Nov. 3, 2021

Accurate coding and reporting of services on medical claims submitted to BlueCross BlueShield of South Carolina and BlueChoice HealthPlan is critical in assuring proper payment to providers.  Modifiers play a vital role in this, as they are used to provide additional information necessary for processing claims.  For this reason, it is important to understand how and when to append modifiers to claims.

Below are helpful tips on proper use of common modifiers used when coding for clinical situations.  Clinical documentation should support the use of any modifier.

Modifier 25

Modifier 25 should be used to report an Evaluation and Management (E/M) service on a day when another procedure or service is rendered to a patient by the same physician or other qualified heath care professional.

Note: This modifier should not be used to report an E/M service that resulted in a decision to perform surgery; see Modifier 57.  Also, the type of bundling a code pair falls under will also impact what modifier actually overrides the bundling. In some cases, no modifier override is possible as the services that bundled may not physically be possible to do or clinically possible to do together. Different types of bundling include same visit, mutually exclusive, and ultimate parent.

Example

A patient visits the cardiologist due to discomfort in his chest while exercising.  This patient has a history of high blood pressure.  Once the physician completes the office visit, it is determined that the patient needs a cardiovascular stress test, which is performed that day by the same physician.

Coding

The physician or qualified health care professional codes for the E/M (99202 – 99215) and the cardiovascular stress test (93015).  The Modifier 25 is appended to the E/M visit to indicate that there was a separately identifiable E/M on the same day of the procedure.

Line 1 – 99213, 25

Line 2 – 93015

Modifier 50

Modifier 50 should be used to report bilateral surgical procedures as a single unit of service.  Do keep in mind that coding claims for surgical procedures performed bilaterally depends on:

• The CPT/HCPCS Level II code descriptor

• The Bilateral Indicator assigned to the CPT/HCPCS Level II codes (whether special payment rules apply)
• The nature of the service

Note: Bilateral procedures that allow payment adjustment will be paid at 150% unless other contract provisions apply. Certain CPT/HCPCS codes are bilateral in nature and thus should not be submitted with a modifier 50 as the code assumes the service was done bilaterally. The use of RT and LT has no impact on services performed bilaterally in terms of payment. RT and LT modifiers are descriptive modifiers only.

Example

A patient has breast cancer that has spread and as a result, must have a double mastectomy performed.

Coding

The physician or qualified health care professional codes for mastectomy (19303).  The Modifier 50 is appended to the code to indicate that service was performed bilaterally.

Line 1 – 19303, 50

Modifier 57

Modifier 57 should be used to report an Evaluation and Management (E/M) service when the E/M results in the decision to go to surgery.  This can take place the day of or the day before the procedure.

Example

A patient visits the emergency room with abdominal pain and fever.  After consulting with the patient, the physician determines that an emergency appendectomy is needed and performs the procedure that day.

Coding

The physician or qualified health care professional codes for the E/M and the appendectomy (44950).  The Modifier 57 is appended to the E/M visit to indicate that service resulted in the decision to go to surgery.

Line 1 – 99243, 57

Line 2 – 44950

Modifier 59

Modifier 59 should be used to report procedures or services that are not normally reported together but are appropriate under the circumstances.  However, if a more appropriately established modifier is available, it should be used rather than modifier 59.  Modifier 59 should only be used when a more descriptive modifier is not available and the use of modifier 59 best explains the circumstances.

Note: The X series of modifiers aligns with modifier 59 and provides more granularity in reporting the actual clinical situation. Also, the type of bundling a code pair falls under will also impact what modifier actually overrides the bundling. In some cases, no modifier override is possible as the services that bundled may not physically be possible to do or clinically possible to do together. Different types of bundling include same visit, mutually exclusive, and ultimate parent.

Example

A patient visits the neurologist to have a nerve conduction study performed on separate nerves.

Coding

The physician or qualified health care professional codes for the nerve conduction studies (95907 and 95908).  The Modifier 59 is appended to one of the codes to indicate that service was performed on separate nerves.

Line 1 – 95907, 59

Line 2 – 95908

Modifier 76

Modifier 76 should be used to report that a procedure or service was repeated subsequent to the original procedure or service by the same physician or qualified health care professional.

Note: The Modifier 76 is only applicable to code ranges 10021-69990, 70010-79999, 90281-99199, and 99500-99607.

Example

A patient visits the hospital with pain in their lower abdomen that radiates to their back.  The physician decides to perform an ultrasound for flank pain and sends the patient home with pain medicine.  The patient returns the same day and sees the same physician who performs another ultrasound for possible renal issues.

Coding

The physician or qualified health care professional codes for both ultrasounds.  The Modifier 76 is appended to one of the codes to indicate that service was repeated on the same day by the same physician or qualified health care professional.

Line 1 – 76700

Line 2 – 76700, 76

Modifier 77

Modifier 77 should be used to report that a procedure or service was repeated subsequent to the original procedure or service by another physician or qualified health care professional.

Note: The Modifier 77 is only applicable to code ranges 10021-69990, 70010-79999, 90281-99199, and 99500-99607.

Example

A patient is involved in a car accident and visits the hospital because of chest pain that spreads to her jaw and arm.  The physician performs an EKG and an arrhythmia is noted. Due to other injuries that cannot be treated at this hospital, she is transferred to another facility.  As the result of increased pain, the physician in the emergency room performs another EKG to rule out cardiac arrest.

Coding

The physician or qualified health care professional codes for the EKG (93000).  The Modifier 77 is appended to the code to indicate that service was repeated on the same day by another physician or qualified health care professional.

Line 1 – 93000, 77

If you have any questions about this bulletin, please contact Provider Education using the Provider Education Contact Form located on www.SouthCarolinaBlues.com or www.BlueChoiceSC.com.