Return to CAP Home

  Your CPT Questions

title
 

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 performed?
  • 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 Affairs Committee.

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.