CPT stands for Current Procedural Terminology. The CPT refers to a medical procedure code book that contains codes and descriptions of procedures, organized by body system. The first section of the CPT manual contains evaluation and management (E/M) codes used for billing physician encounters, whether in an office, hospital or outpatient setting. CPT also has sections covering radiology procedures, pathology and lab tests and medications. This code book is used along with the icd-9 code book of diseases and conditions to bill third-party payers for reimbursement of medical services.
Modifiers are used in addition to a CPT code to add more information on the claim. These modifiers state special circumstances that affect the amount the physician will be reimbursed. Modifiers are used for evaluation and management, as well as, procedure codes. Documentation of special circumstances is sometimes required by the payer to receive full reimbursement on the claim, but guidelines vary from payer to payer.
A bilateral modifier, -50, means the procedure was done on both sides. This modifier is commonly used for procedures of the eyes, ears and limbs. It can also be used for procedures of the kidneys and lungs.
Evaluation and management (E/M) modifiers are used to note special circumstances of a patient's encounter with the physician. Common E/M modifiers are -21, -24, -25 and -57. A modifier -21 means the E/M service was prolonged. The -24 and -25 modifiers refer to unrelated medical visits. The -24 modifier is for an office visit billed during a postoperative period that is unrelated to the operation. The -25 modifier identifies separately physician evaluations in the same visit for unrelated problems. For example if a patient is seen for a routine blood pressure check and complains of foot pain, these E/M services may be reported with two CPT codes. The -25 modifier would be listed on the second procedure code. The -57 modifier states that a decision for surgery was made during the office visit.
Several modifiers are available to add information to anesthesia codes. A -23 modifier notes that unusual anesthesia was used. A -47 modifier is used when the anesthesia was administered by the physician.
Common CPT Modifiers
The -26 modifier means that only the professional component of the service was performed. For example, if a physician is reading a patient the results of his x-rays that were performed at another location, he would bill for only the professional component. Mandated services such as pre-employment drug screens or worker's compensation evaluations would require the use of a -32 modifier. A -51 modifier is used to identify multiple procedures were performed while a -52 modifier states that reduced services were performed. A discontinued procedure is identified with a -53 modifier. Modifier -54 refers to surgical care only, a -55 to postoperative care only, and a -56 for preoperative care only. A -58 modifier is attached to a staged or related procedure by the same physician during the postop period.
Other CPT Modifiers
A modifier -62 identifies that two surgeons performed the procedure. When a physician is performing a procedure on an infant under 4 kilograms, a -63 modifier is used. The -66 identifies a surgical team performed the procedure, a -76 modifier shows a procedure has been repeated by the same physician, and -77 shows a procedure has been repeated by another physician. A modifier -78 identifies an unplanned return to operating room following the initial procedure. The -79 modifier identifies an unrelated procedure performed during the postop period by the same physician. Modifier -80 states an assistant surgeon performed the procedure and -81 identifies a minimum assistant surgeon. Modifiers -90, -91, -92 refer to pathology and lab tests. A -99 modifier is used to show that multiple modifiers are being used on the claim, and is used only on the first CPT code listed on the claim.