-22

Unusual Procedural Service

Used when the service provided is greater than that usually required for the listed procedure

In order to receive extra reimbursement, the op report must document the extra work provided, and usually must be sent with the claim.

-24

Unrelated E&M by the same physician during the Post-op Period

E&M service performed during the post-op period is unrelated to the original procedure

Documentation and diagnosis codes must support that this service was performed during the post-op period for a reason unrelated to the original procedure.

-25

Significant, separately identifiable E&M by same physician on the same day as a procedure or other service

On the day that a procedure is performed, the patient’s condition warranted a separate E&M beyond the usual pre-op and post-op care associated with the procedure.

Example: Pt. Reported to the office for a scheduled Cysto. Upon arrival, pt. Had a new complaint of groin pain, nausea and fever. Physician examined the patient, prescribed medication and made the decision to proceed with the Cysto.

-26

Professional Component

Certain procedures have both a professional and a technical component.

When physician component is reported separately, the service is identified by adding the modifier –26 to the CPT code (ie reading and reporting on an EKG or EEG). The physician’s interpretation must be documented.

-52

Reduced Services

When a service or procedure is partially reduced or eliminated at the physician’s discretion

Example: If an enterocystoplasty (51960) is performed and the surgeon elects not to perform intestinal anastomosis, a –52 modifier would be attached to the procedure code.

-53

Discontinued Procedure

When the surgeon elects to terminate a surgical or diagnostic procedure, this modifier indicates that a procedure was started but discontinued.

Do not use this modifier to report elective cancellation of a procedure prior to the patient’s anesthesia induction and/or surgical prep. This modifier is most frequently used when a procedure is reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient.

-57

Decision for Surgery

Used to indicate that an E&M service resulted in the initial decision to perform the surgery.

Example: Physician consults in the ER, decides patient needs surgery immediately. The modifier would be placed on the consult code, and the surgery would also be billed on the same day or next day.

-58

Staged or Related Procedure by Same Physician During the Post-op Period

Physician must document that e performance of a procedure or service during post-op period was a) planned prospectively, b) more extensive than original procedure or c) for therapy following a diagnostic surgical procedure.

This modifier is not to be used to report the treatment of a problem that requires a return to the operating room. See modifier –78.

-59

Distinct Procedure Service

Indicates that a service was distinct or independent from other services performed on the same day.

Example: Physician performs an emergent stricture dilation in the morning, performs a more extensive surgery in the afternoon. The modifier –59 would show that these were two distinct procedures. Otherwise, the dilation would be bundled into the more extensive surgery

-76

Repeat Procedure by Same Physician

This modifier is used when the physician needs to indicate that a procedure or service was repeated subsequent to the original procedure or service.

TIP: members of the same group practice are viewed as being “the same physician”.

-77

Repeat Procedure by Another Physician

Used when the physician needs to indicate that a procedure or service performed by another physician had to be repeated.

Example: Jefferson physician repeats a nephrolithotomy on a patient previously operated on at another health system.

-78

Return to the OR for a Related Procedure during the Post-op Period

This modifier indicates procedure was performed during the post-op period of the initial procedure

Example: Pt. Who undergoes cysto with removal of bladder tumor now undergoes additional cysto with insertion of a radioactive substance.

-79

Unrelated Procedure by the Same Physician during the Post-Op Period

Indicates the during the post-op period was unrelated to the original procedure

Patient is 60 days status post drainage of a renal abscess undergoes a Cysto with biopsy. Modifier -79 would be appended to the second procedure.