Resource CPT Modifiers

Lori · Dec 13, 2022

Modifier 57- Decision for Surgery

It is only used for the E/M procedure code, where the decision to perform surgery is made the day of or the day before a major surgery during an E/M service.

When not to use:

Appending to a surgical procedure code.
Appending to an E/M procedure code performed the same day as minor surgery.
When the decision to perform a minor procedure is done immediately before the service, it is considered a routine preoperative service and not billable in addition to the procedure.
Do not report on the day of surgery for a preplanned or prescheduled surgery.
Do not report on the day of surgery if the surgical procedure indicates performance in multiple sessions or stages.

Major surgeries have a 90-day postoperative period and minor surgery has either a zero or a 10-day postoperative period.

An E/M service resulting in the initial decision to perform major surgery is furnished during the post-operative period of another unrelated procedure, then the E/M service must be billed with both the 24 and 57 modifiers.

The global period includes:

Day before surgery
Day of the surgery; and
Number of days following the surgery

Modifier 57 Fact Sheet

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Lori · Dec 26, 2022

Modifier 58- Staged or Related Procedure or Service by the Same Physician During the Postoperative Period

Defined as a staged or related procedure performed during the postoperative period of the first procedure by the same physician.

A new postoperative period begins when the staged procedure is billed.

Report when a procedure or service during the postoperative period was:

Planned prospectively or at the time of the original procedure.
More extensive than the original procedure.
For therapy following a diagnostic surgical procedure.
When performing a second or related procedure during the postoperative period.

Staged procedures do not apply to claims for assistant at surgery.
Appending the modifier to ambulatory surgical center (ASC) facility fee claims.
Doesn’t apply to procedures with XXX global period.
Unrelated procedures during the postoperative period.
Reporting the treatment of a complication from original surgery that requires a return to the operating room or service not separately payable that does not require a return to the operating room.

Modifier 58 Fact Sheet

www.novitas-solutions.com

Lori · Dec 26, 2022

Modifier 59- Distinct Procedural Service

The CPT Manual defines modifier 59 as follows: “Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M (Evaluation/Management) services performed on the same day.

Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25.” Don’t use modifiers 59, -X{EPSU} and other NCCI PTP-associated modifiers to bypass an NCCI PTP edit unless the proper criteria for use of the modifiers are met. Medical documentation must satisfy the required criteria

Using modifiers 59 or –XS properly for different anatomic sites during the same encounter only when procedures which aren’t ordinarily performed or encountered on the same day are performed on: • Different organs, or • Different anatomic regions, or • In limited situations on different, non-contiguous lesions in different anatomic regions of the same organ Modifiers 59 or –XS are for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that: • Are performed at different anatomic sites, • Aren’t ordinarily performed or encountered on the same day, and • Can’t be described by one of the more specific anatomic NCCI PTP-associated modifiers – that is, RT, LT, E1-E4, FA, F1-F9, TA, T1-T9, LC, LD, RC, LM, or RI.

Only use modifiers 59 or -XE if no other modifier more properly describes the relationship of the 2 procedure codes. Another common use of modifiers 59 or –XE is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures that are performed during different patient encounters on the same day that can’t be described by one of the more specific NCCI PTP-associated modifiers – that is, 24, 25, 27, 57, 58, 78, 79, or 91.

https://www.cms.gov/files/document/mln1783722-proper-use-modifiers-59-xepsu.pdf

Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-evaluation and management (E/M) services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances.

It is the most reported modifier that affects National Correct Coding Initiative (NCCI) processing.
The Medicare NCCI includes edits that define when two HCPCS / CPT codes should not be reported together.
A correct coding modifier indicator (CCMI) of “0,” indicates the codes should never be reported together by the same provider for the same beneficiary on the same date of service. If they are reported on the same date of service, the column one code is eligible for payment and the column two code is denied.
A CCMI of “1,” indicates the codes may be reported together only in defined circumstances, which are identified on the claim using specific NCCI associated modifiers.
CCMI of "9," NCCI editing does not apply.
This modifier may be reported to indicate that a procedure or service was distinct or independent from other services performed on the same day.

Use when:

A different session
Different procedure or surgery
Different site or organ system: If two procedures are performed at separate anatomical sites or at separate patient encounters on the same date of service separate incision or excision
Separate lesion, or separate injury (or area in injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual
Second initial injection procedure when protocol requires two separate sites or when the patient has to come back for a separately identifiable service
Modifiers XE, XS, XP, and XU give greater reporting specificity in situations where you used modifier 59 previously. Use these modifiers instead of modifier 59 whenever possible. (Only use modifier 59 if no other more specific modifier is appropriate.)
For details, including appropriate and inappropriate uses and examples of modifiers 59 and X(EPSU), please refer to the CMS MLN Fact Sheet, Proper Use of Modifiers 59 & –X{EPSU}
CMS allows the modifiers 59 or –X{ESPU} on Column One or Column Two codes (see the related transmittal at CR11168).
Evaluate other anatomical modifir=erssuch as the RT/LT identifying right and left, F1 - F0 to identify fingers, T1-T0 to identify toes and E1-E4 to identify eyelids, coronary arteries modifiers, LC, LD, LM, RC or RI.

Do not use:

When another established more descriptive modifier is available and more appropriate.
When used with an E/M service.
If submitted on E/M codes 99201-99499, E/M codes are processed as though a modifier were not present (i.e., the code pair will be subject to NCCI editing and has an indicator that does not allow bypass).
To report a separate and distinct E/M service with a non-E/M service performed on the same date (refer modifier 25).
When a valid modifier exists to identify the services.
When documentation does not support the separate and distinct status.
When used to indicate multiple administration of injections of the same drug.
When the NCCI tables lists the procedure code pair with a modifier indicator of "0".

Modifier 59 Fact Sheet

www.novitas-solutions.com

Lori · Jan 6, 2023

62 -Two Surgeons

The individual skills of two surgeons are required to perform surgery on the same patient during the same operative session. This may be required because of the complex nature of the procedure(s) and/or the patient's condition and the additional physician is not acting as an assistant at surgery.

If the two surgeons (each a different specialty) are required to perform a specific procedure, each surgeon bills for the procedure with a modifier 62.

Co-surgery also refers to surgical procedures involving two surgeons performing the parts of the procedure simultaneously (e.g., heart transplant or bilateral knee replacements).

Modifier 62 Fact Sheet

www.novitas-solutions.com

Lori · Jan 6, 2023

63- Procedure Performed on Infants less than 4 kg.

Because there is a significant increase in work intensity for procedures performed on infants less than four kilograms related to temperature control, obtaining IV access, and the operation itself, which is technically more difficult with regard to the maintenance of homeostasis.

The patient’s medical record documentation must indicate:

a. The significantly greater effort required.
b. The reason for the additional work, which may include, but not be limited to:

i. Increased intensity or time.
ii. Technical difficulty of procedure that is not described by a more comprehensive
procedure code.
iii. Severity of the patient's condition.
iv. Increased physical and mental effort

You should append the 63 modifier only when the patient weighs 4 kg or less at the time of the procedure.

In past years, you could append modifier 63 only to procedures/services listed in the 20000-69999 code series only.

Starting in 2019, you could additionally be able to append modifier 63 to Cardiovascular procedures within the Medicine Section (9000-series) of CPT®.

CPT code range of 20100 – 69990, excluding some exceptions that are considered modifier 63 exempt
Medicine/Cardiovascular section code series 92920, 92928, 92953, 92960, 92986, 92987, 92990, 92997, 92998, 93312, 93313, 93314, 93315, 93316, 93317, 93318, 93319, 93452, 93505, 93563, 93564, 93568, 93580, 93582, 93590, 93591, 93592, 93593, 93594, 93595, 93596, 93597, 93598, 93615, 93616. Therefore, modifier 63 is not valid with Evaluation and Management Services, Anesthesia, Radiology, Pathology/Laboratory, or Medicine codes (other than those identified above, from the Medicine/Cardiovascular section).

Modifier -63 should not be confused with Modifier -22. Modifier -22 is for increased procedural services and can be appended to any procedure when the work required to provide the service is substantially greater than typically required.

Modifier 63; Procedure Performed on Infants Less Than 4 kg

Mod 110 - Modifier 63 represents procedures performed on neonates and infants up to a present body weight of 4 kilograms. MOD 110

www.regence.com

Modifier 63 Gets 2019 Update

When a surgeon performs certain procedures on an infant weighing less than 4 kilograms (approx. 8.8 lbs.), append modifier 63 to the CPT® code.

www.aapc.com

Lori · Jan 20, 2023

66- Surgical Team

Current Procedural Terminology (CPT®) modifier 66 describes when three or more surgeons of the same or different specialties work together as primary surgeons performing distinct part(s) of a surgical procedure.

Includes other highly skilled and specially trained personnel
Includes different types of complex equipment
Usually confined to organ transplant teams
Reimbursed "by report"
Every surgeon must append modifier 66 to the CPT code.

Should not be used for two or less surgeons.

Modifier 66 Fact Sheet

www.novitas-solutions.com

Sample form

Screen Shot 2023-01-20 at 9.54.46 AM.webp

https://www.ibx.com/documents/35221/56629/surgical-team-mod66-form.pdf

Lori · Jan 20, 2023

73- Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedure Prior to the Administration of Anesthesia

Modifier -73 is used by the facility to indicate that a surgical or diagnostic procedure requiring anesthesia was terminated due to extenuating circumstances or to circumstances that threatened the well-being of the patient after the patient had been prepared for the procedure (including procedural pre-medication when provided), and been taken to the room where the procedure was to be performed, but prior to administration of anesthesia. For purposes of billing for services furnished in the hospital outpatient department, anesthesia is defined to include local, regional block(s), moderate sedation/analgesia (“conscious sedation”), deep sedation/analgesia, or general anesthesia. This modifier code was created so that the costs incurred by the hospital to prepare the patient for the procedure and the resources expended in the procedure room and recovery room (if needed) could be recognized for payment even though the procedure was discontinued.

Physicians should not use this modifier.

This is only appropriate for use by the ASC.

Use when:

Due to extenuating circumstances or threaten patient well-being

Prior to the procedure started/patient's surgical preparation (including sedation or taken to the procedure room)
Prior to administration of anesthesia (local, regional block, or general)

Do not use when:

Elective cancellation of a procedure

Physician canceled the surgical or diagnostic procedure prior to the administration of anesthesia and/or surgical preparation of the patient

The surgeon cancels or postpones because the patient complained of a cold or flu upon intake

Modifier 73 Fact Sheet

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Lori · Jan 20, 2023

74- Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedure After the Administration of Anesthesia

Modifier -74 is used by the facility to indicate that a surgical or diagnostic procedure requiring anesthesia was terminated after the induction of anesthesia or after the procedure was started (e.g., incision made, intubation started, scope inserted) due to extenuating circumstances or circumstances that threatened the well being of the patient. For purposes of billing for services furnished in the hospital outpatient department, anesthesia is defined to include local, regional block(s), moderate sedation/analgesia (“conscious sedation”), deep sedation/analgesia, and general anesthesia. This modifier code was created so that the costs incurred by the hospital to initiate the procedure (preparation of the patient, procedure room, recovery room) could be recognized for payment even though the procedure was discontinued prior to completion.
Physicians should not use this modifier.

This is only appropriate for use by the ASC.

Use when:

May terminate surgical/diagnostic procedure after procedure starts (incision made, intubation started, scope inserted), and after administration of anesthesia (local, regional block or general).

Do not use when:

Elective cancellation of a procedure

Elective cancellation or postponement of a procedure based on the physician or patient's choice

Termination of the procedure prior to the beginning of the procedure or the administration of anesthesia

Modifier 74 Fact Sheet

www.novitas-solutions.com

Modifiers 73 and 74 have no requirement that the patient’s well being be tied to the procedure’s discontinuance.

One of the reasons that the facilities have more latitude with modifiers 73 and 74, for discontinued procedures before and after the administration of anesthesia is because of the costs involved in setting up an operating room.

Modifiers 52 and 53 vs. 73 and 74

It is important to know that Modifier 53 and Modifiers 73 and 74 are very different. Find out more from coding expert Barbara Cobuzzi.

www.aapc.com

Lori · Feb 14, 2023

76 -Repeat Procedure by Same Physician or Other Qualified Health Care Professional

Use when:

The same physician or other qualified healthcare professional performs the services.
Procedure codes that cannot be quantity billed.

Do not use when:

Adding to each line of service
Adding to a surgical procedure code;
Staged procedures (modifier 58),
Unplanned return to operating room (modifier 78)
Unrelated procedure or service (modifier 79).
Repeat services due to equipment / technical failure
Repeat laboratory services; refer to Current Procedural Terminology (CPT) modifier 91
Services repeated for quality control purposes
A service or procedure was provided more than once; unusual events occurred
Do not report this modifier with 'add-on' codes denoted in CPT with a “+” sign. If a service defined as an 'add-on' code is repeated or provided more than once (based on description) on the same day by the same provider, report the 'add-on' code on one line with a multiplier in the unit field to indicate how many times that service was performed.
For example, CPT 64636 (each additional facet joint) (billed in addition to primary/principle code 64635) is reported on one line as: 64636, units equal 3 (or the total number of additional facet joints (not bilateral) in addition to the initial/single facet joint billed under CPT code 64635). In this example, follow CPT instruction if provided bilaterally.

Modifier 76 Fact Sheet

www.novitas-solutions.com

Lori · Feb 14, 2023

77- Repeat Procedure by Another Physician or Other Qualified Health Care Professional

This modifier may be submitted with EKG interpretations or X-rays that require a second interpretation by another physician.

Used to indicate a procedure or service was repeated by another physician or other qualified healthcare professional.

Use:

Add modifier 77 to the professional component of an x-ray or electrocardiogram (EKG) procedure when the patient has two or more tests and/or more than one physician provides the interpretation and report.

Some payers will reimburse a second interpretation of the same EKG or x-ray only under unusual circumstances, such as:
A questionable finding for which the physician performing the initial interpretation believes another physician's expertise is needed, or
A change in diagnosis resulting from a second interpretation

Do not:

Bill for multiple services which are considered bundled.
Append Modifier 77 to an evaluation and management code.

Lori · Feb 14, 2023

78- Unplanned Return to the Operating Room by Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period

An operating room (OR) is defined as a place of service specifically equipped and staffed for the sole purpose of performing procedures. The term includes a cardiac catheterization suite, a laser suite, and an endoscopy suite. It does not include a patient’s room, a minor treatment room, a recovery room, or an intensive care unit (unless the patient’s condition was so critical there would be insufficient time for transportation to the OR).
Modifier 78 allows for the intraoperative percentage only of major or minor procedures (010 or 090 global periods).
A new postoperative period does not begin when using modifier 78.
Medicare allows codes with global surgery indicators of XXX and ZZZ in the Medicare Physician Fee Schedule (MPFS) database separately without modifier 78.

Use:

To identify a related procedure (that has 10 or 90 global surgery period) requiring a return trip to the operating room within the postoperative period of a major or minor surgery.
To treat the patient for complications resulting from the original surgery
When the procedure code used to describe a service for a treatment of complications is the same as the procedure code used in the original procedure.

Do not use:

On any procedure code that does not have global period of 0010 or 0090.
When surgery is unrelated to the original procedure.
On procedures performed in any place other than the operating room.
On ambulatory surgical center (ASC) facility services.

Lori · Jun 8, 2023

79- Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period

Use:

To describe an unrelated surgical procedure performed during the post-operative period of the original procedure by the same physician.
When reporting identical procedures that are performed on the same day, by the same physician, but are not the same service on the same anatomical site.

Do Not Use:

If the procedure performed is related to the original surgery or staged (anticipated) surgery.
If placed on procedure codes with XXX indicator (global concept does not apply), in the global day field of the Medicare Physician's Fee Schedule (MPFS) database.
If reported on ambulatory surgical center (ASC) services.

Note: If related to the original procedure, it is considered part of the global period.

A new post-operative period begins when the unrelated procedure is billed.

Any procedures appended with Modifier 79 will be denied for inappropriate modifier usage if no other procedure has been billed on either the same date of service or in the post-operative period by the same reporting provider.

Determining Whether Services Are Related, Staged, or Unrelated

1. When determining whether a subsequent procedure is related, staged, or unrelated to the
original surgery, both the reason for the original surgery and the reason for the subsequent
procedure must be considered.
a. Services treating complications from the original surgery are always related.
b. Procedures to treat or assist with expected developments in the healing process are always
related.
c. Services associated with returning the patient to the appropriate post-procedure state are
always related, and unless they require a return to the operating/procedure room,
reimbursement is included in the global surgery fee for the original surgical procedure(s).
d. When the subsequent procedure would not have been needed if the original surgery had
never been performed:
i. Services on the operative site or contiguous structures are related to the original
surgery.
ii. Services on a different body organ or unrelated operative site may be unrelated to the
original surgery. (In addition to modifier 79, use XS or another anatomical modifier as
appropriate.)
e. Procedures to treat the same or similar problems in the contra-lateral, non-operative organ,
extremity, or joint are unrelated.

Unrelated procedures (Modifier 79).
a. In order to verify that services are indeed unrelated to the original surgery creating the global
period, the following is requested:
i. The preoperative history and physical for the original date of surgery or procedure(s).
ii. The operative report for the original date of surgery or procedure(s).
iii. The preoperative history and physical for the subsequent date of surgery or
procedure(s).
iv. The operative report for the subsequent date of surgery or procedure(s).
b. When reporting services with modifier 79, billing offices should either:
i. Attach this documentation to the claim.
ii. Be prepared to submit this supporting documentation for review upon request.

Lori · Jun 8, 2023

80- Assistant Surgeon

Co-Surgeons are defined as two or more surgeons, where the skills of both surgeons are necessary to perform distinct parts of a specific operative procedure. Co-surgery is always performed during the same operative session.
An assistant surgeon is defined as a physician who actively assists the operating surgeon. An assistant may be necessary because of the complex nature of the procedure(s) or the patient’s condition. The assistant surgeon is usually trained in the same specialty.
An assistant-at-surgery may be a physician assistant, nurse practitioner, or nurse midwife acting under the direct supervision of a physician, where the physician acts as the surgeon and the assistant-at-surgery as an assistant.
Under some circumstances, highly complex procedures may require the services of a surgical team, consisting of several physicians, often of different specialties, plus other highly skilled, specially trained personnel, and complex equipment. A physician operating in this setting is referred to as a team surgeon.

Reimbursement for Surgical Assistants

For explaining the reimbursement for Surgical Assistants, we referred to CMS and American College of Surgeons guidelines as its primary source. Reimbursement for co-surgeons is 120 percent of the maximum allowance for the primary procedure divided equally between the co-surgeons. Reimbursement for assistant surgeons is 16 percent of the maximum allowance for the procedure. Reimbursement for team surgery will be determined on an individual consideration basis. Reimbursement for Physician Assistant/Nurse Practitioner/Nurse Midwife may be allowed when medical necessity and appropriateness of assistant surgeon services are met, and when the physician assistant/nurse practitioner/nurse midwife is under the direct supervision of a physician. Separate reimbursement will not be allowed for the hospital-employed physician assistant/nurse practitioner/nurse midwife. The physician assistant/nurse practitioner/nurse midwife reimbursement for a covered procedure is 13.6 percent of the maximum allowed for the procedure.

Billing Guidelines for Co-Surgeons

Services by surgeons of different specialties or subspecialties each performing distinct components of a procedure as primary surgeons will be allowed at 120 percent of the maximum allowance for the primary procedure. Multiple procedure guidelines may apply if additional procedures are performed. Each surgeon should document their distinct operative work in a separate operative report. Claims from both co-surgeons should report the same procedure code with modifier 62 appended. The total allowance for the operative session will be divided equally between the co-surgeons. Co-surgeon claims for procedures designated as co-surgeon allowed will be denied when both surgeons have the same specialty or subspecialty. When a claim for a non-surgical procedure is submitted with modifier 62 for a co-surgeon, the claim will be denied because the co-surgeon concept does not apply.

Physician Assistant/Nurse Practitioner/Nurse Midwife

A physician assistant/nurse practitioner/nurse midwife must be appropriately certified or licensed in the state where the services are provided, and be credentialed in the facility where the procedure is performed. Reimbursement may be allowed when medical necessity and appropriateness of assistant surgeon services are met, and when the physician assistant/nurse practitioner/nurse midwife is under the direct supervision of a physician. Separate reimbursement will not be allowed for the hospital-employed physician assistant/nurse practitioner/nurse midwife. The physician assistant/nurse practitioner/nurse midwife reimbursement for a covered procedure is 13.6 percent of the maximum allowed for the procedure.

Billing Guidelines for Team Surgeons

Highly complex procedures requiring multiple physicians of different specialties, and other highly skilled personnel and equipment may be considered for reimbursement as team surgery. Reimbursement for assistant surgeons is limited to 16 percent of the maximum allowance for the procedure. Services will not be reimbursed if the above criteria are not met. Procedures that are minor, non-surgical, or that are not of sufficient complexity to require multiple physicians of different specialties and other highly skilled personnel and equipment, do not satisfy the definition of team surgery and will be denied if submitted with modifier 66 (Team Surgery).
An "assistant at surgery" is a physician who actively assists the physician in charge of a case in performing a surgical procedure. The "assistant at surgery" provides more than just ancillary services. The operative note should clearly document the assistant surgeon's role during the operative session.

During certain operations, one physician assists another physician in performing a procedure. The physician who assists the operating surgeon would report the same surgical procedure as the operating surgeon. The assistant surgeon generally is present during the entire operation or a substantial portion of the operation to provide assistance to the operating physician. This modifier is not intended for use by non-physicians assisting at surgery (e.g., Nurse Practitioners, Physician Assistants, Registered Nurse First Assistants, etc.).

Use:

Use the "80" modifier when the assistant at surgery service was provided by a medical doctor (MD).
Use the "81" modifier to identify minimum surgical assistant services, and is only submitted with surgery codes.
Use the "82" modifier when the assistant at surgery service was provided by an MD and there was not a qualified resident available. Documentation must include information relating to the unavailability of a qualified resident in this situation.
Use the modifier "AS" for assistant at surgery services provided by a physician's assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS). The provider must accept assignment.

Note: An MD/doctor of osteopathic medicine should not submit the "AS" modifier. This modifier is only valid for use by non-physician practitioners when billing under their own provider number.

Reimbursement:

When reporting modifiers 80, 81 and 82 the fee schedule amount equals 16 percent of the amount otherwise applicable for the surgical payment.
Medicare allows 85% of the 16% for the assistant at surgery services provided by a PA, NP, or CNS.

Billing for Surgical Assistants: What you should know?

In this blog, we tried to cover every aspect of billing for surgical assistants including defining surgical assistants and billing guidelines.

www.medicalbillersandcoders.com

Lori · Jun 8, 2023

81- Minimum Assistant Surgeon

This assistant at surgery is providing minimal assistance to the primary surgeon. This modifier is not intended for use by non-physicians assisting at surgery (e.g., Nurse Practitioners or Physician Assistants).

At times the operating physician plans to perform a surgical procedure alone. When a minor problem is encountered during the operation that requires the service of an assistant surgeon for a relatively short period of time, this is considered a minimum assistant surgeon. (AMA2, 3)This modifier is not intended for use by non-physicians assisting at surgery (e.g., Nurse Practitioners, Physician Assistants, Registered Nurse First Assistants, etc.).

Indicates:

exceptional medical circumstances exist
the primary surgeon has a policy of never involving residents in preoperative, operative, or postoperative care of his/her patient

Use:

Append to appropriate code when more than one assistant is involved or if one person assists during a portion of the surgery. Includes physicians providing minimal assistance to the primary surgeon.

Note: Must be used with Type of Service 8 codes.

Provider types:

MD (Medical Doctor)
DO (Doctor of Osteopathic Medicine)
PA (Physician’s Assistant)
NP (Nurse Practitioner)
RNFA (Registered Nurse First Assistant)

These provider types are also not recognized by Medicare as eligible to bill or be reimbursed for assistant surgery services.

Certified First Assistant (CFA)
Certified Surgical First Assistant (CSFA)
Certified Surgical Assistant (CSA)

Medicare allows 85% of the 16% for the assistant at surgery services provided by a PA, NP, or CNS.

In addition, documentation to support one of the following situations is required in the medical record when the surgery is performed in a teaching hospital:

A statement that no qualified resident was available to perform the service
A statement indicating that exceptional medical circumstances exist
A statement indicating the primary surgeon has an across-the-board policy of never involving residents in the preoperative, operative or postoperative care of his or her patients

Indicator 0 corresponds to payment restriction for assistants at surgery applies to this procedure. Supporting documentation describing the medical necessity for an assistant must be submitted with the claim.
Indicator 1 corresponds to statutory payment restriction for assistants at surgery applies to this procedure. Assistants at surgery will not be paid.
Indicator 2 corresponds to payment restriction for assistants at surgery does not apply to this procedure. Assistants at surgery may be paid.
Indicator 9 corresponds to concept does not apply (the most likely explanation is that the procedure is not a surgery)

Lori · Jun 8, 2023

82- Assistant Surgeon (when qualified surgeon not available)

CPT Modifier 82 represents assistant at surgery by another physician when a qualified resident surgeon is not available to assist the primary surgeon. This modifier is not intended for use by non-physicians assisting at surgery (e.g., Nurse Practitioners or Physician Assistants)

Check Medicare Physician Fee Schedule (MPFS) Indicator/Descriptor List. Column A indicates if assistant at surgery allowed/not allowed.

Use:
When minimal surgical assistance is needed, but a qualified resident was not available (documentation required).

Physician:

Assist-at-surgery allowed with appended modifiers 80, 81 or 82
Allowed = 16% of surgery fee schedule allowable

Modifier 82 needs a statement that "no qualified resident surgeon was available"
- Indicates exceptional medical circumstances exist
- Primary surgeon must have a policy of never involving residents in preoperative, operative or postoperative care of his/her patients

Non Physician Practitioner (NPP) or mid-level practitioner (PA, NP, CNS):

Append AS modifier only
Allowed equals 85% of surgical assist or 16% allowable

Don't use:

to bill physician assistant surgical services with AS modifier
to append modifier 58 (staging) with any assistant surgery

Lori · Jun 9, 2023

90- Reference (Outside) Laboratory

Modifier 90 Reference (Outside) Laboratory: When laboratory procedures are performed by a party other than the treating or reporting physician or other qualified health care professional, the procedure may be identified by adding modifier 90 to the usual procedure number.

When laboratory procedures are performed by a party other than the treating or reporting physician, the procedure may be identified by adding Modifier 90 to the usual procedure number. For the Medicare program, this modifier is used by independent clinical laboratories when referring tests to a reference laboratory for analysis.

Use:

To indicate that although the physician is reporting the performance of a laboratory test, the actual testing component was a service from a laboratory.
By a physician or clinic when the laboratory tests performed for a patient are performed by an outside or reference laboratory. This modifier is used to indicate that although the physician is reporting the performance of a laboratory test, the actual testing component was a service from a laboratory.
When laboratory procedures are performed by a party other than the treating or reporting physician and the laboratory bills the physician for the service. For example, the physician (in his office) orders a CBC, the physician draws the blood, and sends the specimen to an outside laboratory. When outside reference laboratory services are billed using modifier 90.

Outside laboratory performs procedure, unrelated to treating/reporting physician lab furnishing the service usually would bill the claim
Possible for one lab to bill service performed by another lab by referring specimen to another laboratory for testing & the lab that receives specimen from another lab and performs one or more tests on such specimen.
Appropriate modifier 90 claims include two different Clinical Lab Improvement Amendment (CLIA) numbers to reflect billing provider information & the Laboratory where services were performed (reference lab)

Do Not:

Report modifier 90 with anatomic pathology and lab services
Append modifier 90 for drawing fee (36415)-Cannot be referenced out to another lab

Tips:

Sometimes a clinical diagnostic independent lab, place of service (POS) 81, refers to a specimen to another lab for testing, where a modifier 90 is appended.
Modifier 90 (reference laboratory) will not bypass clinical edits, subsets, bundling, etc.
If some of the blood and/or serum lab procedures are performed by the provider and others are sent to an outside lab and billed with modifier 90, CPT 36415 is not eligible for separate reimbursement.
CPT codes 99000 and 99001 (handling fees) are not eligible for separate reimbursement.
Must append modifier 90 to referred laboratory test code
- Item 20 mark "Yes" = outside lab
- Purchase price must be reflected under charges
- Complete item 32 with NPI, name and address where performed
Bill claims with modifier 90 and without modifier 90 separately
If no purchased services, leave item 20 blank

90 - JE Part B - Noridian

View modifier definition, instructions, correct/incorrect use, claim example, and resource.

med.noridianmedicare.com

Lori · Jun 9, 2023

91- Repeat Clinical Diagnostic Laboratory Test

Modifier 91 is used when multiple, serial laboratory tests are needed in the course of treatment of a patient (e.g., repeat blood glucose tests). Modifier 91 is used when a clinical laboratory test must be repeated on the same date of service and the results are used to assist in managing the treatment of a patient.

A single service (same CPT code) is ordered (for the same beneficiary)
A specimen is collected more than once in a single day
The service is medically necessary.

Use:

• Used for a rerun of a laboratory test to confirm results
• Due to testing problems for the specimen or equipment
• When another procedure code describes a series test
• When the procedure code describes a series of test

Do Not Use:

For lab tests that are repeated to confirm the initial results
For lab tests that are repeated due to malfunctions of either the testing equipment or the specimen
For lab tests when another appropriate one-time code is all that is needed to report the service
For any reason when a normal one-time result is required

Reimbursement:

Bill all services performed same day on the same claim
Report each service on a separate line, with the quantity of one, and append 91 to the repeat procedure
Documentation must support the use of the modifier

Modifier 91 causes a lot of confusion when differentiating its use from that of modifier 59 Distinct procedural service. When reporting lab procedures, modifier 59 is used when the same lab procedure is done, but different specimens are obtained, or the cultures are obtained from different sites.• For any reason when a normal one-time result is required.

Proper Use of Modifier 91

Modifier 91 Repeat clinical diagnostic laboratory test is used to report the same lab test when performed on the same patient, on the same day, to obtain

www.aapc.com

Lori · Jun 9, 2023

92-Alternative Laboratory Platform Testing

Append modifier 92 to a lab test in the form of a kit or transportable instrument that consists of a single use, disposable, analytical chamber.

(HIV testing 86701-86703 & 87389)

Use:

When a laboratory test is performed using a kit or transportable instrument that wholly or in part consists of a single-use, disposable, analytical chamber
When the test does not require permanent dedicated space
When the test is designed to be carried or transported to the vicinity of the patient for immediate testing at that site

Tip:

The test does not require permanent dedicated space, hence by its design it 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

AdaijiaR_82779 · Jun 9, 2023

goodmoring do you know if these test are current for this year

Lori · Jun 9, 2023

93 – Synchronous Telemedicine Service Rendered Via Telephone or Other Real-Time Interactive Audio-Only Telecommunications System

FQ – Service furnished using audio-only communication technology

Synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located away at a distant site from the physician or other qualified health care professional. The totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that is sufficient to meet the key components and/or requirements of the same service when rendered via face-to-face interaction.

At its February 2022 meeting, the CPT® Editorial Panel accepted addition of Appendix T. This appendix is a listing of CPT codes that may be used for reporting audio-only services when appended with Modifier 93.

Appendix T
CPT Codes That May Be Used For Synchronous Real-Time Interactive AudioOnly Telemedicine Services
This listing is a summary of CPT codes that may be used for reporting audio-only
services when appended with Modifier 93. Procedures on this list involve electronic
communication using interactive telecommunications equipment that includes, at a
minimum, audio. The codes listed below are identified with the  symbol.
90785 97804
90791 99354
90792 99355
90832 99356
90833 99357
90834 99406
90836 99407
90837 99408
90838 99409
90839 99497
90840 99498◄
90845
90846
90847
92507
92508
92521
92522
92523
92524
96040
96110
96116
96160
96161
97802
97803

https://www.ama-assn.org/system/files/cpt-appendix-t.pdf

Use:

If the real-time interaction occurs between a physician/other qualified health care professional and a patient who is located at a distant site

Tips:

Communication during the audio-only service must be of an amount or nature that meets the same key components and/or requirements of a face-to-face interaction.
Codes 99441, 99442, 99443: for physicians and other qualified healthcare professionals that can bill evaluation and management services (EMS) under their own name and NPI number
Codes 98966, 98967, 98968: for all other qualified non-physician healthcare professionals
POS 02 – Telehealth provided other than in the patient's home
The location where health services are provided or received through telecommunications. The patient is physically not located in their home when receiving these related health services via telecommunication technology.
POS 10 – Telehealth provided in the patients home (effective January 1, 2022)
The location where health services are provided or received through telecommunications. The patient is physically in their home (a location other than a hospital or facility where the patient receives care in a private residence) when receiving these related health services via telecommunications technology.

Examples of CMS Originating Sites:
• The office of a physician or practitioner
• A hospital (inpatient or outpatient)
• A critical access hospital (CAH)
• A rural health clinic (RHC)
• A federally qualified health center (FQHC)
• A hospital-based or critical access hospital-based renal dialysis center (including satellites);

NOTE: Independent renal dialysis facilities are not eligible Originating Sites

• A skilled nursing facility (SNF)
• A community mental health center (CMHC)
• Mobile Stroke Unit
• Patient home – for monthly end stage renal, ESRD-related clinical

Eligible Care Providers As described by CMS, the types of care providers eligible to deliver Telehealth services include, for example:
• Physician
• Nurse practitioner
.• Physician assistant
• Nurse-midwife
• Clinical nurse specialist
• Registered dietitian or nutrition professional
• Clinical psychologist
• Clinical social worker
• Certified Registered Nurse Anesthetists

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Resource - Telehealth

Telemedicine-“a two-way, real- time interactive communication between a patient and a physician or practitioner at a distant site through telecommunications equipment that includes, at a minimum, audio and visual equipment.” Telemedicine services may make up 2 distinct services, depending on...

www.cco.community

https://www.cco.community/threads/the-ultimate-telemedicine-guide-what-is-telemedicine.3572/

https://downloads.aap.org/AAP/PDF/coding_factsheet_telemedicine.pdf

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Resource CPT Modifiers

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Reimbursement for Surgical Assistants​

Billing Guidelines for Co-Surgeons​

Physician Assistant/Nurse Practitioner/Nurse Midwife​

Billing Guidelines for Team Surgeons​

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Attachments

New member

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Use when:

Do not use when:

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Do not:

Use:

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Reimbursement for Surgical Assistants

Billing Guidelines for Co-Surgeons

Physician Assistant/Nurse Practitioner/Nurse Midwife

Billing Guidelines for Team Surgeons