Brachytherapy: Applications and Technique, 1st Edition

Appendix

Common Modifiers in the Coding Process

Modifiers

Modifiers are two-digit suffix codes that are appended to the primary CPT-4 code to identify additional information about the service. Certain modifiers will affect the payment rate and others will allow for bypassing of code edits. Examples of commonly used modifiers are listed in the table below.

-25

Identified in the CPT Manual as a “significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service.”

Appended to an evaluation and management (E & M) code reported with another procedure on the same day of service. The E & M and procedure(s) may be related to the same or different diagnoses.

-26

Distinguishes the service code as professional services, only.

Payment is reduced compared to global service.

-TC

Distinguishes the service code as technical services, only.

Payment is reduced compared to global service.

-76

Represents a repeat service by the same physician on the same day.

Does not affect the level of the payment.

-58

Describes a staged or related procedure or service by the same physician during a postoperative period.

From the National Correct Coding Initiative perspective, this modifier addition allows reporting of one procedure followed by another procedure or service during the postoperative period services as separate and distinct.

-59*

Distinct Procedural Service: Indicates that two or more procedures are performed at different anatomic sites or different patient encounters are independent from other services performed on the same day.

· Often used incorrectly.

· Should only be used if no other modifier more appropriately describes the relationships of the two or more procedure codes.

· Used to identify services that are not normally reported together, but are appropriate under the circumstances.

Use of modifier -59 does not require a different diagnosis for each HCPCS/CPT coded. Different diagnoses are not adequate criteria for use of modifier -59.

· This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury.

· According to NCCI, the definition of different anatomic sites includes different organs or different lesions in the same organ.

Modifier -59 and other NCCI-associated modifiers should NOT be used to bypass an NCCI edit unless the proper criteria for use of the modifier is met.

 

*Note: The Centers for Medicare & Medicaid Services encourages carriers to conduct prepayment and postpayment reviews of the use of modifier -59.



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