Reprinted from February 2000 CAP TODAY
Q: The article “Cracking the code: advice for CPT dilemmas”
(CAP TODAY, July 1999, page 1) advised using
the -22 modifier for difficult or time-consuming cases and the -59 modifier
for services that aren’t ordinarily billed separately. Are specific guidelines
available that would help me decide when it is appropriate to use a modifier
with a CPT code?
A: Questions one should consider when deciding if it is appropriate to
use a modifier include:
- Will the modifier help to avoid the appearance of duplicate billing?
Example: Use of the -91 modifier to indicate that it was
necessary to repeat the same laboratory test on the same day to obtain
subsequent, medically necessary, sequential data.
- Will the modifier help to avoid the appearance of unbundling?
Example: Use of the -59 modifier to indicate that a service
or procedure was distinct or independent from other services performed
on the same day.
- Will the modifier add specificity to the reporting of the procedure
Example: Use of the -26 modifier to indicate that only the
physician component of the service is being reported. Example: Use
of the -22 modifier to indicate that the service provided was greater
than that usually required for the listed procedure.
If the answer to any of these questions is “yes,” then it would
be appropriate to use the applicable modifier.
The correct modifier not only can better describe the service provided,
but also show that the separate billing of a service, while not normally
allowed, is appropriate under the circumstances. Some commonly used modifiers
for pathology services are -22, -26, -59, -91, and -TC. A definition of
each modifier and guidelines for appropriate use are listed in appendix
A of the CPT 2000 book.
Q: I received two separately identified tonsils, as well as adenoids,
from a patient. Can I use code 88304x3?
A: If the tonsils have been identified separately, then each can receive
one unit of 88304. However, the adenoids cannot receive a separate unit
of 88304. The wording of the code, “Tonsil and/or Adenoids,”
indicates that the adenoids are bundled into the code for the tonsil.
If two tonsils are received and they are not separately identified as
right and left, then they are considered a single specimen and should
receive only one unit of 88304.
Frequently asked questions about CPT are published bimonthly in “Capitol
Scan.” This addition to CAP TODAY is a product of the CAP Economic
The codes and descriptions listed here are from Current Procedural Terminology,
a copyrighted publication of the American Medical Association. To purchase
CPT books, call the AMA at (800) 621-8335.