2008's new modifiers should be used correctly

October 15, 2008

Current Procedural Terminology (CPT) is updated regularly, often in response to difficulties reported by practitioners. Practices that fail to keep up with the changes experience negative consequences on revenue and compliance. Staying familiar with changes in CPT can be very useful, and potentially quite rewarding.

Key Points

Essentially, the purpose of modifiers is to convey that the CPT service has been altered in a meaningful way. Often, modifiers have a significant impact on reimbursement. The proper use of modifiers is frequently the key factor in determining the payment (or lack thereof) on the claim.

Not all payers accept all modifiers. You or your staff should review which modifiers are acceptable to your various payers.

Modifier –22

Modifier –22, "Increased Procedural Services," has been changed. Now, those that report this modifier are explicitly required to provide documentation of substantially greater work than is typical for the procedure. Such documentation might include a description of the increased time required to perform the service or the technical difficulty the service presents. It is generally believed that a 30% to 50% increment would be necessary to justify use of this modifier, which some payers reward with additional reimbursement.

However, experience has shown that many payers are loath to pay extra in situations where this modifier is used. Casually speaking, the payers' philosophy against providing a higher payment is summed up by, "we don't pay less for the easy cases, so don't expect to be paid more for the hard cases."

Modifier –22 may be used with procedures, but CPT now explicitly prohibits the use of –22 with Evaluation and Management codes. Similarly, modifier –22 should not be used with Eye Codes in the series 92002-92014. A comment should be placed on the claim form to indicate increased procedural difficulty.

Modifier –25

Modifier –25, "Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service," has also been changed. The description intended to clarify use of this modifier is somewhat confusing for ophthalmologists, however. The confusion arises because even though the instruction suggests that modifier –25 may only be used with Evaluation and Management codes, this modifier may be used with Eye Codes as well.

Modifier –58

Modifier –58, "Staged or Related Procedure or Service by the Same Physician During the Postoperative Period," may be appended in select postoperative period scenarios. There are three situations in which –58 might apply. One situation is when the second procedure is planned or anticipated. The next is when the second procedure is more involved than the first procedure. Finally, the modifier may be used when a therapeutic procedure follows another procedure, commonly a diagnostic procedure.

Typically, procedure codes carrying the –58 modifier within the global period start a new global period. Payment under Medicare for services designated with the –58 modifier is 100% of the allowable.