CPT Modifiers

CPT Modifiers provide additional information to payers to make sure your provider gets paid correctly for their procedures or services performed.

Modifiers that are located after the CPT code provide additional information to insurance payers for procedures or services that have been altered or “modified” in some way. It is a prefix (comes after) modifier to the CPT 5 digit procedure codes. These modifiers were developed by the American Medical Association (AMA) and are copyrighted by the AMA. The use of modifiers is important to insure provider services are properly reimbursed. Adding the modifier is the last step in the coding process.

A complete listing of modifiers is in Appendix A of the CPT coding book.

Format of Modifiers
CPT modifiers can be 2 digit numbers ranging from 21 to 99, two character modifiers, or alpha-numeric. The numbering order of modifiers does not necessarily mean modifiers are related to one another just because the numbers are adjacent. New modifiers were assigned based on the availability of numbers with no clear link to the established modifiers. More than one modifier may be used with a procedure code.

CPT modifiers are not applicable to every category of the CPT codes. Some modifiers are only used with a particular category. For example -21, 24, 25, & 27 are only used with Evaluation and Management (E&M) procedures.

Some modifiers are not compatible with others. For example the -50 Bilateral Procedure is not compatible with the -LT (Left Side) and -RT (Right Side) modifiers.

Typically Use Only Two
The CMS 1500 and UB-04 forms allow four modifiers. However the Centers for Medicare and Medicaid Services (CMS) or other payers may not recognize the third and forth modifiers. That’s why its important to place the modifiers first which will affect reimbursement. Some modifiers are informational only and do not affect reimbursement. They can however, determine if the service will be covered or denied.

Other modifiers such as modifier -22 (unusual procedural services) will increase the reimbursement and protocol for many third-party payers if documentation supports the use of this modifier. Modifier -52 (reduced services) will usually equate to a reduction in payment.

Modifiers -LT and -RT identify the left and right sides of the body. These are often confused with the -50 Bilateral Procedure modifier. -LT and -RT are only used when the procedure is performed on one side of the body and is and organ that is paired like kidneys, lungs, legs, ears, etc.

Functional Modifiers
When more than one modifier is used, the functional (or pricing) modifier is placed in the first modifier field. The informational modifier is then placed in the second modifier field. A good example is if a provider bused a CPT code with the -22 and the -LT modifier, the -22 is placed first and the -LT in the second modifier field.

If the informational modifier is listed first, the insurance payers system will suspend the claim for manual review and slows claim processing.

CPT Codes and their associated modifiers and descriptions are owned, copyrighted, and trademarked by the AMA (American Medical Association). They can be purchased directly from the AMA Bookstore or from their licensees such as SuperCoder.com and FindaCode.com or Amazon.

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