Most Commonly Used CPT Code Modifiers

● CPT Modifier 22 Increased Procedural Service

Modifier 22 is used to describe an increased workload associated with a procedure.

This modifier should be used in exceptional cases only, and payors will frequently
require documentation of the service before they make payment. The 22 modifier can
be used during surgeries or other procedures when there is increased technical difficulty
or because of the severity of the patient’s condition. For example, 22 can be used when
there is unusual or excessive hemorrhaging during a procedure.

● CPT Modifier 25 Significant, Separately Identifiable Service

Modifier 25 is used when there is a significant, separately identifiable evaluation and

management (E/M) service done by the same physician on the same day of service;
and it can only be used with an E/M code. The correct use of a 25 modifier is usually
indicated when there are two distinct diagnoses made during the visit. However, under
the right circumstances, only one diagnosis may be required. For more detailed
information, visit our fact sheet about using this modifier.

● CPT Modifier 26 Professional Component and TC modifier

Modifier 26 indicates the professional service of a CPT that has a global (professional
and technical) definition. For example, an orthopedist receives an x-ray and determines
a diagnosis from the x-ray. The correct code CPT would be 73070-26 because the
x-ray was taken elsewhere. The CPT 73070 without the modifier would indicate that
both the x-ray and its interpretation were done by the same provider group.
 ● CPT Modifier 50 Bilateral Procedure

Modifier 50 indicates that a procedure took place on both sides of the body. Before
applying this modifier, it is important to check the definition of the CPT to confirm
bilaterally is not already mentioned in the code definition.

● CPT Modifier 51 Multiple Procedures

Modifier 51 indicates that multiple procedures were performed by the same physician in
the same session. The procedure with the highest reimbursement should be listed first
without the modifier and additional procedures listed in order of reimbursement value
with the modifier. For example, if a patient were to come in for multiple x-rays, the first
x-ray with the highest reimbursement would be coded with the CPT, and all subsequent
X-rays would be amended with modifier 51.

● CPT Modifier 52 Reduced Services

Modifier52 indicates that the physician has elected to discontinue a service or

procedure. This modifier can be attached to an E/M service if an examination needs to
be discontinued due to a situation such as patient non-cooperation. It can also be
attached to a procedure CPT if it is not completed.

● CPT Modifier 59 Distinct Procedural Service

Modifier 59 is useful for situations where two CPT codes that are not normally reported
together on the same day of service by the same provider are necessary because of
circumstances. Documentation must support that each CPT procedure was required
due to an entirely separate visit on the same day, a different site or organ system was
involved, or a separate injury. This modifier should not be used with E/M services and is
only applicable when no other modifier adequately describes the situation.

Categories of CPT Modifiers

CPT modifiers can be grouped into two large categories: those that can be used with
an E/M service, and those that can’t. The most widely used CPTs in an office setting
are the E/M Codes 99201-99215; however, very few modifiers can be associated with
these services.

CPT modifier 25 can only be used for E/M CPTs, and under certain circumstances
modifier 52 can be used as well. The majority of modifiers cannot be used with E/M
coding, so it is critical to check the definition of a modifier before assigning it to a code.

HCPCS Medicare Modifiers

For the most, HCPCS Medicare modifiers further define where the procedure happened
in the body. Commonly used modifiers are RT (right side) and LT (left side). There are
letter categories, such as the E sequence (ex. E1 upper left, eyelid) and F sequence
(ex. F5 right hand, thumb) that create a more accurate anatomical pointer to indicate
specifically where the procedure happened. Four HCPCS Medicare modifiers are
commonly used to define the 59 modifier further. They are:

● XE – Separate encounter
● XS – Separate structure
● XP – Separate practitioner
● XU – Unusual on-Overlapping Service
HCPCS modifiers are used much less frequently than their CPT counterparts but are
equally as important when creating a line item that will be accepted by payors.

Impact of Modifiers on Reimbursement

● Modifier 22

Using modifiers correctly can impact reimbursement significantly. When reviewing

payor fee schedules, make sure that there is a standard reimbursement formula for
modifiers such as 22. For example, if modifier 22 is used, the provider would receive
110% of the standard CPT fee.

● Modifier 26

For modifiers such as 26, which indicates the professional component of a procedure,
many payor fee schedules will reflect a reduction in reimbursement due to the technical
component not being performed by the same provider group. The provider group that
performs the technical component will receive a payment that reimburses the technical
aspect of the procedure.

● Modifier 50

As with modifier 22, the reimbursement formula for using modifier 50 should be defined
in your payer contract. Since using the modifier indicates that the same procedure was
done twice, most contracts pay out approximately 150% of the fee schedule.
 ● Modifier 51

The importance of listing CPTs in order of reimbursement value when using the 51
modifier cannot be understated. Reimbursement is paid at 100% allowable for the first
procedure and is then reduced by 50% for each subsequent procedure unless the CPTs
are exempt from multiple procedure logic. For further direction on this topic, click here.

How is Correct Medical Coding Determined?

The Need for Documentation
Tip 1

Almost every conceivable procedure performed in an office or hospital has a CPT or

HCPCS code. With literally thousands to choose from, attention to detail by the medical
provider documenting the visit is essential, as it determines the correct codes to use.

For example, when shaving epidermal and dermal lesions, the diameter of the lesion
needs to be noted. If there is a single lesion removed which is .5 cm or less, the correct
CPT code is 11300. However, if the lesion is .6 to 1.0 centimeters in diameter, the
correct code is 11301. There could be a difference in reimbursement between codes
11300 and 11301, so it is important to make the size distinction in the visit notes.
Tip 2

With the advent of MIPS reporting, it may also be necessary to document what
procedures have been done in the past, or the medications previously administered, to
treat the presenting problem in the notations of the visit. This will allow coders to apply
the necessary CPT category II code to be measured so the provider can receive credit.
It is critical that all providers participating in MIPS programs be aware of the measures
they are submitting to the program, so they know what to include in their documentation.
Learn more about the transition from fee-for-service to value-based reimbursement.

Tip 3

In addition to recording things like lesion sizes and past medical history, documentation
also needs to contain details such as the exact location of a procedure. For example, if
the procedure is done on the left or right hand, and which finger of the hand. A coder
may not be able to properly assign a modifier, CPT, or ICD-10 diagnosis code without
this information. Many healthcare providers use templates in their EHR systems to
ensure they have captured all the information necessary to code accurately. Discover
what an EHR system should include for your specialty.