Reference
Modifiers, by the question they answer.
Grouped by what the payer is asking: was the visit separate from the procedure, was there more than one procedure, how much of the service was this, and where was it done.
Visits around a procedure
The modifiers that keep a visit payable when a procedure or a global period would otherwise swallow it.
| Modifier | Name | When it applies |
|---|---|---|
25 | Significant, separately identifiable E/M on the same day as a procedure | The visit addressed more than the decision to do the minor procedure and the note shows it.The most audited modifier in office practice; the procedure's own pre-work is never enough. |
57 | Decision for surgery | The visit on the day of, or the day before, a major (90-day global) procedure where the decision to operate was made. |
24 | Unrelated E/M during a postoperative period | A visit inside a 10- or 90-day global for a problem unrelated to the surgery.The diagnosis on the visit must differ from the surgical one. |
FT | Unrelated E/M by the same physician during a postoperative period (critical care) | Critical care or another unrelated E/M in the global, on Medicare claims since 2022. |
58 | Staged or related procedure during the postoperative period | A planned second stage, a more extensive procedure, or therapy after a diagnostic procedure; a new global starts. |
78 | Unplanned return to the operating room for a related procedure | A complication takes the patient back to the OR during the global; paid at the intra-operative share, no new global. |
79 | Unrelated procedure during the postoperative period | A different problem, a different procedure, inside the global; a new global starts. |
More than one procedure
How the claim shows two things were done, on two structures, or on both sides.
| Modifier | Name | When it applies |
|---|---|---|
59 | Distinct procedural service | A procedure normally bundled with another was done at a separate site, session, incision or lesion.Medicare prefers the X modifiers below; use 59 only when none of them fits. |
XE | Separate encounter | The second procedure was in a separate encounter on the same day. |
XS | Separate structure | The second procedure was on a separate organ or structure. |
XP | Separate practitioner | A different practitioner performed the second procedure. |
XU | Unusual non-overlapping service | The service does not overlap the usual components of the main service. |
50 | Bilateral procedure | The same procedure on both sides in one session, where the code's bilateral indicator allows it.Some payers want RT and LT on two lines instead. |
51 | Multiple procedures | Additional procedures in the same session; most payers apply the multiple-procedure reduction themselves. |
RT / LT | Right side / left side | Which side a paired structure was treated; required by most payers for eyes, ears, limbs and joints. |
FA-F9, TA-T9 | Finger and toe modifiers | Which digit was treated (FA left thumb, F5 right thumb, TA left great toe, T5 right great toe). |
E1-E4 | Eyelid modifiers | Upper left, lower left, upper right, lower right eyelid. |
How much of the service
Reduced, discontinued, split or shared work.
| Modifier | Name | When it applies |
|---|---|---|
22 | Increased procedural services | The work was substantially greater than usual and the note says why; expect a request for records. |
52 | Reduced services | The procedure was partially reduced or eliminated at the physician's discretion. |
53 | Discontinued procedure | Stopped after anesthesia or start because of the patient's wellbeing. |
54 | Surgical care only | The surgeon operates and another physician takes over post-operative care (co-management). |
55 | Postoperative management only | The physician who provides the post-operative care in a co-managed global. |
56 | Preoperative management only | Pre-operative care alone, rarely used. |
26 | Professional component | The interpretation and report of a test whose equipment belongs to someone else. |
TC | Technical component | The equipment, supplies and technologist for a test read by someone else. |
62 | Two surgeons | Two surgeons each perform a distinct part of one procedure; both use the modifier. |
66 | Surgical team | A team of surgeons under one code, in complex procedures. |
80 / 81 / 82 | Assistant surgeon | 80 for a full assistant, 81 minimum assistant, 82 when a qualified resident was not available. |
AS | Non-physician assistant at surgery | A PA, NP or CNS assisting at surgery. |
FS | Split or shared E/M | A visit shared between a physician and a non-physician practitioner in a facility setting (Medicare). |
76 / 77 | Repeat procedure by the same / another physician | The same procedure repeated on the same day, for example a repeat x-ray. |
Setting, coverage and telehealth
The modifiers a payer reads before it reads the code.
| Modifier | Name | When it applies |
|---|---|---|
95 | Synchronous telemedicine, audio and video | A real-time video visit, with the place of service the payer requires (02 or 10). |
93 | Synchronous telemedicine, audio only | A telephone visit where the payer covers audio-only services. |
GT | Via interactive audio and video (older telehealth modifier) | Still required by some Medicaid plans and institutional claims. |
33 | Preventive service | A service that is preventive under the ACA and must have no cost-share, including a screening that became diagnostic. |
PT | Colorectal screening converted to diagnostic (Medicare) | A screening colonoscopy where a polyp was removed. |
GC | Service performed in part by a resident under a teaching physician | Teaching settings. |
Q6 | Locum tenens physician | A substitute physician billing under the absent physician's number, up to 60 days. |
KX | Requirements in the medical policy have been met | Therapy caps, DME and certain drugs where the payer wants an attestation. |
GA | Waiver of liability on file | An Advance Beneficiary Notice was signed for a service Medicare may deny. |
GY | Statutorily excluded | A service Medicare never covers, billed to get the denial for the secondary payer. |
GZ | Expected to be denied as not reasonable and necessary, no ABN | Same as GA without the notice; the patient cannot be billed. |
JW / JZ | Drug amount discarded / zero discarded | Single-dose vials on Medicare claims; JZ is required since 2023 when nothing was discarded. |
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