Every Modifier Tells A Story

CPT and HCPCS modifiers are used on claims to help tell a story. Without the modifiers, the claim might not give an accurate picture of a patient encounter. Using modifiers properly and in the right order can be challenging, but with a bit of knowledge, modifiers can help you paint a clear picture of a claim. 

Here are a few examples of how rules can clarify the use of reporting modifiers.

Modifier 27 – Multiple outpatient hospital evaluation and management encounters on the same date

Order of appearance is important. Modifiers that affect payment should be listed first, followed by modifiers that are solely informational.

Adding modifier 27 to the second and subsequent evaluation and management code signals that there were different encounters with the same patient on the same date. For example, it may be used when a patient is seen in Internal Medicine and Orthopedics on the same date of service for different reasons. This may avoid an unnecessary denial for a claim that appears to be a duplicate. Modifier 27 is used for outpatient visits, and can be combined with other modifiers. Since modifier 27 doesn’t affect payment, it would be sequenced after any payment modifiers, if they are needed.

Modifier 52 – Reduced services and Modifier 53 – Discontinued procedure

Surgical procedures that are started but are not completed should have modifier 52 or 53 appended, depending upon the reason that the procedure is stopped.

Use Modifier 52 –

  • When the provider or the patient decide that the service should be reduced or ended.
  • Modifier 52 can also be used for procedures when the CPT code is defined as a bilateral procedure but is not performed on both sides.

Use Modifier 53 –

  • When there is an unexpected issue that causes the end of the procedure.
  • This includes situations where the patient’s health deteriorates during the procedure or the provider decides that continuing would cause unforeseen risk.

Both modifiers that signal a discontinued procedure could impact payment and should be listed first if there is more than one modifier used for the discontinued service.

Modifier 22 – Increased procedural services

If the work involved in a procedure is considered substantially greater than normally expected, modifier 22 can be added. This may include substantial –

  • Intensity
  • Time
  • Technical difficulty
  • Severity of patient’s condition
  • Physical and mental effort

Modifier 22 is considered a payment modifier – however, it’s not a guarantee that payment will be adjusted. Documentation must also accompany the claim to explain the extra work involved.

Many other modifiers (both payment and informational) can be found on the CMS website and within your CPT resource.

As always, proper coding is the key to efficient claims processing and results in a lower incidence of denials. 

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