How to Use CPT Modifiers | Coding & Billing | MD&D # 38

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Today we're going to talk about modifiers. This is a topic that is confusing not only for doctors finishing training, but for many of us who have been practicing medicine for quite some time. So, I'm going to try to put this in layman's terms.

Imagine you see an outpatient in the office or the hospital clinic. In addition to evaluating the patient for the condition that they came for, you also perform a procedure. And then you have two CPT codes to submit. The first one is the E/M code for the encounter, and the second one is the procedure CPT code.

So, if you don't use something called a modifier, one of them will most probably get denied by the insurance company. Why? Because modifiers are a way of telling the insurance company that there was an additional charge. That's it. That should be easy to do, right? Well, not so fast. If you don't use the right modifier, insurance companies may deny your charges. And of course, not only will you not get the reimbursement that you rightly deserve, but your company will not get it either.

So, let's start with a very important point. A modifier does not change the work RVU that was assigned to the CPT code that you chose for the encounter.

Remember what I mentioned in previous podcasts: whenever you see a patient, you must, not should, must choose a CPT code. And that CPT code has a certain number of RVUs, these casino chips, attached to it. And then, your organization assigns a dollar value to 1 RVU specifically for you (the value of one casino chip).

Well, the modifier does not change the number of casino chips you get for that encounter, nor the dollar value of each chip. In other words, it doesn't change the RVU or the conversion factor of that RVU. What the modifier does to the CPT code is saying there is another charge to be added during the same encounter, and it tells the insurance company how it was performed, when it was performed, or under what circumstances you performed it. Think of modifiers like adjectives. They just add more detail to the encounter.

Then the insurance company recognizes the modifier, reads your note, and assesses if the documentation matches what the modifier is explaining you did.

The reason why a lot of doctors become confused with the use of modifiers, which is understandable, is because in compensation reports, sometimes you see, for example, a 99214 as a CPT E/M code and a modifier 25 attached to it, and then you see your work RVUs. So, it's easy to think that the modifier generated more RVUs, which is not true.

Modifier 25: The Most Commonly Used Modifier

The most common modifier by far is modifier 25. I use it every single day in the office.

For example, if a patient comes for an annual GYN exam and she also has an issue with, let's say, chest pain, then I use modifier 25 to address that other issue in addition to the preventive visit that she came for.

Or if a patient comes with abnormal bleeding, and I also perform an endometrial biopsy, then I use modifier 25 to let the insurance company know that I did something else. Modifier 25 is just one of many modifiers out there, but it's the most common one.

So, if you understand this correctly, the modifier is not adding more money or RVUs. It is just informing them that there are other charges attached to that encounter. That's it.

But that little two-digit number means thousands of dollars in difference in payment, not only to you for your work RVUs, but for your company, due to practice expense RVUs and malpractice RVUs.

The way the American Medical Association explains modifier 25 is: Modifier 25 tells the payer that the E/M service was significant and separately identifiable from the work associated with performing the procedure.

Remember, modifier 25 doesn't simply mean that you saw a patient and performed a procedure during the same visit. Just because you did both doesn't automatically mean you can use it. What you're telling the insurance company is that, in addition to performing the encounter, you also provided a significant, separate evaluation or procedure that went beyond the usual work involved.

That is why documentation matters. If you don't document the separate evaluation and justify it, then your charge can be denied.

Modifiers 52 and 53: When You Cannot Complete a Procedure

Two modifiers that I particularly like are modifier 52 and modifier 53. I use them regularly in my office. For example, modifier 52 means that you tried to do a procedure and you cannot complete it for a non-threatening condition. For example, if I am trying to perform an endometrial biopsy on a patient, but the cervix was so closed that I couldn't complete the endometrial biopsy, then I use modifier 52.

Now, if I couldn't complete the procedure because of an unexpected threat to the patient's well-being, for example, if the patient's blood pressure dropped or there was some major equipment failure, then modifier 53 is the right choice.

Modifier 24: An Unrelated Visit During the Postoperative Period

Another modifier that I tend to use is modifier 24. For example, if you do surgery on a patient and the patient shows up during the postoperative global period for a completely unrelated medical issue, then unless you use modifier 24, the payer may assume that the visit was part of the postoperative care, which is already included in the surgical payment.

So, with modifier 24, you are telling them that the E/M service was unrelated to the surgery.

An example: if I do a hysterectomy on a patient and then she comes with ear pain, that has nothing to do with the surgery.

Modifier 57: The Decision for Surgery

Another modifier that I used many times, in this case unfortunately, is modifier 57. Let me explain. For example, I see a patient for a condition in my office, and we decide that she needs surgery immediately or on the same day, then I attach a modifier 57 to the encounter.

I am telling the insurance company that I am making the decision to take the patient to the OR at that moment, that same day.

Other Modifiers Used for Surgical Procedures

For example, if you spend two more hours in the OR doing a surgery that normally takes you an hour because it was a complicated case, then you can use modifier 22. But again, the most important thing is that you document in your note that you spent those two extra hours and why.

Another modifier is 50. If I take a patient to the OR to remove one ovarian cyst, and I find I must remove another cyst from the other side that the images did not mention, then I can use this modifier.

Modifier 51 talks about multiple procedures done at the same time.

Modifier 59: Distinct Procedures on the Same Day

Modifier 59 deserves a few words. It is used when two distinct procedures are done on the same day.

For example, a dermatologist does a complex repair of the skin on a patient's forearm and then finds a lesion completely separate from the skin repair, on the same forearm.

Then the dermatologist can code for both the primary reason, meaning the skin repair, and the secondary reason, meaning the excision of the mass, using modifier 59.

The problem with modifier 59 is that it is very scrutinized by insurance companies because there has been misuse of it. And now we also have other modifiers similar to 59 (the X modifiers) that give more detail on the separate encounter or separate structure addressed during the same day. Did I scare you or bore you enough? I hope not. This topic is dense, I know.

There are also modifiers if two surgeons are performing surgery together, both as primary surgeons in a highly complex procedure. Modifier 60.

And another if you get called to help a colleague complete the surgery in an intra-operative consultation. That is modifier 80.

In the case of anesthesiologists, for example, they usually use modifier AA, which means that the anesthesiologist did the job alone. They're getting 100% of the fee.

And modifier QK, meaning the anesthesiologist managed two to four nurse anesthetists at the same time, and they get 50% of the fee.

Why You Should Know Your Coding Team

I know this is complicated, but it is very, very important that you become familiar and have a great relationship with your coding team in your office. And if you don't have a coding team and you're doing this on your own, it's important that you learn about modifiers by either buying the CPT professional book from the American Medical Association or attending meetings.

I bought the AMA's CPT professional book. And it helped a lot. I bought mine 10 years ago, and if you just read the few pages that are related to the modifiers that you will use in your own practice, it will help you quite a bit.

But always have a good relationship with your coder because they can actually give you the updates as they happen every year.

I Don't Care About Modifiers

Many employed physicians say: "I don't code. My billing department handles that."

That may be true. But you still need to understand modifiers. Because your coder does not have the clinical knowledge that you have, period. They can check accuracy, but they cannot tell you what work you did and how you could have charged for that work. So, if you leave everything to the coder, you might as well leave money on the table.

Work with your coding team. I always joke with the head of our coding team and the vice president for billing and coding that they are like my best friends. Whenever I have a question, I'll reach out to them.

My Take on Modifiers

Modifiers, Reimbursement, and Physician Compensation Are Three Different Things. Modifiers can affect reimbursement. But they don't change the wRVU assigned to the CPT code. The payer, nonetheless, may deny reimbursement without the appropriate modifier attached to the CPT code for your encounter.

Do I like modifiers? No. I think they are not useful in their current form. I believe there must be a much easier way to tell payers that you did something extra. And honestly, in my opinion, this is all a game. Because you may do the work, but if you don't use the right modifier, your work won't get paid. And that is not fair.

The problem is that with all these rules, which are intended to be an accurate depiction of what was done, they're just adding another layer of difficulty to properly code, to already busy people, like we all are.

You don't have to know all the modifiers. That's completely unnecessary. But you must know those that you use most commonly and when to use them.

What's Happening to Modifier 25 in 2027?

Well, there has been quite a bit of a ruckus about the proposed changes involving modifier 25.

In simple terms, CMS is proposing that when you see a patient in the office and perform a procedure on the same day, the insurance company will no longer necessarily reimburse both services at 100%.

Instead, the service with the higher payment will be reimbursed at 100%, while the other will be reimbursed at only 50%. For example, if I see a patient for abnormal bleeding and she ends up having an endometrial biopsy, I may get 100% reimbursement for the office visit, but only 50% for the biopsy. Or the other way around, depending on which service has the higher reimbursement.

Do I agree with this? No. I don't think many doctors would agree with it.

But unfortunately, what many physicians may not realize is that some private insurance companies have already been using similar payment policies in parts of the country, including here in New York, where I practice.

And this is what I find particularly interesting. We are used to seeing private insurance companies follow Medicare's lead. But in this case, CMS is proposing something like what some private insurers are already doing.

Of course, CMS argues that when a physician evaluates a patient and performs a procedure during the same visit, some of the work may overlap, and therefore, paying 100% for both services may not be justified. I disagree. If I performed a separately identifiable evaluation and performed a procedure, why should one of those services be reimbursed at half its value?

Now, this is still a proposal, not a final rule. Let's see if it gets approved. And if it does, well, many physicians around the country may start experiencing what some of us have already been dealing with, which will affect reimbursement.

The purpose of modifiers is not to give you any extra money. The purpose is to prevent the insurance company from denying payment for the services that you provided. That's it.

1. Modifiers help you get paid for the work you do. They tell insurance companies that you did something extra, so your services are billed correctly.

2. Modifiers do not change your work RVUs. They can affect reimbursement, but they don't change the work RVUs assigned to your CPT code.

3. Your documentation matters. Even if you have a coding team, they cannot report services that your notes don't support.

"A modifier is the difference between getting paid and getting audited."

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