussed more fully next month, should be used for significant, separately identifiable non-E&M services.
For example, an orthopaedic surgeon sees an established patient for a trochanteric bursitis of the hip that has not responded or is aggravated by standard treatment (physical therapy, medication). After performing a secondary work-up, the surgeon decides to administer a 000-global service injection procedure at the time of this visit. The surgeon would report code 20610 (arthrocentesis, aspiration and/or injection; major joint or bursa [eg, shoulder, hip, knee joint, subacromial bursa]) and append modifier 25 to the established patient E&M code.
Using modifier 76
Modifier 76 (repeat procedure or service by same physician) should be used to indicate that a procedure or service was repeated subsequent to the original procedure. According to the AMA CPT Manual, modifier 76 was revised to designate the intent of the procedure to be used to report repeat procedures, as well as repeat services provided by the same physician.
As indicated in the definition of modifier 78, modifier 76 is not restricted to procedures performed on the same day. Modifier 76 is applicable to both surgical and diagnostic procedures and services that are repeated. It should not be used for planned or anticipated subsequent or staged procedures or related unplanned procedures (such as for complications).
If, for example, a physician reduces a distal radius fracture in the office on May 15 and the reduction is lost so that the fracture must be reduced a second time on May 22, the physician would report CPT code 25605 (Closed treatment of distal radial fracture [eg, Colles or Smith type] or epiphyseal separation, includes closed treatment of fracture of ulnar styloid, when performed; with manipulation) for the May 15 visit and 25605-76 to indicate a repeat reduction for the May 22 visit.
Source: CPT Changes: Insiders Edition 2000-2008.
Mary LeGrand, RN, MA, CCS-P CPC, is a consultant with KarenZupko & Associates. The information in this article has been reviewed by members of the AAOS Coding, Coverage, and Reimbursement Committee. If you have coding questions or would like to see a coding column on a specific topic, e-mail firstname.lastname@example.org