Common Modifiers and How to Use Them

Q: I have been having problems with billing, specifically when the insurance company states that I have the wrong modifier or that a modifier is needed. Can you give me some information on the most common modifiers and how I should be using them to bill for services?

A: Modifiers are a necessary part of billing for health care services and are most commonly used to distinguish specific CPT codes, to keep them from being bundled into another service and billed the same day. They also are used to demonstrate other unique factors of a given procedure or service. Codes that require a modifier, but are billed without one, will be rejected by the carrier with an explanation on the EOB of bundling with another service, but will not specify what service. Further, if you call the carrier, they will not provide any information as to which codes they are referring to. In other words, the insurer will not help you get the claim paid by telling you what modifiers are needed.

Modifiers are part of the CPT code structure and can be found in the appendix of the CPT code book. While there are several modifiers, the following three are the most commonly used in the chiropractic profession.

1. The most commonly used modifier is -25. This modifier, exclusively used for evaluation and management codes when billed in conjunction with treatment, is defined as follows: -25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of a Procedure or Other Service. The physician may need to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E&M service above and beyond the other service provided, or beyond the usual preoperative or postoperative care associated with the procedure that was performed. This circumstance may be reported by adding the modifier -25 to the appropriate level of E&M service; or the separate five-digit modifier 09925 may be used.

   If the -25 modifier is not used with the E&M service done with treatment, the E&M service will not be paid, with the explanation that the value of service is included in another service performed the same day.

2. Another commonly used modifier is -52. This modifier is used to indicate that a particular service or procedure was reduced or eliminated at the doctor's discretion. Most commonly, it is used to indicate when a timed service does not meet the minimum standard time for that particular service, but was still performed. It is specifically defined as -52: Reduced Services. Under certain circumstances, a service or procedure is partially reduced or eliminated at the physician's election. Under these circumstances, the service provided can be identified by its usual procedure number and the addition of the modifier -52, signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service. Modifier code 09952 may be used as an alternative to modifier -52.

   For instance, a patient may have had a massage for only five minutes, so the doctor would bill the code for massage with -52 to indicate that a reduced service was performed (97124-52).

3. The other common modifier that will lead to nonpayment when not included is -59. This modifier is used to distinguish that a particular service is distinctly separate from another. This is used for codes 97110-97124 when billed in conjunction with a chiropractic manipulative therapy (CMT) or for 97140 when billed with a CMT. Specifically, this modifier is defined as -59: Distinct Procedural Service. Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier -59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. Modifier code 09959 may be used as an alternative to modifier -59.

   Note that under strict interpretation, for 97140 to be paid it not only needs a modifier -59, but also must be performed in a separate region than the CMT service.