Global surgery
| 25 | Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service: It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or be beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform major surgery. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59. | - Modifier 25 should be appended only to evaluation and management service codes with status indicator V-Medical Visit
- E/M codes include G0463, 99201-99215, outpatient service, visit
- Do not report E/M level if the sole reason for the scheduled visit is to undergo a diagnostic or therapeutic test/service procedure.
- To support clinic E/M on the same day as a procedure, documentation must support a patient’s new problem, sign, symptom, chief complaint with separate evaluation and medical decision making.
- Do not include pre, intra or post-operative as separate and distinct as these are part of the procedure being performed.
- Example: Patient presents for follow-up wound care visit with existing ulcer on left great toe. The patient has a new wound on the left heel. The small toe ulcer is debrided of devitalized dermal tissue. The left heel wound is evaluated and does not require debridement at this time. The wound is then cleaned and dressed
- Report appropriate level E/M code with modifier 25 and procedure code (99212-25, 97597)
| [1]
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| Other CPT | 27 | Multiple outpatient hospital evaluation and management encounters on the same date. | - Reported when multiple outpatient hospital E/M encounters occur on the same day
- Append only to E/M service or Status Indicator V
- Append modifier 27 to the second and subsequent E/M code(s) to indicate that the E/M service is separate and distinct E/M encounter from the service previously provided that same day in multiple outpatient hospital settings
- Report condition code G0 when multiple medical visits occur on the same day in the same revenue center
- Example: Patient is seen in the ED in the morning for bronchitis. The patient is treated and discharged. An E/M level is charged by the ED. Later that same day, the patient goes to the wound clinic for a scheduled wound visit. An E/M service is also charged by the wound clinic. Modifier 27 should be applied to the second E/M
| [2]
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| Surgical | 50 | Bilateral procedure: Unless otherwise identified in the listings, bilateral procedures that are performed at the same operative session should be identified by adding the modifier 50 to the appropriate five-digit code.
| Report a single line item with modifier 50 for bilateral procedure performed during the same operative session; report with a unit of 1Do not attach this modifier to CPT codes that contain language “one or both”, “bilateral” or “unilateral or bilateral”Append modifier 50 for surgical procedures and other diagnostic servicesRefer to current Medicare physician’s fee schedule data base bilateral indicator column, for appropriate application of 50 modifierModifiers RT and LT are not used when 50 appliesAn Unna boot is applied to both lower extremitiesReport 29580-50 with a unit of 1 | [3][4]
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| Surgical | 52 | Reduced services: Under certain circumstances a service or procedure is partially reduced or eliminated at the physician’s discretion. Under these circumstances the service provided can be identified by its usual procedure number and the addition of the modifier 52, signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service. | - Report to indicate partial reduction of procedure
- Paid at 50% of the full OPPS payment amount when 52 is appended
- Example: Transcutaneous Oxygen performed 1-2 level unilaterally. (TCOM codes are bilateral)
- Report 93922-52
| [5][6][7]
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| Other CPT | 59 | Distinct procedural service Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures or services, other than E/M services, that are not normally reported together but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, or separate injury (or area in injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than modifier 59. Modifier 59 should only be used if there is no other more descriptive modifier available and the Modifier 76 use of modifier 59 best explains the circumstances. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25. | Used when 2 procedures not normally reported together are appropriate under the circumstances.If reported, modifier 59 (valid) is always appended on the lesser procedure or code subject to denial. (Column II NCCI EDITS)Use Medicare’s most recent version of the National Correct Coding Initiative (NCCI) Edits to help determine the appropriate use for the 59 modifierDocumentation in the record must support different procedure, test or service; different site or organ system; separate incision; separate injury; different session or patient encounter.Example: Subcutaneous debridement totaling 8 sqcm of a left lateral ankle ulcer and placement of a multilayer compression wrap on the right lower extremity during the same encounter.Report 11042, 29581-RT (Reporting modifier RT alone will not show that the MLCW application is separate from the debridement, therefore both modifiers should be reported)Example: Subcutaneous debridement totaling 8 sq. cm. of a left lateral ankle ulcer and debridement of devitalized dermal tissue from a pressure ulcer of the sacrum (totaling 18 sq. cm.Report 11042, 97597-59 | [8][9]
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| Other CPT | 76 | Repeat procedure or service by same physician or other qualified healthcare professional It may be necessary to indicate that a procedure or service was repeated subsequent to the original procedure or service. This circumstance may be reported by adding the modifier 76 to the repeated procedure or service. | - Used to report a repeat procedure (same CPT code) by the same physician on the same calendar day as the original procedure
- Example: An Unna boot was applied to the left lower extremity by the wound clinic physician. The patient went home and inadvertently saturated the Unna boot. The patient returned to the wound clinic and the same physician reapplied the Unna boot,
- Report 29580-LT, 29580-76-LT
| [10]
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| Other CPT | 77 | Repeat procedure by another physician or other qualified healthcare professional The physician may need to indicate that a basic procedure or service performed by another physician had to be repeated. This situation may be reported by adding modifier 77 to the repeated procedure or service. | Similar to modifier 76, except that a different physician performs the repeat procedure (same CPT code) on the same calendar day.Example: An Unna boot was applied to the left lower extremity by the wound clinic physician. The patient went home and inadvertently saturated the Unna boot. The patient returned to the wound clinic and a different physician reapplied the Unna bootReport 29580-LT, 29580-77-LT | [11]
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| Anatomical (coronary artery, eye lid, finger, side of body, toe) | LT | Left side (used to identify procedures performed on the left side of the body)
| - Left side (used to identify procedures performed on the left side of the body)
- When the service could be performed on a right or left anatomical body part and the service is performed on the left side only on the specific date of service.
- Append for procedures, tests, and services performed on paired organs or joints
- The modifier LT does not affect the allowed amount on a claim; however, lack of the modifier can cause denials or development to occur.
- Inappropriate to use when a procedure code specifies bi-lateral or a side of the body
| [12][13]
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Anatomical (coronary artery, eye lid, finger, side of body, toe)
| RT | Right side (used to identify procedures performed on the right side of the body)
| Right side (used to identify procedures performed on the right side of the body)
When the service could be performed on a right or left anatomical body part and the service is performed on the right side only on the specific date of service.
Append for procedures, tests, and services performed on paired organs or jointsThe modifier RT does not affect the allowed amount on a claim; however, lack of the modifier can cause denials or development to occur.Inappropriate to use when a procedure code specifies bi-lateral or a side of the body | [12][13]
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| Additional HCPCS | XS | Separate structure: A service that is distinct because it was performed on a separate organ / structure (subset of modifier 59).
| - Separate Structure, A Service That Is Distinct Because It Was Performed on A Separate Organ/Structure
- Documentation indicates the services were provided on different organs/structures
- Use Modifier XS with the Column 2 procedure code in the NCCI files
- Use Modifier XS only when there is no other modifier to describe the situation
| [14][15][16]
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| Additional HCPCS | JW | Drug / biological discarded / not administered to any patient.
| JW drug or biological amount discarded/not administered to any patient.Effective 01/01/2017, the use of the JW modifier to identify unused drugs or biologicals from single use vials or single use packages that are appropriately discarded is required. The discarded amount shall be billed on a separate claim line using the JW modifier. Providers are required to document the discarded drug or biological in the patient’s medical record.Regardless of modifier, wastage of drug or biological must be documented clearly in the medical record with the date, time, amount wasted and reason | [17]
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| Additional HCPCS | JZ | Zero drug amount discarded/not administered to any patient
| Effective July 2023, the JZ modifier is required in order to attest that there were no discarded amounts and no JW modifier amount is reportedThe JW and JZ modifier policy applies to all providers and suppliers who buy and bill separately payable drugs under Medicare Part B (e.g. physician’s office) The JW and JZ modifier policy does not apply for drugs that are not separately payable, such as packaged OPPS or ASC drugs | [2]
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| Additional HCPCS | JC
| Skin substitute used as a graft.
| - JC skin substitute used as a graft
- Check with your MAC if modifier is required
- Example: Application of 14sq.cm of Apligraf to the right medial diabetic foot ulcer and 10 sq. cm applied to the right lateral diabetic ankle ulcer. A total of 24 sq. cm of Apligraf was used to cover these wounds and the remaining 20 sq. cm in the package is wasted. The Apligraf was fixated using steri-strips. The Apligraf was handled, applied, and immobilized according to the manufacturer’s label instructions.
- Report 15271-KX, 15275-KX, Q4101-KX-JC (24 units), Q4101-KX-JW (20 units)
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| Additional HCPCS | JD | Skin substitute NOT used as a graft.
| - JD skin substitute not used as a graft
- Check with your MAC if modifier is required
- Example: Application of 14sq.cm of Apligraf to the right medial diabetic foot ulcer and 10 sq. cm applied to the right lateral diabetic ankle ulcer. A total of 24 sq. cm of Apligraf was used to cover these wounds and the remaining 20 sq. cm in the package is wasted. The Apligraf was fixated using steri-strips. The Apligraf was handled, applied, and immobilized according to the manufacturer’s label instructions.
- Report 15271-KX, 15275-KX, Q4101-KX-JC (24 units), Q4101-KX-JW (20 units)
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| Additional HCPCS | KX | Requirements specified in the medical policy have been met
| - Check with your MAC if modifier is required
- Example: Application of 14sq.cm of Apligraf to the right medial diabetic foot ulcer and 10 sq. cm applied to the right lateral diabetic ankle ulcer. A total of 24 sq. cm of Apligraf was used to cover these wounds and the remaining 20 sq. cm in the package is wasted. The Apligraf was fixated using steri-strips. The Apligraf was handled, applied, and immobilized according to the manufacturer’s label instructions.
- Report 15271-KX, 15275-KX, Q4101-KX-JC (24 units), Q4101-KX-JW (20 units)
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| Advanced beneficiary notice of noncoverage (ABN) | GA | Waiver of Liability Statement Issued, as Required by Payer Policy
| GA Waiver of Liability Statement issues as required by payer policy or ABN is on fileMODIFIER GF METHOD II PRACTITIONER SERVICES (NP, PA)Must have a GF modifier reported on outpatient claims billed on the UB. | [18][19][20][21][22]
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Advanced beneficiary notice of noncoverage (ABN)
| GY | Item or service statutorily excluded, does not meet the definition of any Medicare benefit
| GY Notice of Liability Not issued; Not required under payer policy; item or service statutorily excludedMODIFIER GF METHOD II PRACTITIONER SERVICES (NP, PA)Must have a GF modifier reported on outpatient claims billed on the UB. | [18][19][20][21][22]
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Advanced beneficiary notice of noncoverage (ABN)
| GZ | Item or service expected to be denied as not reasonable and necessary
| GZ Item or service expected to be denied as not reasonable and necessary-ABN is not on file
MODIFIER GF METHOD II PRACTITIONER SERVICES (NP, PA)Must have a GF modifier reported on outpatient claims billed on the UB. | [18][19][20][21][22] |
