CPT codes provide a means of communicating the service or procedure performed in a uniform way. Coding rules require a perfect match between the code description and what was actually performed. But in the event that a service or procedure has to be altered, a modifier may be assigned. When a CPT code and modifier are assigned, the CPT code is reported first, followed by the modifier. For example: 99213-25
The purpose of CPT codes, modifiers, and ICD-9-CM codes is to communicate what was performed and why it was performed. In other words, these codes are used as a means of telling a story of what happened between the patient and the provider. And because some stories are more complex than others, multiple modifiers may need to be assigned. This article was written to provide guidance on sequencing multiple modifier assignments.
Not all modifiers have the same job: some identify an anatomical site, some are used for statistical purposes, some identify eligibility, and some alter payments. Here are just a few examples:
LOCATION LT-left, TA-left foot, great toe, F1-left hand, second digit, RT-right, T5-right foot, great toe
STATISTICAL 76-repeat same physician, 77-repeat by another physician, Q6-locum tenens physician
ELIGIBILITY 24-unrelated EM, 59-distinct procedure, 58-staged or planned, 79-unrelated procedure during post-op
PAYMENT ALTERING 26-professional component, 52-reduced, 53-discontinued, 22-increased work, 62-co-surgeon
When documentation dictates multiple modifier assignments for a single CPT code, there is a general hierarchy that should be followed:
• Payment altering modifiers are listed before eligibility, statistical, and location modifiers
• Eligibility modifiers are listed before statistical and location modifiers
• Statistical modifiers are listed before location modifiers
• Location modifiers are always listed last
• Modifier 26 is always the first modifier
• When the patient is in a global period, payment eligibility modifiers such as 78, 79, and 58 would be assigned before other modifiers.
It is important to note that even though most payers do follow Medicare guidelines, not all do. It is recommended that you check with the specific payer for instructions on modifier assignments.
Although the current CPT manual specifies that CPT modifier 99 may be used when it is necessary to indicate more than 2 modifiers on a single detail line or service, Medicare allows for use of up to four modifiers. If four or more modifiers are required, place modifiers with major importance in the first three positions, then modifier 99 in the fourth. Place the additional modifiers in the comment field.
All encounters were performed on the same patient, by the same physician.
July 1st, (hospital) under CT guidance, to alleviate pain due to compression fractures, vertebroplasty was performed in the hospital on a 68 year old patient at T12 and L1. A different physician provided the formal interpretation of the films obtained from the CT guidance.
22520 Thoracic vertebroplasty (T12)
22521-59 Lumbar vertebroplasty (L1)
72292-26-52 CT guidance for vertebroplasty (T12)
72292-26-52-59 CT guidance for vertebroplasty (L1)
July 5th (office) due to the need for chemotherapy administration along with severe emphysema the patient was counseled and an expanded problem focused evaluation and management was performed.
99213-24 Evaluation and Management
July 9th (office) PICC line was inserted utilizing fluoroscopy and ultrasound guidance, but due the patient’s tortuous veins the catheter could not be advanced. The physician discontinued this procedure.
36569-79-53 Insertion of PICC line
76937 Ultrasound guidance
77001 Fluoroscopic guidance
• Modifier 59, identifies the service is eligible for payment consideration and indicates a distinct procedure was performed.
• Modifier 24, identifies the service is eligible for payment consideration as it was in a global period and was unrelated to 22520 and 22521.
• Modifier 26, identifies professional component only and is always the first listed modifier.
• Modifier 52, indicates only the supervision component was performed. This is a payment altering modifier.
• Modifier 79, identifies the service is eligible for payment as the procedure was performed in a global period.
• Modifier 53, indicates the procedure was discontinued based on the physician’s discretion.
Again, it is important to note that even though most payers do follow Medicare guidelines, not all do. It is recommended that you check with the specific payer for instructions on modifier assignments.
Ref: MPFS = Medicare Physician Fee Schedule, see: Medicare Physician Fee Schedule Search