Make Modifiers Simple: 6 Tips for Medical Coders

August 22, 2022 |
August 22, 2022

Modifiers. They’re small but mighty. They help ensure a healthcare organization can receive timely reimbursement. They can even help prevent denials and avoid inappropriate reimbursements.

Yet using them the right way can be a challenge, even for the most experienced of medical coders. And when modifiers are used incorrectly, it could lead to a painful and unnecessary audit.

To help medical coders gain more confidence in their abilities, we recently hosted a webinar called Simplifying Modifiers and Common Edits filled with plenty of helpful hints. Here are 6 quick-and-easy tips coders can use to help make modifiers simple:

1. Use Appendix A within the CPT manual to understand modifier definitions.

When in doubt, the CPT manual is always a medical coder’s best friend. Appendix A includes all definitions and should be the single source of truth when researching modifiers or CPT codes.

2. Use the physician fee schedule to determine global periods.

The physician fee schedule is available on the CMS website. Medical coders should refer to it when dealing with global period modifiers, including:

  • 24 – Unrelated evaluation and management (E/M) service by the same physician during a postoperative period
  • 25 – Significant, separately identifiable E/M by same physician on same day of the procedure or another service
  • 57 – Decision for surgery
  • 58 – Staged or related procedure or service by the same physician during the postoperative period
  • 78 – Unplanned return to the OR by the same physician following initial procedure for a related procedure during the postoperative period
  • 79 – Unrelated procedure or service by the same physician during the postoperative procedure

These are among the most commonly used—and misused—modifiers.

The global period is the amount of time a physician may not bill for office visits or other services related to a particular surgery. Depending on the procedure, the global period may be 0 days, 10 days, or 90 days. Generally speaking, a minor surgery has a global period of 0 or 10 days, and a major surgery has a global period of 90 days.

But there are times within those global periods when a physician does need to bill for an unrelated service that’s separately reimbursable. Knowing the proper global period and applying the correct modifier will communicate this special circumstance to a payer and satisfy edits based on National Correct Coding Initiative (NCCI) standards.

3. Use the NCCI PTP file from CMS to identify bundled services and know when unbundling is permitted.

CMS publishes two separate tables of NCCI procedure-to-procedure (PTP) edits on a quarterly basis. One table covers pro-fee coding (physicians and practitioners). The other covers facility-based coding (outpatient hospital coding). Using these tables will help medical coders know when to bundle services, and when they can’t be bundled.

Column F of each table shows when a modifier is allowed (marked with a 1) and when it’s not allowed (marked with a 0).

Here’s how this works in practice. CPT 25500 is for Closed Treatment; Radial Shaft Fracture; without manipulation. CPT 29075 is for Application, cast; elbow to finger. These two codes are bundled together which means the cast application is included with the treatment of the radial shaft fracture. The only way a medical coder can unbundle them is by applying an appropriately utilized modifier.

Let’s say the radial fracture was to the patient’s right arm, but during the same treatment session, the provider also put a cast on the patient’s left arm. In this case, adding a lateral modifier (-LT or -RT) will bypass the edit and make it clear to the payer that the treatment on the left arm is separate and distinct; it had nothing to do with the treatment on the right arm. These would be coded properly as 25500-RT and 29075-LT.

It’s our job as medical coders to determine whether a modifier is justified.

When I think of modifier use and bundling, I like to use the example of getting an oil change on a car. A standard oil change includes a new oil filter. That oil filter is usually included in the total price of the oil change; it’s not a separate procedure or a separate charge. Medical coding works much the same way. If the treatment is a usual and customary part of that procedure, it shouldn’t be unbundled

4. Use the most specified modifier available describing the scenario and ensure the chosen modifier aligns with the CPT code definition.

This relates in particular to anatomic modifiers, which include:

  • E1 – E4 – Eyelids
  • FA, F1 – F9 – Fingers and thumbs
  • TA, T1 – T9 – Toes
  • LC, LD, RC, LM, RI – Coronary Arteries
  • LT, RT, 50 – Laterality (LT and RT indicating left or right, or 50 indicating a bilateral procedure)

When applying these anatomical modifiers, medical coders should read their code descriptor carefully to determine whether the modifier is appropriate. One common error to avoid: Don’t add modifiers to laceration repair codes.

For example, CPT 12001 is for the simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less. This CPT does not describe a procedure for a paired organ, so it’s not appropriate to add -LT to the code even if the laceration being treated is on a patient’s left hand.

5. When reporting a separate procedure on the same day as an E/M visit, consider -25 for minor procedures and -57 for major procedures.

Modifiers -25 has come under scrutiny by payers recently. One way to know when to use this modifier is to remember that any procedure code a provider reports includes pre-, intra- and postoperative work. Therefore, an E/M visit must not be simply pre-procedure work, because that’s bundled with the procedure code.

In addition, when using modifier -25, the procedure in question should be a minor procedure, typically with a 0-day or 10-day global period on the physician fee schedule. If the procedure is major, typically with a 90-day global period, consider using -57 when the provider is making a decision to perform the procedure as part of the E/M visit.

Whenever medical coders use either modifier -25 or modifier -57, they should be sure that their documentation supports the fact that a medically necessary visit was completed in addition to the procedure.

6. Check payer preference for modifier -59 or -X(EPSU) modifiers, requirements around return trips to the OR, and telemedicine policies.

Modifier -59 should be used with caution. It’s become a catchall for clearing NCCI edits when no other modifier appropriate distinguishes one CPT code from another. The key is to ensure the procedures being documented are truly distinct.

The X modifiers were released by CMS in January 2015 as a replacement for modifier -59, although some payers will still only accept -59. If one of these X modifiers better describes a situation, medical coders should use the -X modifier and not modifier -59. X modifiers are:

  • XE – Separate encounter
  • XP – Separate practitioner
  • XS – Separate structure
  • XU – Usually non-overlapping service

Learn about the 5 new modifiers for 2022.

Watch the entire webinar to get more details on all of these modifiers and a few other commonly used ones. You’ll also learn about five new modifiers launched in 2022 that help medical coders properly document items like telehealth visits, mental health counseling through telehealth, and split/shared services.

And if you want to know how Coding and Revenue Integrity solutions and expertise from DeliverHealth can help make medical coding simpler for physicians, midlevel providers, and medical coders, let’s talk.