Thursday, April 23, 2015

Surgical Modifiers - 50,, 51, 53, 54, 55, 62, 66, 73, 74, 80, 81, 82


Modifier    Description

50  -  Bilateral Procedure: Unless otherwise identified in the listings, bilateral procedures that are performed at the same operative session should be identified by adding the modifier 50 to the appropriate five digit code.

Report such procedures as a single line item with a unit of 1. For example, when procedure code 19303 (Mastectomy, simple, complete) is performed bilaterally, report the service as 1930350.
If a procedure is identified by the terminology as bilateral ( or unilateral or bilateral), do NOT report the procedure code with modifier 50. For example, procedure code 68810 to 68815, (probing of nasolacrimal duct, with or without irrigation, unilateral or bilateral) includes terminology which indicates the procedure is performed either unilaterally or bilaterally. Therefore it’s not appropriate to report this modifier with this code. Additionally some procedure codes, i.e., 52000

(Cystourethroscopy, separate procedure) should NOT be reported with the 50 modifier since anatomy does not permit this procedure to be performed bilaterally.

51 -   Multiple Procedures: When multiple procedures, other than E/M services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same provider, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by appending the modifier 51 to the additional procedure or service code(s).

Note: This modifier should not be appended to designated "add-on" codes.


Multiple Procedure (Modifier 51) Medicare code indicator usage

Indicator indicates which payment adjustment rule for multiple procedures applies to the service. 0 = No payment adjustment rules for multiple procedures apply. If the procedure is reported on the same day as another procedure, base payment on the lower of: (a) the actual charge or (b) the fee schedule amount for the procedure.

1 = Standard payment adjustment rules in effect before January 1, 1996, for multiple procedures apply. In the 1996 MPFSDB, this indicator only applies to codes with procedure status of “D.” If a procedure is reported on the same day as another procedure with an indicator of 1,2, or 3, rank the procedures by fee schedule amount and apply the appropriate reduction to this code (100 percent, 50 percent, 25 percent, 25 percent, 25 percent, and by report). Base payment on the lower of: (a) the actual charge or (b) the fee schedule amount reduced by the appropriate percentage.

2 = Standard payment adjustment rules for multiple procedures apply. If the procedure is reported on the same day as another procedure with an indicator of 1, 2, or 3, rank the procedures by fee schedule amount and apply the appropriate reduction to this code (100 percent, 50 percent, 50 percent, 50 percent, 50 percent, and by report). Base payment on the lower of: (a) the actual charge or (b) the fee schedule amount reduced by the appropriate percentage.

3 = Special rules for multiple endoscopic procedures apply if procedure is billed with another endoscopy in the same family (i.e., another endoscopy that has the same base procedure). The base procedure for each code with this indicator is identified in the endoscopic base code field.

Apply the multiple endoscopy rules to a family before ranking the family with other procedures performed on the same day (for example, if multiple endoscopies in the same family are reported on the same day as endoscopies in another family or on the same day as a non-endoscopic procedure). If an endoscopic procedure is reported with only its base procedure, do not pay separately for the base procedure. Payment for the base procedure is included in the payment for the other endoscopy.

4 = Subject to MPPR reduction.
9 = Concept does not apply


53  -  Discontinued Procedure: Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. This circumstance may be reported by adding the modifier 53 to the code reported by the physician for the discontinued procedure.

Modifier 53 is used for “unusual (discontinued) circumstances”. Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure due to extenuating circumstances that may threaten the well being of the patient. In many instances, attachments, medical records, etc are not required to be sent in if an explanation for the discontinuation is in the narrative field of the claim. For example, submit “discontinued due to elevated blood pressure”. When additional information to support the use of the 53 modifier cannot be contained in the narrative of the claim, additional documentation may be submitted.

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. For outpatient hospital/ambulatory surgery center (ASC) 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 hospital outpatient use)

54  -  Surgical Care Only: When one physician performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding the modifier 54 to the usual procedure code.

Services billed with a 54 modifier will be reimbursed at the intraoperative allowance for the surgical procedure. The intraoperative allowance includes the one day preoperative care, the intraoperative service, as well as any in-hospital visits that are performed.

55  -  Postoperative Management Only: When one physician performs the postoperative management and another physician has performed the surgical procedure, the postoperative component may be identified by adding the modifier 55 to the usual procedure number.
This modifier is used to identify postoperative, out of hospital medical care associated with a given surgical procedure. When billing for postoperative care only, report the original date of surgery as your date of service and the procedure code for the surgical procedure followed by the 55 modifier. In rare situations where the out of hospital postoperative care is split between physicians, each physician must also indicate the period of his/her responsibility for the patient’s postoperative care by reporting the appropriate range of dates. Where a transfer of postoperative care occurs, the receiving physician cannot bill for any part of the global services until he/she has provided at least one service.

62 -   Two surgeons:
When two surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. Each surgeon should report the co-surgery once using the same procedure code. If additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added.

Note: If a co-surgeon acts as an assistant in the performance of additional procedure(s) during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate.

66 -   Surgical Team: Under some circumstances, highly complex procedures (requiring the concomitant services of several physicians, often of different specialties, plus other highly skilled, specially trained personnel and various types of complex equipment) are carried out under the "surgical team" concept. Such circumstances may be identified by each participating physician with the addition of the modifier 66 to the basic procedure number used for reporting services.
Documentation establishing that a surgical team was medically necessary is required for certain services identified by Centers for Medicare & Medicaid Services (CMS). All claims for team surgeons must contain sufficient information i.e., operative reports, to allow pricing "by report".

73 -   Discontinued Out-patient Hospital/Ambulatory Surgical Center (ASC) Procedure Prior to the Administration of Anesthesia: Due to extenuating circumstances or those that threaten the well being of the patient, the physician may cancel a surgical or diagnostic procedure subsequent to the patient’s surgical preparation (including sedation when provided, and being taken to the room where the procedure is to be preformed), but prior to the administration of anesthesia (local, regional block(s) or general). Under these circumstances, the intended service that is prepared for but cancelled can be reported by its usual procedure number and the addition of the modifier 73.
Note: The elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. For physician reporting of a discontinued procedure, see modifier 53.

74  -  Discontinued Out-patient Hospital/Ambulatory Surgical Center (ASC) Procedure after Administration of Anesthesia: Due to extenuating circumstances or those that threaten the well being of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia (local, regional block(s) or general) or after the procedure was started (incision made, intubation started, scope inserted, etc.). Under these circumstances, the procedure started but terminated can be reported by its usual procedure number and the addition of the modifier 74.

Note: The elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. For physician reporting of a discontinued procedure, see modifier 53.

80 -   Assistant Surgeon: Surgical assistant services may be identified by adding the modifier 80 to the usual procedure number(s).

This modifier should be reported to identify surgical assistant services performed in a non-teaching setting or in a teaching setting when a resident was available but the surgeon opted not to use the resident. In the latter case, the service is generally not covered by Medicare. When the surgical services are performed in a non-teaching setting, report "Non-teaching" in the narrative section of an electronic claim submission, or in item 24D for paper claims.

81  -  Minimum Assistant Surgeon: Minimum surgical assistant services are identified by adding modifier 81 to the usual procedure number.

82  -  Assistant Surgeon (when qualified resident surgeon not available): The unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s).
This modifier is used in teaching hospitals if there is no approved training program related to the medical specialty required for the surgical procedure or no qualified resident was available.


Billing Guidelines.

• When a provider performs surgery and all the postoperative services related to the surgery, the provider bills the surgery code without modifier 54 or 55.

• When one provider performs surgery and another assumes all related follow up care, the surgeon bills the surgery code with modifier 54. The provider performing the postoperative care bills the surgery code with modifier 55. The date of service on each claim must be the date of surgery.

• If the provider that performs surgery also performs a portion of the follow-up, he must bill the surgical procedure code on one detail with modifier 54, and a second detail with the same date of service and same surgical procedure code with modifier 55. The dates the provider was responsible for postoperative care must be noted in the new FROM and TO date fields on the HCFA 1500 in block 16 or in the designated field for tape or ECS formats. For example: a neurosurgeon performs a craniotomy (procedure code 61312) on 02-03-99. The postoperative plan for the patient is that the surgeon will oversee postoperative care for the 5 days while the patient remains in the hospital, then relinquish postoperative care to a neurologist.

* The surgeon must bill code 61312-54 with date of service 02-03-99 on one detail.

* On a separate detail he must bill 61312-55, also with date of service 02-03-99. (Individual dates of service for follow up care are not billed.)

* In the new date field, (block 16 on the paper HCFA 1500 form), the surgeon must place 02-04-99 in the FROM date and 02-08-99 in the TO date. Postoperative management starts the day following surgery.

• If multiple surgical procedures are performed, append modifier 54 to each surgery if the physician that performs the procedures plans to have another physician perform the postoperative care for each surgery. Multiple surgery rules for modifier 51 also apply.

• Modifier 54 must be appended to the surgery code, never to an evaluation and management code.

• Reimbursement for preoperative care is included in payment for surgery. At this time, Medicaid is not recognizing modifier 56 to denote a provider other than the surgeon providing preoperative care. Reimbursement is determined through the payment percentage as defined by the Federal Register Percentage Table.


• Some CPT codes are defined as treatment for complication to a primary procedure (such as bleeding or hemorrhage). If a complication arises during the postoperative period and requires a return trip to the OR, modifier 78 should be appended. (Postoperative day “1” begins the day following surgery.) If a procedure rendered due to a complication is handled during the original operative session, the service is billed as a multiple surgery with modifier 51.

• Modifier 78 is only used during the postoperative period, which begins the day following surgery. If the second surgical procedure is done on the day of surgery, it is billed with modifier 51 to denote multiple surgery. Modifier 51 example: A single vessel coronary artery graft is performed on July 1. That evening, on the same day, the patient’s vital signs are unstable and the nurse observes that hemorrhagic complications following the surgery occurred. The patient is returned to the operating room to locate and control the source of hemorrhage. Procedure code 35820, Exploration for hemorrhage, thrombosis or infection; chest, is billed for the original graft procedure and 35820-51 is billed. The date of service for both procedures is July 1.

• Modifier 79 indicates the procedure is unrelated to the original service or procedure. Example: A total knee replacement (27447) is performed. Within the 90-day follow-up for the knee replacement, care for a colles fracture of the wrist (25620) is provided. Procedure code 25620-79 should be submitted.

• Modifier 79 is intended for use by the operating surgeon only.

• Modifier 79 is appended to major and minor surgical procedures only. It is not to be used on evaluation and management (E/M) codes.

• All unrelated procedures performed within the postoperative period should be billed with modifier 79. (E.g., if three unrelated procedures are rendered, all three are appended with modifier 79. If they are rendered on the same day, one is identified as the primary  with no modifier 51 and the other two “secondary” procedures are further appended with modifier 51 to designate multiple procedures.)

Modifier 51: Multiple Procedures


Billing Usage

• The primary procedure is determined by the billing physician, and is billed on the first detail of the claim. Modifier 51 is not appended. Modifier 51 represents the secondary procedure(s) or service(s) if multiple procedures are performed. Failure to bill modifier 51 on secondary procedures will result in denial of the claim.

• In a multiple procedure situation, the surgeon and the assistant surgeon should identify the same primary procedure by billing that code without modifier 51. All secondary procedures must be billed with modifier 51. It is possible for the surgeon to bill for secondary procedures for which there is no assistant surgeon.

• Medicaid will not adjust for payment if the provider neglects to correctly identify primary and secondary procedures.

• If multiple units of the same procedure are performed on the same day, the procedure code with one unit is billed on the first detail of the claim without modifier 51. The same procedure code and the remaining units are billed on subsequent line(s) with modifier 51 and the appropriate number of units.

• For North Carolina Medicaid, anesthesia is billed using the primary procedure code and is reimbursed through a calculation using both base units and time expended. Therefore,  billing modifier 51 on an anesthesia claim is not required but is allowed for informational purposes, and will not affect reimbursement.

• “Add on” codes are those whose CPT description includes phrases such as “each additional” or “list separately in addition to primary procedure.” These codes are not billed with modifier 51. “Add on” codes will not be paid unless the primary procedure is billed and paid. An exception to this is the “add on” codes related to coronary intervention. “Add on” codes 92981, 92984, and 92996 can be billed with any one of the three primary codes of 92980, 92982, or 92995. Please refer to modifier LC, LD, RC for further information on the billing of these codes. A list of “Add on” codes can be found in Appendix E of the 1999 CPT book.

• If billing for multiple endoscopy codes as noted in the November, 1998 Medicaid Bulletin, do not bill with modifier 51. The system will recognize the multiple surgery and price by both endoscopy allowable amounts and multiple surgery allowable amounts.  Modifier 51 is not used:

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