Modifiers

Unusual procedural service


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

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

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


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

Professional component


Certain procedures have both a professional and technical component

Bilateral procedure


Used when the same procedure is performed on both sides of the body at the same operative session

Multiple procedures


Used when multiple surgeries are performed at the same operative session

Reduced services


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

Decision for surgery


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

Staged or related procedure by same physician during the post-op period


Physician must document that the performance of a procedure or service during post-op was A) planned prospectively, B) more extensive than original procedure or C) for therapy following a diagnostic surgical procedure.

Distinct procedure service


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

Repeat procedure by same physician


Used when a physician needs to indicate that a procedure or service was repeated subsequent to the original procedure or service

Repeat procedure by another physician


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

Return to the OR for a related procedure during the post-op period


Used to indicate procedure was performed during the post-op period of the initial procedure

Assistant surgeon


Surgical assistant and/or physician assistant services

Multiple modifiers


Under certain circumstances, two or more modifiers may be necessary to completely describe a service

Primary physician


Used for primary surgery code performed on given DOS, each subsequent line should be billed with a mod 51

Assistant surgeon


Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant-at-surgery

Medicare not covered, ABN (CMS R 131) obtained

Used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or services as reasonable and necessary and they have on file an ABN signed by the beneficiary

Attending physician not hospice physician


Used when physician is providing terminal related care to a hospice patient but is not a hospice physician

Service unrelated to terminal condition (Hospice)


Used when physician see’s patient in a SNF or hospital setting and condition is not related to terminal condition

Medicare non covered benefit


Used when physicians, practitioners, or suppliers want to indicate that the item or services is statutorily non-covered or a is a Medicare benefit

Medicare not covered, no ABN (CMS R131)


Used when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny an item or services as reasonable and necessary and they have not has an ABN signed by the beneficiary.

Left side


Used to identified procedures performed on the left side of the body

Clia waived test


Used when a lab test is performed in a clinical setting

Right side


Used to identified procedures performed on the right side of the body

Services by certified diabetes educator


Used when services is provided by a certified diabetes educator

Technical component


Certain procedures have both a professional and technical component

Medi-Cal Global charge for radiology


Certain procedures have both a professional and technical component