Using Insurance Modifiers

Medical coding is the means of getting the "story" out to an insurance company and modifiers provide additional information about the service performed. Modifiers often provide justification as to why additional procedures should be paid. Using modifiers can prevent bundling of procedures, however, they should only be used if the chart note justifies it.

The following are descriptions of some commonly used modifiers followed by a broader list. This list is intended as a quick guide. Be sure to consult your CPT code book for more details about modifiers.

Commonly Used Modifiers

25          is billed with an evaluation and management (E/M) code to indicate that the patient’s condition required a significant, separately identifiable E/M service on the same day a procedure was performed. This modifier indicates that the E/M service was required beyond the procedure that was provided.

59          indicates that a procedure or service was distinct or independent from other services that were performed on the same day. It is used to identify procedures that are not normally reported together but are appropriate under the circumstances.

51          is used to reflect multiple procedures other than evaluation and management services, are performed at the same session by the same provider. The primary procedure is reported first and the additional procedure(s) are identified by adding modifier 51.

79          is used to indicate an unrelated procedure or service by the same physician during the postoperative period. To avoid audits, coders should ensure sufficient documentation exists to support modifier 79 use. Use modifier 79 only when a visit within the global period is unrelated to the surgery.

LT          indicates left, a procedure on the left eye, left arm, left foot, for example

RT          indicates right, a procedure on the right eye, right arm, right foot for example

GA         is a Medicare modifier used to indicate that the patient has signed an ABN (Advanced Beneficiary Notification). This allows the provider to bill the patient if the service is not covered by Medicare. Use of this modifier ensures that upon denial, Medicare will automatically assign the beneficiary liability.

GY         is used in conjunction with modifier GA to obtain a denial on a non covered service. Use it to tell Medicare that you know the service is not covered.

You can find a more comprehensive list of modifiers here.

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