{"id":8185,"date":"2018-10-01T21:00:41","date_gmt":"2018-10-01T15:30:41","guid":{"rendered":"http:\/\/www.medicalbillersandcoders.com\/blog\/?p=8185"},"modified":"2025-06-27T10:38:47","modified_gmt":"2025-06-27T10:38:47","slug":"what-are-cpt-modifiers-and-why-medical-billing-companies-use-them","status":"publish","type":"post","link":"https:\/\/www.medicalbillersandcoders.com\/blog\/what-are-cpt-modifiers-and-why-medical-billing-companies-use-them\/","title":{"rendered":"What Are CPT Modifiers And Why Medical Billing Companies Use Them?"},"content":{"rendered":"<p style=\"text-align: left;\">Since medical procedures and services are often complex, we sometimes need to supply additional information when we\u2019re coding. CPT modifiers may describe whether multiple procedures were performed, why that procedure was necessary, where the procedure was performed on the body, how many surgeons worked on the patient, and lots of other information that may be critical to a claim\u2019s status with the insurance payer.<\/p>\n<h2 style=\"text-align: left;\">Some of the common reasons for using a Modifier are:<\/h2>\n<ul style=\"text-align: left;\">\n<li>The procedure was more complicated than anticipated<\/li>\n<li>Another procedure was required during the same procedure<\/li>\n<li>The same diagnostic test had to be re-run on the same day<\/li>\n<li>The X-Ray was done in one facility and the results were read in a different facility<\/li>\n<\/ul>\n<p style=\"text-align: left;\">Consider this example: while doing surgery for a wrist repair &#8211; 25607, during the same procedure, a carpal tunnel release &#8211; 64721 is done.\u00a0 You need to append modifier 51 to show the secondary procedure was performed.<\/p>\n<p style=\"text-align: left;\">CPT Modifiers are always two characters and may be numeric or alphanumeric. Most of the CPT modifiers you\u2019ll see are numeric, but there are a few alphanumeric Anesthesia modifiers also. CPT modifiers are added to the end of a CPT code with a hyphen.<\/p>\n<p style=\"text-align: left;\">In the case of more than one modifier, you code the \u201cfunctional\u201d modifier first, and the \u201cinformational\u201d modifier second. The distinction between the two is simple: you always want to list the modifiers that most directly affect the reimbursement process first.<\/p>\n<p style=\"text-align: left;\">Take, for example, the partial mastectomy of the left breast (code 19302-LT-53). If you were to swap out the -53 (discontinued procedure) with the functional modifier -52 (for reduced services), you would then code the whole procedure 19302-52-LT.<\/p>\n<p style=\"text-align: left;\">Note that the functional modifier (-52) now comes before the informational modifier (-LT). If the informational modifier is listed first in a claim, an insurance company will deny that claim and return it to the healthcare provider.<\/p>\n<p style=\"text-align: left;\">In CMS-1500 and UB-04 forms, the two most common claim forms, have space for four modifiers, payers don\u2019t always look at modifiers after the first two. Because of this, you always want the most important modifiers to be visible.<\/p>\n<h3 style=\"text-align: left;\">Let\u2019s take a quick look at an example of a CPT modifier in action:<\/h3>\n<p style=\"text-align: left;\">A surgeon performs a procedure to remove a bone cyst in the upper arm of a patient. The procedure also includes obtaining a graft from elsewhere in the body. Due to minor complications, the surgeon is unable to fully excise the bone cyst.<\/p>\n<p style=\"text-align: left;\">For the procedure, we\u2019d code 23140 for \u201cexcision or curettage of bone cyst or benign tumor, humerus; with autograft (includes obtaining the graft).\u201d Since the procedure was completed but not fully successful, we\u2019d add the -52 modifier, for reduced services, to the code, and we\u2019d end up with 23140-52.<\/p>\n<p style=\"text-align: left;\">Certain modifiers also have guidelines specific to them. The modifier -51, for multiple procedures, is one of the more commonly used CPT modifiers. In the instance of multiple procedures provided by the same specialist or healthcare provider, a coder would list the initial procedure\u2019s CPT code, then append the modifier -51 to the end of the code for the additional procedure or procedures. Certain procedures, however, are listed in the CPT book as \u201c-51 exempt,\u201d and coders must be aware of this distinction.<\/p>\n<p style=\"text-align: left;\">Note that some modifiers can be used in conjunction with each other (like -23, unusual anesthesia, and -47, for anesthesia by the surgeon). Others contradict one another and cannot be included in the same code, For example, the modifier \u2013LT (procedure on the left of two paired appendages or organs) cannot be coded with the modifier -50, which describes a bilateral procedure.<\/p>\n<p style=\"text-align: left;\">Payers have what is called reimbursement edits for reporting code combinations. If using two codes are stand-alone codes they may be subject to multiple procedure payment reductions. You would append modifier 51 to the procedure that has less value than the primary procedure. You need to be aware of special rules that are applied when using modifiers.<\/p>\n<p style=\"text-align: left;\">Using the appropriate modifiers can substantially impact reimbursement. If you do not report a modifier and the procedure allows a modifier you will not be paid for the procedure. There are industry standards related to the use of modifiers and reimbursement.<\/p>\n<p style=\"text-align: left;\">While some modifiers change the payment rates some are for informational use only or impacts bundling edits. It pays to understand and get familiar with modifiers and how they are used.\u00a0 Modifiers have different pricing, some pay 10% of the fee schedule and some pay 100%.<\/p>\n<h2 style=\"text-align: left;\">These are just a few examples to show the impact of modifiers:<\/h2>\n<table class=\" alignleft\">\n<tbody>\n<tr>\n<td width=\"61\"><strong>Sr. No.<\/strong><\/td>\n<td width=\"90\"><strong>Modifier type<\/strong><\/td>\n<td width=\"146\"><strong>Details<\/strong><\/td>\n<td width=\"340\"><strong>Reimbursements<\/strong><\/td>\n<\/tr>\n<tr>\n<td width=\"61\">1<\/td>\n<td width=\"90\">Modifier 22<\/td>\n<td width=\"146\">Increased Procedural services<\/td>\n<td width=\"340\">Maximum of 110% of Fee Schedule Allowance\/Contracted Rate with supporting documentation<\/td>\n<\/tr>\n<tr>\n<td width=\"61\">2<\/td>\n<td width=\"90\">Modifier50<\/td>\n<td width=\"146\">Bilateral Procedure<\/td>\n<td width=\"340\">150% of Fee Schedule Allowance\/Contracted Rate Submit one line with one unit<\/td>\n<\/tr>\n<tr>\n<td width=\"61\">3<\/td>\n<td width=\"90\">Modifier 51<\/td>\n<td width=\"146\">Multiple Procedures<\/td>\n<td width=\"340\">50% of Fee Schedule Allowances\/Contracted Rate for each additional procedure unless the procedure is exempt from multiple procedure logic<\/td>\n<\/tr>\n<tr>\n<td width=\"61\">4<\/td>\n<td width=\"90\">Modifier 55<\/td>\n<td width=\"146\">Follow up care only<\/td>\n<td width=\"340\">20% of Fee Schedule Allowance\/Contracted Rate<\/td>\n<\/tr>\n<tr>\n<td width=\"61\">5<\/td>\n<td width=\"90\">Modifier XE<\/td>\n<td width=\"146\">Separate encounter, distinct service<\/td>\n<td width=\"340\">Informational \/impacts bundling<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h4 style=\"text-align: left;\"><strong><br \/><\/strong>References:<\/h4>\n<ol>\n<li style=\"text-align: left;\">Centre of Medicare and Medicaid Services (CMS), Global Surgery Booklet (Sept 2018).<\/li>\n<li style=\"text-align: left;\">Ingenix Coding Lab-Understanding Modifiers.<\/li>\n<\/ol>\n<h2>FAQs:<\/h2>\n\n\n<div class=\"schema-faq wp-block-yoast-faq-block\"><div class=\"schema-faq-section\" id=\"faq-question-1751020667725\"><strong class=\"schema-faq-question\">1. What are CPT modifiers?<\/strong> <p class=\"schema-faq-answer\">CPT modifiers are two-character codes that provide additional details about medical procedures, helping clarify claims for insurance reimbursement.<\/p> <\/div> <div class=\"schema-faq-section\" id=\"faq-question-1751020680286\"><strong class=\"schema-faq-question\">2. When should modifiers be used?<\/strong> <p class=\"schema-faq-answer\">Modifiers should be used when procedures are more complex than expected, when multiple procedures are performed, or when a service is altered in some way.<\/p> <\/div> <div class=\"schema-faq-section\" id=\"faq-question-1751020690922\"><strong class=\"schema-faq-question\">3. How do you apply modifiers to CPT codes?<\/strong> <p class=\"schema-faq-answer\">Modifiers are added to the end of a CPT code with a hyphen; when using multiple modifiers, list the functional modifier first, followed by the informational one.<\/p> <\/div> <div class=\"schema-faq-section\" id=\"faq-question-1751020700200\"><strong class=\"schema-faq-question\">4. What happens if you don&#8217;t use the correct modifiers?<\/strong> <p class=\"schema-faq-answer\">Failing to report the appropriate modifiers can lead to claim denials, reduced reimbursement, or delays in payment from insurance payers.<\/p> <\/div> <div class=\"schema-faq-section\" id=\"faq-question-1751020709700\"><strong class=\"schema-faq-question\">5. Can multiple modifiers be used together?<\/strong> <p class=\"schema-faq-answer\">Yes, some modifiers can be used together, but others cannot. For example, modifier -LT (left side) cannot be combined with modifier -50 (bilateral procedure).<\/p> <\/div> <\/div>\n","protected":false},"excerpt":{"rendered":"<p>Since medical procedures and services are often complex, we sometimes need to supply additional information when we\u2019re coding. CPT modifiers may describe whether multiple procedures were performed, why that procedure was necessary, where the procedure was performed on the body, how many surgeons worked on the patient, and lots of other information that may be [&hellip;]<\/p>\n","protected":false},"author":2,"featured_media":8188,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[2],"tags":[1086,746,1276,907,117,371,1128,1136,123,418,144,163,86,27],"class_list":["post-8185","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-medical-billing-services","tag-american-healthcare-billing-services","tag-billing-services-for-doctors","tag-dermatology-billing-and-coding","tag-dme-medical-billing-services","tag-medical-billers-and-coders-2","tag-medical-billing-coding","tag-medical-billing-services-in-florida","tag-medical-billing-services-in-usa","tag-medical-coding-services","tag-online-medical-billing","tag-outsource-medical-billing","tag-outsourced-medical-billing","tag-physician-billing","tag-revenue-cycle-management-2"],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v27.8 (Yoast SEO v27.8) - 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The main goal of our organization is to assist physicians looking for billers and coders, at the same time help billing specialists looking for jobs, reach the right place.\"},{\"@type\":\"Question\",\"@id\":\"https:\\\/\\\/www.medicalbillersandcoders.com\\\/blog\\\/what-are-cpt-modifiers-and-why-medical-billing-companies-use-them\\\/#faq-question-1751020667725\",\"position\":1,\"url\":\"https:\\\/\\\/www.medicalbillersandcoders.com\\\/blog\\\/what-are-cpt-modifiers-and-why-medical-billing-companies-use-them\\\/#faq-question-1751020667725\",\"name\":\"1. What are CPT modifiers?\",\"answerCount\":1,\"acceptedAnswer\":{\"@type\":\"Answer\",\"text\":\"CPT modifiers are two-character codes that provide additional details about medical procedures, helping clarify claims for insurance reimbursement.\",\"inLanguage\":\"en-US\"},\"inLanguage\":\"en-US\"},{\"@type\":\"Question\",\"@id\":\"https:\\\/\\\/www.medicalbillersandcoders.com\\\/blog\\\/what-are-cpt-modifiers-and-why-medical-billing-companies-use-them\\\/#faq-question-1751020680286\",\"position\":2,\"url\":\"https:\\\/\\\/www.medicalbillersandcoders.com\\\/blog\\\/what-are-cpt-modifiers-and-why-medical-billing-companies-use-them\\\/#faq-question-1751020680286\",\"name\":\"2. 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