POLICY: USE OF CPT MODIFIERS
Policy Number: FIN – 2175 / Page(s): 1of2
Approved by: / Effective Date:

PURPOSE:Modifiers are used to report or indicate that a service or procedure that has been performed has been altered by some specific circumstance but not changed in its definition or code.

POLICY: Use of modifiers will strictly follow CPT guidelines and where necessary, documentation will support the appropriate usage.

PROCEDURE:

Modifier –25

  • Significantly, separately identifiable Evaluation and Management service by the same physician on the same day of the procedure or other service.
  • Used when a complete examination, new or established, is performed on the same day as a chiropractic office visit that is significantly more extensive than the normal pre-adjustment examination that is included with the office visit code.

Modifier –51

  • Multiple Procedures
  • Included with an extra-spinal manipulation (98943) when performed on the same visit as spinal manipulation (98940, 98941, 98942).

Modifier –52

  • Reduced services
  • Used when a time-based code (97110, 97112, 97140, 97124) does not meet the required minutes to report a full unit of the procedure.

Modifier –59

  • Distinct Procedural Service
  • Indicates that a procedure was distinct or independent from other non-E/M services performed on the same day.
  • Primarily used for 97124, 97140, and 97112 to indicate that it was performed on a region of the body SEPARATE and DISTINCT form the adjustment reported in the office visit code of 98940, 98941, or 98942.
  • Documentation must also indicate that the procedure was done on a separate region.
  • The procedure must be linked to distinctly separate ICD codes.

Modifier –AT

  • Indicates that the service is part of an active treatment program to reduce pain or improve function.
  • On Medicare, this modifier will only be included on covered services,which is the office visit (98940, 98941, 98942).
  • Will be placed on all services for other carriers that require its use.

Modifier –GA

  • Indicates that a financial waiver (i.e. signed mandatory ABN form) is on file for those specific services and the patient has been informed PRIOR to the service that those services would not be covered and be the patient’s financial responsibility.

Modifier –GY

  • Is used when an item or service is statutorily excluded or does not meet the definition of any Medicare benefit. The use of this modifier will automatically signal Medicare’s software to deny any service that is linked to this modifier. If the service is statutorily non-covered or is not a Medicare benefit, modifier GY may be used if the charge will still be submitted so it can be denied and sent to a secondary insurer.

Modifier –GX

  • Is used when an item or service is expected to be denied because it is not a covered service AND an ABN is signed. The GX modifier is used to indicate an ABN has been used to voluntarily notify a beneficiary that a statutorily non-covered Medicare service will not be covered.