Surgical Modifiers

 CPT Modifier  :  50

Description :Bilateral Procedure: Unless otherwise identified in the listings, bilateral procedures that are performed at the same operative session should be identified by adding the CPT modifi er 50 to the appropriate five digit code. 

Report such procedures as a single line item with a unit of 1. For example, when CPT code 19303 (Mastectomy, simple, complete) is performed bilaterally, report the service as 1930350 (CPT code/modifier). 

If a procedure is identified by the terminology as bilateral (or unilateral or bilateral), do NOT report the procedure code with CPT modifier 50. For example, CPT code 68810 to 68815, (probing of nasolacrimal duct, with or without irrigation, unilateral or bilateral) includes terminology which indicates the procedure is performed either unilaterally or bilaterally. Therefore it’s not appropriate to report this modifier with this code. 

Additionally some procedure codes, i.e., CPT code 52000 (Cystourethroscopy, separate procedure) should NOT be reported with the 50 CPT modifier since anatomy does not permit this procedure to be performed bilaterally.

 CPT Modifier  :  51

Description : 

Multiple Procedures: When multiple procedures, other than E/M services, physical medicine and rehabilitation services or provision of supplies (e.g., vaccines), are performed at the same session by the same provider, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by appending the CPT modifier 51 to the additional procedure or service code(s). 

Note: This modifier should not be appended to designated “add-on” codes. 

 CPT Modifier  :  53

Description : 

Discontinued Procedure: Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well-being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. This circumstance may be reported by adding the CPT modifier 53 to the code reported by the physician for the discontinued procedure. 

CPT modifier 53 is used for “unusual (discontinued) circumstances”. Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure due to extenuating circumstances that may threaten the well-being of the patient. In many instances, attachments, medical records, etc. are not required to be sent in if an explanation for the discontinuation is in the narrative field of the claim. For example, submit “discontinued due to elevated blood pressure”. When additional information to support the use of the 53 CPT modifier cannot be contained in the narrative of the claim, additional documentation may be submitted. 

Note: This modifier is not used to report the elective cancellation of a procedure prior to the patient’s anesthesia induction and/or surgical preparation in the operating suite. For outpatient hospital/ambulatory surgery center (ASC) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see CPT modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use) 

 CPT Modifier  :  54

Description : Surgical Care Only: When one physician performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding the CPT modifier 54 to the usual procedure code. Services billed with a 54 CPT modifier will be reimbursed at the intraoperative allowance for the surgical procedure. The intraoperative allowance includes the one day preoperative care, the intraoperative service, as well as any in-hospital visits that are performed.

 CPT Modifier  :  55

Description : Postoperative Management Only: When one physician performs the postoperative management and another physician has performed the surgical procedure, the postoperative component may be identified by adding the CPT modifier 55 to the usual procedure number. 

This modifier is used to identify postoperative, out of hospital medical care associated with a given surgical procedure. When billing for postoperative care only, report the original date of surgery as your date of service and the procedure code for the surgical procedure followed by the 55 CPT modifier. In rare situations where the out of hospital postoperative care is split between physicians, each physician must also indicate the period of his/her responsibility for the patient’s postoperative care by reporting the appropriate range of dates. Where a transfer of postoperative care occurs, the receiving physician cannot bill for any part of the global services until he/she has provided at least one service.