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CURRENT PROCEDURAL TERMINOLOGY
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CHAPTER: MODIFIERS - APPENDIX A
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Appendix A
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Modifiers
This list includes all of the modifiers applicable to CPT 2022 codes.
A modifier provides the means to report or indicate that a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code. Modifiers also enable health care professionals to effectively respond to payment policy requirements established by other entities.
22 Increased Procedural Services: When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. Documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient’s condition, physical and mental effort required).
Note: This modifier should not be appended to an E/M service.
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Examples for Appending Modifier 22 to a Procedure or Service:
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Example 1:
Surgical Procedure :
In a patient undergoing laparoscopic oophorectomy, significant omental adhesions were noted on entrance into the abdomen.
A small, clear space allowed placement of a right-lower-quadrant 10-mm trocar.
An offset scope was used through this port to lyse adhesions to free the omentum from the anterior abdominal wall, allowing inspection of the pelvis.
This procedure required 20 to 30 minutes of additional surgical time.
Inspection of the pelvis revealed complete distortion of the normal anatomic relationships.
The uterus was deviated to the left.
The left round ligament could not be visualized.
The sigmoid colon was densely adherent to the left pelvic sidewall.
The left fallopian tube remnant could not be identified.
The right adnexa demonstrated an irregular ovary with cystic enlargement consistent with endometrioma.
A second left lower-quadrant trocar was placed.
With a combination of electrodissection, sharp blunt dissection, and hydrodissection, the multiple dense adhesions were lysed. Relative anatomic relationships were restored.
The dissection involved releasing the dense adhesions of the sigmoid colon to the peritoneum with mobilization of the sigmoid to identify the infundibula pelvic vessels and the course of the left ureter.
The left pelvic sidewall was opened and the left round ligament identified.
The total additional operative time to restore anatomy so as to identify vital anatomic structures before proceeding with oophorectomy was 1 hour of surgical work.
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CPT Code(s) : 58661 22 Laparoscopy, surgical; with removal of adnexal structures (partial or total oophorectomy and/ or salpingectomy)
Rationale for Using Modifier 22 In this example, there are 2 reasons why modifier 22 would be appropriate. The first is the extensive lysis of adhesions requiring 20 to 30 additional minutes of surgical time. The second is that the physician spent an additional hour to reverse the distortion of the anatomy before proceeding with the intended oophorectomy.
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Example 2:
Surgical Procedure:
A physician performed a laminotomy with decompression of the nerve root with a partial facetectomy, foraminotomy, and excision of a herniated disk of the lumbar spine (L2-L3). During the surgery, the physician encountered excessive bleeding (hemorrhage) that was difficult to control, which required an additional 60 minutes to complete the surgery.
CPT Code(s) : 63030 22 Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disc; 1 interspace, lumbar
Rationale for Using Modifier 22 The patient experienced excessive hemorrhaging, control of which required an additional 60 minutes of surgical time
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Example 3
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Anesthesia A 72-year-old female underwent left cemented total hip arthroplasty 1 year previously.
After recovery from the first total hip replacement, the patient had 2 left hip dislocations.
Radiographic studies revealed a loosening of the femoral component. The surgical plan included removal and replacement of the femoral component and assessment and possible replacement of the acetabular components to prevent further dislocations.
During the surgery, the patient went into cardiac arrest, and it took the anesthesiologist 45 minutes to stabilize the patient’s condition before the procedure could be continued. The procedure was completed and the patient taken to the recovery room in critical condition. She was closely monitored and moved to the critical care unit after 2 hours. The circumstances of the case prolonged the surgery by 45 minutes. The anesthesia code was submitted with modifier 22 along with the documentation.
CPT Code(s) : 01215 22 Anesthesia for open procedures involving hip joint; revision of total hip arthroplasty
Rationale for Using Modifier 22 The patient went into cardiac arrest, and her condition had to be stabilized by the anesthesiologist before the procedure could be completed. This additional work of stabilization required an additional 45 minutes beyond the usual procedure time, so modifier 22 is appropriate.
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23 Unusual Anesthesia: Occasionally, a procedure, which usually requires either no anesthesia or local anesthesia, because of unusual circumstances must be done under general anesthesia. This circumstance may be reported by adding modifier 23 to the procedure code of the basic service.
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Modifier 23 should be appended to the anesthesia code to indicate a procedure that is normally performed under local anesthesia or with a regional block required general anesthesia.
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ADDITIONAL INFORMATION:
One of the following modifiers must be reported with anesthesia services to indicate who performed the service:
• AA—Anesthesia services performed personally by anesthesiologist
• AD—Medical supervision by a physician: more than 4 concurrent anesthesia procedures
• QK—Medically directed by a physician: 2, 3, or 4 concurrent procedures
• QY—Anesthesiologist medically directs 1 CRNA
• QX—CRNA service: with medical direction by a physician
• QZ—CRNA service: without medical direction by a physician
Submit the modifier indicating that the service was personally performed, medically directed, or medically supervised first (anesthesia modifiers) and CPT modifier 23 second for the unusual anesthesia if applicable.
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Modifiers that are applied in the second position include:
• QS—Monitored anesthesia care service
• 23—Unusual anesthesia
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Examples for Modifier 23 Unusual Anesthesia
Example 1
A 4-year-old patient with Down syndrome was diagnosed with acute lymphoblastic leukemia after having symptoms and signs including fatigue, fever, and weight loss. Significant history included surgical repair of a ventricular septal defect at 2 years of age. The patient was extremely anxious, and the parents requested the child be anesthetized for cerebrospinal fluid testing and administration of intrathecal methotrexate. The anesthesiologist performed the service.
CPT Code(s) : 00635 AA 23 Anesthesia for procedures in lumbar region; diagnostic or therapeutic lumbar puncture
Rationale for Using Modifier 23 Because the child had Down syndrome and was anxious, there was a possibility local anesthesia might not be effective and/or might increase the child’s anxiety. The anesthesiologist agreed with the parents and anesthetized the patient with the general method
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Example 2
An 85-year-old male with a history of COPD, hypertension, and 40 pack years of smoking with a 3-cm peripheral nodule in the right upper lobe of the lung was scheduled for a diagnostic thoracoscopy and biopsy by means of a left lateral position. The patient was nervous and uncooperative, so general anesthesia with double-lumen endotracheal tube and arterial blood pressure monitoring was performed. The anesthesia service was provided by a CRNA under medical direction.
CPT Code(s) : 00528 QX 23 Anesthesia for closed chest procedures; mediastinoscopy and diagnostic thoracoscopy not utilizing 1 lung ventilation
Rationale for Using Modifier 23 Because the patient was anxious and uncooperative, the anesthesiologist determined that general anesthesia was indicated.
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Example 3:
A 69-year-old man with COPD, hypertension, and severe back and radicular pain secondary to possible herniated lumbar disks was scheduled for a diagnostic lumbar myelography of the L3-L4, L4-L5, and L5-S1 disks in the prone position. Because the patient was extremely anxious and agitated and in a great deal of pain, the anesthesiologist elected to perform the procedure under general anesthesia instead of local anesthesia, which would normally have been used.
CPT Code(s) : 01935 AA 23 Anesthesia for percutaneous image guided procedures on the spine and spinal cord; diagnostic
Rationale for Using Modifier 23 The patient was anxious and agitated and in a great deal of pain, which supports the use of general anesthesia to perform the procedure, so modifier 23 was appended to the claim. Insurance companies will want to know why anesthesia was required. Therefore, when the unusual anesthesia modifier is submitted, a report should include the circumstances that necessitated use of the general anesthetic. Most insurance carriers will require documentation to support the use of general anesthesia when local anesthesia is the accepted method.
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24 Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period: The physician or other qualified health care professional may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. This circumstance may be reported by adding modifier 24 to the appropriate level of E/M service.
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For surgical procedures that have no global days, modifier 24 is not to be used.
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Examples for Modifier 24
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Example 1:
A patient had a cholecystectomy and returned to the general surgeon for a 2-week follow-up visit. At that time, the patient complained of a sore throat and throbbing headache. Examination showed a streptococcal throat infection, which was unrelated to the postoperative follow-up, and the physician prescribed medication for the infection in addition to the routine postoperative evaluation.
CPT Code(s) Billed: 99212 24 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making
Rationale for Using Modifier 24
The streptococcal throat infection was unrelated to the cholecystectomy, and the claim would be submitted with a different diagnosis.
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Example 2:
A patient underwent a pericardiotomy for removal of a clot and returned 6 weeks later for a surgical follow-up visit to the cardiovascular surgeon. The patient was feeling fatigued and lethargic and had a migraine-type headache. After a detailed history and examination were performed, the physician determined the patient’s blood pressure was exceptionally higher than normal and adjusted the patient’s medication regimen. The physician asked the patient keep a record of blood pressure readings for the next 3 days and contact the office daily with the results.
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CPT Code(s) Billed: 99214 24 Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity.
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Rationale for Using Modifier 24 Because the increased blood pressure did not appear to be related to the surgery and the physician thought it necessary to perform a detailed history and examination to determine the problem, modifier 24 is appropriate as long as there was evidence in the documentation and/or diagnosis to support the encounter was unrelated to the surgery. This surgery typically has a 90-day global period with many insurance carriers.
25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service: It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59.
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Examples for Modifier 25
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Example 1:
A dermatologist saw a new patient in the office. The patient has noticed a spot on her right arm. The patient has a history of skin cancer so the physician performed a comprehensive history and a comprehensive examination including a full examination of the skin. The decision making is of low complexity. The lesion appeared to be benign of 1.2 cm. The physician excised the lesion during the visit and performed a simple closure. Since the work went above and beyond the normal work for the procedure, the physician may report the E/M service with modifier 25. This is how the physician reported the patient encounter:
CPT Code(s) 11402 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 1.1 to 2.0 cm 99203 25 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of low complexity
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99203 25 Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; and Medical decision making of low complexity
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Example 2
A 65-year-old patient was admitted to the hospital in the morning because of chest pain and shortness of breath. The physician performed and documented a comprehensive history and examination with moderately complex decision making. The patient had a history of heart disease, and her last myocardial infarction (MI) was 6 months ago. The physician was called to the hospital that same evening because the patient had another MI. The patient was transferred to the critical care unit where the physician spent 1 hour and 45 minutes stabilizing her condition after the MI. The patient was expected to remain in critical condition for several days owing to her history. The patient was admitted in the morning and the MI occurred in the evening. Because the diagnosis for the morning admission would be chest pain and shortness of breath with history of an MI, an E/M service for the admission would be appropriate. However, because the patient’s condition changed significantly in the evening and resulted in the MI, it also would be appropriate to report critical care services with modifier 25.
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CPT Code(s) : 99222 25 Initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity.
99291 Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes
99292 × 2 each additional 30 minutes
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Example 3:
A 30-year-old established patient saw a gynecologist for an annual well-woman examination. The physician performed and documented a comprehensive review of systems along with an interval medical, family, and social history. A comprehensive genitourinary (GU) examination was performed, and a Papanicolaou smear was obtained. Counseling on diet, exercise, and prevention was provided, and appropriate laboratory tests were ordered. During the encounter, the patient asked for renewal of the prescription for her anti-allergy medication. The services for this patient would only be considered preventive.
CPT Codes(s) : 99395 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization(s), laboratory/diagnostic procedures, established patient; 18-39 years
Rationale for Not Using Modifier 25 Because the request for allergy medication is considered incidental to the visit and the key components of a problem-oriented E/M service were not performed, a problematic E/M service would not be warranted.
26 Professional Component: Certain procedures are a combination of a physician or other qualified health care professional component and a technical component. When the physician or other qualified health care professional component is reported separately, the service may be identified by adding modifier 26 to the usual procedure number.
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Examples for Modifier 26
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Example 1:
A 66-year-old female complained of urinary frequency and urgency with residual urine volume of 120 mL. The physician performed a cystometrogram as a diagnostic measure to identify the cause. The patient was sent to the hospital outpatient department for the test. The physician will interpret the diagnostic test and render a report. CPT Code(s) Billed: 51725 Simple cystometrogram (CMG) (eg, spinal manometer) CPT code 51725 includes all supplies, equipment, and the technician’s work, including interpretation of the results. If the physician only interpreted the results and dictated a report, modifier 26 would be appended to the claim. The outpatient department will append an HCPCS level II modifier TC (technical component) to the same procedure code to report the supplies, equipment, facility, and technician’s work. The physician will bill 51725 26 to indicate he interpreted the study and wrote the report.
The outpatient department where the diagnostic procedure was performed will bill 51725 TC to indicate it performed only the technical component.
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Rationale for Using Modifier 26 In this example, the hospital outpatient department provided the technical component of the service and would bill using the same CPT code with modifier TC, and the physician who interpreted and provided the report will submit the claim with modifier 26.
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Modifier 26 with Radiology Procedures A radiologist read films and prepared a written report for a posteroanterior and lateral chest X ray in his own facility.
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