Procedure Code Modifiers
Appropriate use of modifier 22 for increased procedural services:
When the work required to provide a service is substantially greater than typically required (i.e., increased intensity, time, technical difficulty of procedure, severity of patient’s condition, physical or mental effort required).
When sufficient documentation is present in the medical record that supports the substantial additional work and the reason for the additional work which necessitated the use of this modifier.
Inappropriate use of modifier 22 includes, but is not limited to:
A slight extension of the procedure (e.g. a procedure extended by 15 to 20 minutes) or the performance of a routine part of a procedure, such as routine lysis of adhesions.
Surgical technique, surgeon’s expertise or surgeon’s choice of approach which does not justify increased work or resource (e.g., robotic surgical techniques, laparoscopic to open technique).
When reported with global maternity codes to indicate additional prenatal visits.
The use of specialized technology.
Increased post-operative recovery time.
Unlisted/non-specified procedure codes.
Patient’s BMI when no significant complications or difficulty presented during procedure.
Factors to consider when billing modifier 22:
Using modifier 22 identifies the service as one requiring individual consideration and manual review.
The claim must be accompanied by the relevant clinical documentation, and a cover letter, both of which explain the unusual circumstances.
Documentation includes, but is not limited to, descriptive statements identifying the unusual circumstances within the operative reports (and, if appropriate, state the usual industry standard time for performing the procedure and the prolonged time due to the complication) or, if applicable, pathology reports, progress notes, or other relevant clinical notes, etc.
All attachments to the claim for justification of the increased procedural services should explain the special circumstances in a concise, clear manner. This information should be easy to locate within the attached documentation. Highlight the information, if necessary, to facilitate the medical reviewer’s access to the pertinent supporting data.
Claims submitted containing modifier 22 that do not have supporting documentation attached to the claim demonstrating the increased effort will generally be processed as if the procedure code(s) did not contain the modifier.
For more information about billing and reimbursement guidelines for procedures reported with modifier 22, please refer to the Health Plan’s Administrative Policy 32, Increased Procedural Services (Login Required).
Correct Use of Modifier 25 for E/M Services:
- The E/M service is separate from the procedure performed, is not a part of the procedure, and is clearly documented in the medical record.
- An initial hospital visit, initial inpatient consult and/or hospital discharge service is billed for the same date as inpatient dialysis providing the service is unrelated or cannot be rendered during the dialysis session.
- Preoperative critical care codes are billed within a global surgical period.
- During a preventive care visit a significantly, separately identifiable acute care E/M service is also provided. In this instance, modifier 25 should be appended to the acute E/M service code, not the preventive service code.
- During a routine foot care visit, a significantly, separately identifiable service is medically necessary.
We recognize the use of Modifier 25 for these code ranges:
- CPT Codes:
- 99201 - 99499 (E/M)
- 92002 - 92014 (Ophthalmology)
- 99026 - 99027 (Hospital mandated on-call)
- 98966 - 98969, 99441 - 99444 (Telephonic/On-line Evaluation)
- 99050 - 99060 (Miscellaneous services)
- HCPCS Codes:
- G0101 (GYN cancer screening exam)
- G0344 (Initial Preventive Physical Exam)
- S0605 (Annual rectal exam)
- S0610 - S0613 (Annual GYN exam)
Modifier 25 is not allowed:
- On the day a procedure is performed if the patient's condition did not require an additional evaluation above and beyond the usual pre operative care required by the primary procedure.
- On a surgical code, since this modifier explains the special circumstances of providing the E/M service on the same day as the procedure.
- When reporting an E/M service that resulted in a decision to perform major surgery.
- On days 2 through 10 when billing E/M services with minor procedures (Global Fee Period of 0 - 10).
- When billing E/M services for Pre-op service one day prior to a major procedure, and on day 2 through 90 of a major procedure (Global Fee Period of 90 days).
- When billing:
- Lab / Path
- Category III codes
- HCPCS Codes: All except G0101, G0344, S0605 - S0613
Health Care Reform legislation under the Protection and Affordable Care Act (PPACA) outlines mandated preventive services and codes for which modifier 33 is required. Any copayments, coinsurances or deductibles called for under the member’s benefit plan are not applicable for these services.
If the preventive care is provided during an office visit please be aware that a copayment for the visit may apply if:
- The preventive care is not the primary purpose of the office visit
- The preventive service is billed with other services that require copayment.
It is important to verify benefits and eligibility when delivering any of the preventive services included in the mandate. Please verify benefits and eligibility prior to rendering services.
Correct Use of Modifier 59:
- When billing a combination of codes that would normally not be billed together.
- To indicate that the ordinarily bundled code represents a service done at a different anatomic site or different session on the same date.
- Use only on the procedure designated as the distinct procedural service.
- Ensure the medical record documentation is clear as to the separate, distinct procedure before appending modifier 59 to a code.
Modifier 59 is not allowed when:
- A procedure/service was not independent or distinct from any other service performed on the same day, same session, same site or lesion.
- There is another, existing modifier that better represents the service or procedure.
- When billing:
- E/M Codes: 99201 - 99499
- Codes considered as E/M: 92002 - 92014, 99026, 99027, 99050 - 99060, 98966 - 98969, 99441 - 99444, G0101, G0344 Codes S0605 - S0613.
Codes not specific to telemedicine services should be identified utilizing the following modifiers:
GQ - Via asynchronous telecommunications system
GT - Via interactive audio and video telecommunications system