Modifiers Get Modified in 2008

By Barbara Cobuzzi, CPC-OTO, CPC-H, CPC-P, CPC-I, CHCC and Michelle Dick, Senior Editor

Doesn’t it seem like only yesterday you were trying to memorize what circumstances constitute the use of certain modifiers? Unfortunately, 2008 means more memorizing with its modifier changes and the addition of the new modifier 92. The good news is we’ll help you with the learning process by streamlining the changes made to modifier usage.

First, let’s clear up any confusion by remembering the purpose of a modifier is to adjust a code description without changing the code meaning, adding information regarding the service provided. They are an integral part of CPT® and the HCPCS Level II coding systems because they clarify the services provided.

In 2008, there are changes to modifiers 22, 25, 32, 51, 58, 59, 76 and 78, plus the addition of modifier 92. Let’s elaborate on these changes.

Modifier 22

Modifier 22’s former descriptor Unusual procedural services changed to Increased procedural services. What this implies is that extra work was involved in a procedure so monetary compensation is due. When modifier 22 is reported you must document in detail the circumstances behind the extra work. Overuse of this claim can trigger an audit. Do not append 22 to an evaluation and management (E/M) service.

Modifier 25

Use modifier 25 for Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service. When using 25 append to E/M codes only to indicate it was separate from that required for the procedure and a clearly documented, distinct, and significantly identifiable service was rendered. Note that many third-party payers will not necessarily pay initially when billed with a minor procedure on the same day but will often pay once appealed with appropriate documentation which shows the E/M was significantly and separately identifiable from any workup for the minor procedure.

Modifier 25’s descriptor revisions in 2008 eliminate the physician restriction. It now includes chiropractors, physical or occupational therapists, speech language pathologists, physician assistants, clinical psychologists and social workers, and registered dieticians. For non-E/M services see modifier 59 Distinct procedural services.

Modifier 32

Modifier 32 describes Mandated services. Use when the physician is aware of third-party involvement regarding mandated services. When using this modifier, clearly document who and why. Modifier 32 is considered informational and when used, many insurers allow 100 percent reimbursement without a deductible or copay. This modifier has no effect on Medicare payment.

For 2008, the modifier 32 descriptor is as follows: 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. The change to 32’s descriptor is the deletion of the word “PRO” as it is obsolete at this point.

Modifier 51

Use modifier 51 for Multiple procedures to indicate that more than one surgical service was performed by the same physician at the same session. Usually there is some shared component to the work. Watch for circle with the slash icon in the CPT® manual  that indicates the code is Modifier 51 exempt. Also, there is reduced reimbursement due to pre and post operative period preparation.

2008 changes for Modifier 51:

  • Appendix E lists the codes that are considered modifier 51 exempt
  • The Resource Utilization Committee (RUC) and the CPT® Editorial Panel develops the criteria for inclusion of codes in Appendix E
  • To be included, a code needs to be considered adjunctive to another procedure and should not be reduced when typically performed with the other procedure
  • Multiple surgery rules do not apply when a code is exempt from modifier 51

CMS agreed with all the removal recommendations that the CPT® Editorial Panel made

An example of a modifier 51 exempt removal is change of the Mohs codes (17311-17315)  to add-on codes. Add-on codes are moved from Appendix E to Appendix D and the icon “+” is placed in front of the CPT® codes

Modifier 58

Modifier 58 describes Staged or related procedure or service by the same physician during the postoperative period. Append to a CPT® code when the procedure is secondary and/or related to the original or first procedure. Note: a new post-op period begins when the next procedure in a staged or related procedure is provided. Don’t use for return to OR (see modifier 78), and don’t use for unrelated procedures in the global period (see modifier 79). Modifier 58 can be used:

When a biopsy (excluding skin biopsy, 11100 Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple enclosures), unless otherwise listed; single lesions  and 11101 each separate/additional lesion (List separately in addition to code for primary procedure) is done based on an unknown outcome and as a result an excision is performed the same day. The excision is coded and the biopsy is coded with a 58 modifier (for example, a breast biopsy frozen section leading to mastectomy with axillary lymphandectomy).

When skin biopsies are done that lead to lesion excision, only the widest margin or re-excision code may be billed

Examples of staged or related procedures in the post operative period include the following:

A burn victim who has multiple debridements

A patient who first has a malignant skin lesion removed and then has repairs done in stages to cosmetically repair the defect.

In 2008, the term “physician” was removed so that Modifier 58 can apply to nonphysician practitioners. The phrase “planned prospectively at the time of the original procedure” is replaced with “planned or anticipated” because it implied that decisions to perform subsequent procedures would be required at the time of the initial procedure, thus eliminating circumstances in which decisions to perform subsequent procedures are dependent on the outcome of the surgery and the patient’s post operative status. The former language put limitations on procedures that couldn’t be planned in advance.

Modifier 59

Use Modifier 59 Distinct procedural service to indicate a procedure was distinct or separate from other services provided on the same date. Watch Out! Because this unbundling modifier allows bypassing of payer edits (CCI), be careful when using it. Repeated inappropriate use can prevent reimbursement or arouse the suspicions of auditors. Use this modifier as a last resort. You need good supportive documentation to use this modifier. When using, look for “separate procedure” notation in CPT® descriptor, as in. 29870 Arthroscopy, knee diagnostic with or without synovial biopsy (separate procedure)

There are a few revisions to Modifier 59’s descriptor in 2008:

The “physician” restriction was lifted as the term “individual” is now used

The instruction was added to not report with E/M services

The definition now states there is a documentation requirement

The terminology of “patient encounter” was omitted

Modifier 76

Use modifier 76 Repeat procedure or service by same physician by appending to CPT® codes to indicate when the same physician repeats the same service and when the same CPT® code as previously reported. What it says is “I know this is the same CPT® code as above (or reported earlier) but it is a repeat, not a duplicate.”

One revision to modifier 76 is that it now applies to services and procedures whereas before it was restricted to only procedures. This is important as many have interpreted this modifier to apply only to radiology procedures as opposed to all services. This change should clear this confusion up. Also, the “physician only” restriction that was in the previous year’s modifier 76 description is eliminated.

Modifier 78

Modifier 78’s revised 2008 definition is Return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period. It may be necessary to indicate that another procedure was performed during the postoperative period of initial procedure (unplanned procedure following initial procedure). When this procedure is related to the first, and requires the use of an operating or procedure room, it may be reported by adding modifier 78 to the related procedure. (for repeat procedures, see modifier 76.)

The new definition emphasizes “Unplanned procedure following initial procedure” during the post-operative period. The modifier is now applicable to both the operating room and procedure room and also applicable to the same physician who performed the initial procedure. For repeat procedures done on the same day, see modifier 76.

Use modifier 78 when there is a return to the operating room for a related procedure during the postoperative period. Modifier 78 is a global package modifier that does not reset global days from previous surgery. Report when treatment for complications requires a return to the operating room (OR). Use it with a different CPT® code from original surgery. Payment is usually at 70 to 80 percent.

When to report 78 is for a patient returning to the operating room with a related procedure in the global period, such as, post-surgical infection debridement in the OR. Modifier 78 is the only modifier recognized by Medicare payable for post operative complications.

New! Modifier 92

Modifier 92 is added to Appendix A Modifiers with the descriptor Alternative laboratory platform testing: When laboratory testing is being performed using a kit or transportable instrument that wholly or in part consists of a single use, disposable analytical chamber, the service may be identified by adding modifier 92 to the usual laboratory procedure code (HIV Testing 86701-86703). The test does not require permanent dedicated space, hence by its design may be hand carried or transported to the vicinity of the patient for immediate testing at that site, although location of the testing is not in itself determinative of the use of this modifier. This modifier was created to report alternative laboratory platform testing. Right now, modifier 92 is used for HIV testing codes 86701-86703. Modifier 92 does not require the test kit be used in a permanent space allocated to the laboratory testing.


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