Modifiers accepted and how they affect reimbursement; documentation and medical necessity requirements are specified per modifier.
Providers must meet the specific modifier requirements below to support reimbursement; absence of an appropriate modifier or use of an inappropriate modifier may result in claim denial.
Modifier 22 — Unusual Procedure or Service: If a procedure is substantially greater than typical, the provider must document the additional work and the reason for the additional work (increased intensity, increased time, increased technical difficulty, severity of the patient's condition, physical and mental effort required) to bill for additional reimbursement.
Modifier 24 — Post-Surgical Visits: Post-surgical visits billed by the physician who performed the surgery are considered inclusive in the surgical procedure and are not separately reimbursable. Exception: visits not related to the surgery may be separately reimbursable; bill modifier 24 to indicate a visit outside the global package.
Modifier 25 — Separately Identifiable E/M: Use modifier 25 on Evaluation and Management (E/M) codes only to indicate a significant, separately identifiable E/M service performed by the same physician on the same day as a procedure; do not append modifier 25 to the surgical procedure code.
Modifiers 26 and TC: Modifiers 26 (professional component) and TC (technical component): Report professional and technical components separately when applicable by appending the appropriate modifier to the usual procedure code.
Modifiers 58 and 78: Modifiers 58/78 — Return to the Operating Room: Use to indicate procedures performed during the postoperative period of the initial surgery. Medical records may be required to substantiate medical necessity. Do not bill these modifiers when no return to the operating room occurred. Bill the procedure code that best describes the procedure performed; do not bill the initial procedure code unless the exact identical procedure is again performed. Note: a new postoperative period does not begin when treating a complication; when a procedure with a 000 global period is performed to treat complications, the follow-up is reimbursed at 100%. Full payment is allowed for treatment of complications by another physician or surgeon (these services should not be billed with modifier 78).
Modifiers 54, 55, 56: Modifiers 54/55/56 — Portions of the global surgical package: Use when only part of the global surgical package is performed. These modifiers should be added to procedures with a 90-day global period (not for 0- or 10-day globals). Percentages paid for these modifiers are set by contract or Neighborhood standard modifier allowances. Do not use when physicians are within the same group or a covering physician arrangement exists. Specifics: 54 = surgical care only (must document transfer of postoperative care); 55 = postoperative management only (use after initial postoperative visit and after hospital discharge); 56 = preoperative management only (rarely used and only on surgical codes).
Modifier 59 and CMS subsets (XE/XP/XS/XU): Modifier 59 (Distinct Procedural Service) and CMS subset modifiers XE/XP/XS/XU: Use to indicate distinct procedural services when procedures not normally reported together are performed; prefer the more descriptive CMS subset modifier when applicable. These modifiers are subject to applicable Procedure-to-Procedure edits and correct coding guidelines.
Modifiers 62 and 66: Modifiers 62/66 — Team and Co-Surgeons: Use to indicate two surgeons or a surgical team billing the same procedure. Appropriate documentation establishing medical necessity for two surgeons is required; payment for assistant surgeons is generally not allowed unless clear, compelling documentation supports medical necessity. Services for procedures that do not call for a co-surgeon or team will be denied.
Modifier 79 — Unrelated Service During Post-Operative Period: Use to indicate a procedure or service performed during a post-operative period that was unrelated to the original procedure.
Modifiers 80/81/82/AS — Assistants at Surgery: Assistant at surgery modifiers are accepted when medically necessary. Definitions: 80 = assistant surgeon (full assistance); 81 = minimal assistance; 82 = used at teaching hospitals when a qualified resident is unavailable; AS = non-physician assistant (PA, NP, CNS) and should not be billed by a physician. Medical notes may be required. If a procedure does not call for an assistant, the service will be denied.
Modifier 91 — Repeat Clinical Diagnostic Laboratory Test: Use for repeat clinical diagnostic laboratory tests performed on the same day. (See multiple procedures payment guidance where applicable.)
Documentation and claims requirements: Neighborhood reserves the right to request medical records for any billed service; documentation must support billed services and medical necessity and follows CMS documentation standards. Providers must submit complete claims within contractually determined timely filing guidelines and use required coding systems (CPT, ICD-10-CM, HCPCS Level II).