Wednesday, December 9, 2015

Surgical Modifiers - 51, 53, 54, 55, 56, 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.

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.

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