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Modifying procedures in CPT codes

Ambulatory Safety Monitor, July 28, 2005

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You can modify procedures described in current procedural terminology (CPT) codes under certain circumstances. When applicable, identify the modifying circumstances by adding the appropriate modifier code. The following are guidelines:

• The modifier may be reported by a two-digit number placed after the usual procedure number, from which it is separated by a hyphen (e.g., modifier -50 can be attached to code 29848 to report a bilateral arthroscopic carpal ligament release).

Specific modifiers may be required for freestanding ambulatory surgery center (ASC) reporting to meet at least one of the following criteria for Medicare facility claims:

• Payment implications
• Future need for payment data for constructing an outpatient prospective payment system
• Coding consistency and editing

Commonly reported modifiers

Placement of a modifier after a CPT or Healthcare Common Procedure Coding System (HCPCS) Level II code does not ensure reimbursement because some modifiers are informational.

If a third-party payer requires your ASC to report specific modifiers, comply with those reporting requirements as well. Below are brief descriptions of some of the more commonly reported CPT modifiers. Review your third-party payer bulletins, newsletters, and Web sites (as applicable) for specific modifier-reporting requirements:

• -50 Bilateral procedure: Bilateral procedures that are performed at the same operative session should be identified by the appropriate CPT or HCPCS Level II code for the first procedure. The third-party payer may require that the -50 modifier be appended to either the second (bilateral) procedure code or to the first code with a unit of "one" reported in box 24G (days or units) of the CMS-1500 claim form.
• -59 Distinct procedural service: When a procedure or service that is designated as a "separate procedure" in the CPT manual is carried out independently or considered to be unrelated or distinct from the other services provided at the same session, you may report it by appending the -59 modifier to the specific separate procedure code to clarify that it is a distinct, independent procedure. Assign modifier -59 when there is not a more descriptive modifier available and the use of modifier -59 best explains the circumstance.
• -73 Discontinued outpatient hospital/ASC procedure prior to administering anesthesia: Due to extenuating circumstances or those that threaten the well-being of patients, a physician may cancel a surgical or diagnostic procedure after preparing the patient for surgery (including after sedation, when provided, and after being taken to the room where the procedure is to be performed), but prior to the administration of anesthesia (local, regional block(s), or general).

Under these circumstances, the service that is prepared for but cancelled can be reported by its usual procedure number and the addition of the modifier -73.

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