Assigning CPT Modifiers

by Maureen Thompson

Using Current Procedural Terminology (CPT) code modifiers is confusing because numerous modifiers exist, different rules apply to different modifiers, and the modifiers may change, just like CPT codes. To ensure correct payment for a procedure, it is critical that you know what modifiers are and when to use them.

What is a CPT modifier?

A. Modifiers indicate that a service was altered in some way from the stated CPT descriptor without changing the definition. The American Medical Association (AMA) CPT modifiers are two-digit numeric codes listed after a procedure code and separated from the CPT code by a hyphen (e.g., 92506-22).

When should I use a modifier?

A. When you need to communicate to the payer that something is atypical about that particular claim. Most audiology and speech-language pathology CPT codes represent a "typical" visit length unless a time period is included in the CPT descriptor.

Use of a modifier is appropriate, for example, if the service: (a) has been increased or decreased, (b) has both a technical and professional component, (c) only part of the service was performed, or (d) if unusual events occurred.

Can modifiers be used when billing Medicare as well as private health plans?

A. Medicare carriers and intermediaries vary on the use and acceptance of modifiers. Some Medicare payers will accept all modifiers listed in the CPT and Healthcare Procedural Coding System (HCPCS) books. (The CPT system does not include all the codes needed to report medical services and supplies, so HCPCS was developed as a second level of codes.) Other payers may accept only select modifier codes. The same is true for private health plans, so it is important that you check with individual payers regarding their requirements.

What CPT modifiers are typically used by audiologists and speech-language pathologists?

A. Modifier 22: Unusual Procedural Services —The service provided is greater than that usually provided for the listed procedure. For example, a speech and language evaluation (CPT 92506) requires twice the amount of time as "typical." Although 92506 is not a time-based code, the timeframe is the basis for determining an unusually long evaluation. As such, the SLP could bill with the 22 modifier (i.e., 92506-22).

Modifier 22 produces an automatic review or audit by payers, so supporting documentation must be attached to the claim. In addition, don’t expect 22 to be honored for extra payment if it is used too frequently—remember it is to be used for unusual services only. If approved, payment for 22 may be an additional 20%–50% of the allowable rate for the procedure performed.

• Modifier 52: Reduced Services —The provider reduces or eliminates a portion of the service or procedure, which results in a reduction in reimbursement. The reduced service can be identified by its CPT code and the addition of the modifier -52 (e.g., 92557-52).
• Modifier 26 and TC —Medicare policies require specific modifiers. For example, these two modifiers affect reimbursement for some audiology codes that are not found in the AMA CPT book: Modifier 26 represents the professional component or the portion of the diagnostic test that involves a physician’s work, and TC represents the technical component or the portion of the diagnostic test that does not include a physician’s participation (i.e., the audiologist’s work).

In the 2002 Medicare Physician Fee Schedule, the national global value—which combines the professional and technical component—for CPT 92541(spontaneous nystagmus) is $68.42, the technical component (i.e., audiologist’s work) is $45.97, and the professional component is $22.45.

If an audiologist is an employee or contractor of the physician, the full global value is billed. If the audiologist is an independent practitioner, only the technical component can be billed to Medicare.

Where can I find a list of CPT modifiers?

A. The AMA CPT and HCPCS books , designed for the professional coder, are available through the AMA Press (call 800-621-8335). The Coders’ Desk Reference, designed for the lay person, is available through Ingenix Companies (call 800-765-6588). ASHA’s Private Health Plans Handbook contains a list of the CPT modifiers most commonly used by audiologists and SLPs. In addition, the information in the handbook can help practitioners to file a claim, code diagnoses and treatment procedures, appeal denied claims, improve knowledge of costs for services, understand the Medicare Physician Fee Schedule, and understand general contracting terms. This product is available through ASHA Product Sales (call 888-498-6699).

For answers to additional questions you may have about modifiers or reimbursement, email reimbursement@asha.org .

Maureen Thompson  is ASHA’s director of private health plans advocacy.