Modifier Usage
Table of Contents
- E/M Services Within a Global Surgical Period – Modifiers 24, 25 and 57
- Surgical Codes Only During a Global Surgical Period – Modifiers 58, 78 and 79
- 58 – Staged or Related Procedure or Service by the Same Physician During the Postoperative Period
- 78 – Unplanned Return to the Operating/Procedure Room by the Same Physician or other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period
- 79 – Unrelated Procedure or Service by the Same Physician During the Postoperative Period
- Modifier 22 – Increased Procedural Service
- Modifier 50 – Bilateral Procedures
- Modifier 51 – Multiple Procedures
- Modifier 52 - Reduced Services
- Modifier 53 – Discontinued Procedure
E/M Services Within a Global Surgical Period – Modifiers 24, 25 and 57
24 – Unrelated E/M Service by the Same Physician During a Postoperative Period
An E/M service coded with modifier 24 indicates a visit in the postoperative period that is unrelated to the original procedure (surgery). This modifier is only to be used with an E/M visit. It is not valid when used with surgeries or other types of services. It is not necessary or appropriate, for modifier 24 to be used with tests done in the postoperative period. When using modifier 24, ensure that the patient’s records and ICD-10 codes recorded on the claim clearly indicate that the E/M visit is unrelated to the original procedure.
25 – Significant, Separately Identifiable E/M Service by the Same Physician on the Same Day of the Procedure or Other Service
Medicare allows payment for an E/M service performed on the same day as a minor surgical procedure, if all requirements are met. The term surgery or service includes therapeutic injections and wound repairs. The additional E/M service must be separately identifiable from the surgical procedure and require significant effort above and beyond the usual pre-and post-procedure service routinely required for the procedure. 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. Medical records should document the E/M service to such an extent that, upon review, the extra effort may be readily identifiable. Note: The diagnosis may be the same for both the E/M and the surgery/procedure.
57 - Decision for Major Surgery
An E/M examination code with modifier 57 indicates a visit that resulted in the initial decision to perform a major surgery. Surgeries that have a 90-day follow-up period are considered major surgeries. When coding modifier 57, ensure the patient’s records clearly indicate when the initial decision to perform the surgery was made. Do not use modifier 57 with an E/M performed on the same day as minor surgery.
Surgical Codes Only During a Global Surgical Period – Modifiers 58, 78 and 79
58 – Staged or Related Procedure or Service by the Same Physician During the Postoperative Period
Modifier 58 can be used when a second surgery is done in the postoperative period of another surgery when the subsequent procedure:
- Was planned prospectively (or “staged”) at the time of the original procedure; or
- Was more extensive than the original procedure; or
- Was for therapy following a diagnostic surgical procedure
A new postoperative period begins when the next procedure in the series is billed.
78 – Unplanned Return to the Operating/Procedure Room by the Same Physician or other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period
Modifier 78 is used for a return trip to the operating room for a related surgical procedure during the postoperative period of a previous major surgery. The allowance will be reduced, since pre and postoperative care is included in the allowance for the prior surgical procedure. An “operating room” is defined as a place of service specifically equipped and staffed for the sole purpose of performing surgical procedures. The term includes a cardiac catheterization suite, a laser suite, and an endoscopy suite. It does not include a patient’s room, a minor treatment room, a recovery room, or an intensive care unit unless the patient’s condition was so critical there would be insufficient time for transportation to an operating room.
79 – Unrelated Procedure or Service by the Same Physician During the Postoperative Period
Modifier 79 is used for unrelated procedures by the same physician (or physician of the same specialty in the same surgical group) during the postoperative period. Unrelated procedures are usually reported using a different ICD-10 diagnosis code. Note: The use of RT and LT modifiers is helpful and should be used with modifier 79, not in place of it.
Ophthalmological procedures involving the eyelid or eyelids should be submitted with the modifier that defines the specific anatomic site. Modifiers E1 through E4 define the specific eyelid.
- E1 – Upper left, eyelid
- E2 – Lower left, eyelid
- E3 – Upper right, eyelid
- E4 – Lower right, eyelid
Modifier 22 – Increased Procedural Service
Modifier 22 is used to identify procedures which require individual consideration and should not be subject to the automated claims process. A description of the increased services may be entered in the comments field of electronically billed claims or submitted as an attachment with paper claims. NGS may require additional documentation to support the substantial additional work (for example, increased intensity, time, technical difficulty of the procedure, severity of the patient’s condition, and physical/mental effort required). Documentation includes, but is not limited to, descriptive statements identifying the increased services, operative reports, pathology reports, progress notes, office notes, etc. If additional information is needed, we will request it.
The submission of a procedure with modifier 22 does not ensure coverage or additional payment. All claims with modifier 22 and appropriate documentation are reviewed by medical review staff to determine whether payment is justified.
Modifier 22 can be used on all procedure codes with a global period of 0, 10 or 90 days when unusual circumstances warrant consideration of payment in excess of the fee schedule allowance.
Modifier 50 – Bilateral Procedures
Bilateral services are procedures performed on both sides of the body during the same session. Medicare considers bilateral procedures as one payment amount equal to 150 percent of the Medicare Physician Fee Schedule allowance for items identified as surgical procedures.
Modifier 51 – Multiple Procedures
Modifier 51 need not be reported to Medicare. The contractor will add, if appropriate.
Modifier 52 – Reduced Services
Under certain circumstances a service or procedure is partially reduced or eliminated at the physician's discretion. Under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced. This provides a means for reporting reduced services without disturbing the identification of the basic service.
Note: for hospital outpatient reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC outpatient visit use).
Claims for surgeries billed with a “-52” modifier, are priced by individual consideration if the documentation is submitted. Documentation may include office records, test results, operative notes, hospital records to substantiate the reason for reporting a reduced service.
Modifier 53 – Discontinued Procedure
Modifier 53 is used when it is necessary to indicate that a surgical or diagnostic procedure was started but discontinued, due to extenuating circumstances or those that threaten the well-being of the patient. Note: This modifier is not used to report the elective cancellation of a procedure prior to the patient’s anesthesia induction and/or surgical preparation in the operating suite.
Revised 10/16/2024