CPT Modifiers

 CPT Modifier  :  62

Description : 

Two surgeons: When two surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding CPT modifier 62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. Each surgeon should report the co-surgery once using the same procedure code. If additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with CPT modifier 62 added. 

Note: If a co-surgeon acts as an assistant in the performance of additional procedure(s) during the same surgical session, those services may be reported using separate procedure code(s) with CPT modifier 80 or modifier 82 added, as appropriate. 

 CPT Modifier  :  66

Description : Surgical Team: Under some circumstances, highly complex procedures (requiring the concomitant services of several physicians, often of different specialties, plus other highly skilled, specially trained personnel and various types of complex equipment) are carried out under the “surgical team” concept. Such circumstances may be identified by each participating physician with the addition of the CPT modifier 66 to the basic procedure number used for reporting services.

 Documentation establishing that a surgical team was medically necessary is required for certain services identified by Centers for Medicare & Medicaid Services (CMS). All claims for team surgeons must contain sufficient information i.e., operative reports, to allow pricing “by report”.

 CPT Modifier  :  73

Description : Discontinued Out-patient Hospital/Ambulatory Surgical Center (ASC) Procedure Prior to the Administration of Anesthesia: Due to extenuating circumstances or those that threaten the well-being of the patient, the physician may cancel a surgical or diagnostic procedure subsequent to the patient’s surgical preparation (including sedation when provided, and being taken to the room where the procedure is to be performed), but prior to the administration of anesthesia (local, regional block(s) or general). Under these circumstances, the intended service that is prepared for but cancelled can be reported by its usual procedure number and the addition of the CPT modifi er 73. 

Note: The elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. For physician reporting of a discontinued procedure, see CPT modifi er 53.

 CPT Modifier  :  74

Description : Discontinued Out-patient Hospital/Ambulatory Surgical Center (ASC) Procedure after Administration of Anesthesia: Due to extenuating circumstances or those that threaten the well-being of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia (local, regional block(s) or general) or after the procedure was started (incision made, intubation started, scope inserted, etc.). Under these circumstances, the procedure started but terminated can be reported by its usual procedure number and the addition of the CPT modifi er 74. 

Note: The elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. For physician reporting of a discontinued procedure, see CPT modifi er 53.

 CPT Modifier  :  80

Description : Assistant Surgeon: Surgical assistant services may be identified by adding the CPT modifier 80 to the usual procedure number(s). 

This modifi er should be reported to identify surgical assistant services performed in a nonteaching setting or in a teaching setting when a resident was available but the surgeon opted not to use the resident. In the latter case, the service is generally not covered by Medicare. When the surgical services are performed in a non-teaching setting, report “Non-teaching” in the narrative section of an electronic claim submission.

 CPT Modifier  :  81

Description : Minimum Assistant Surgeon: Minimum surgical assistant services are identified by adding CPT modifier 81 to the usual procedure number. 

 CPT Modifier  :  82

Description : Assistant Surgeon (when qualified resident surgeon not available): The unavailability of a qualified resident surgeon is a prerequisite for use of CPT modifier 82 appended to the usual procedure code number(s). 

This modifier is used in teaching hospitals if there is no approved training program related to the medical specialty required for the surgical procedure or no qualified resident was available.

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.

Global Surgery Modifiers

CPT Modifier  :  25

Description : Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Day of a Procedure or Other Service: It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or be beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding CPT modifier 25 to the appropriate level of E/M service. 

Note: This modifier is not used to report an E/M service that resulted in a decision to perform major surgery. See CPT modifier 57. For significant, separately identifiable non-E/M services, see CPT modifi er 59.

 

CPT Modifier  :  57

Description :

Decision for Surgery: An evaluation and management service that resulted in the initial decision to perform the surgery may be identified by adding CPT modifier 57 to the appropriate level of E/M service. 

E/M services on the day before or on the day of major surgery (90 day global period) which result in the initial decision to perform the surgery are not included in the global surgery payment.

 These E/M services may be billed separately and identified with the 57 CPT modifi er. This modifier should not be used for visits furnished during the global period of minor procedures (0 or 10 day global period) unless the purpose of the visit is a decision for major surgery. 

This modifier is not used with minor surgeries because the global period for minor surgeries does not include the day prior to the surgery. When the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine preoperative service and a visit or consultation is not billed in addition to the procedure.

CPT Modifier  :  58

Description :

Staged or Related Procedure or Service by the Same Physician During the Postoperative Period: It may be necessary to indicate that the performance of a procedure or service during the postoperative period was (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. This circumstance may be reported by adding the CPT modifier 58 to the staged or related procedure. 

Note: For treatment of a problem that required a return to the operating or procedure room (e.g., unanticipated clinical condition), see CPT modifier 78. 

CPT Modifier  :  59

Description :Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. CPT modifier 59 is used to identify procedures or services, other than E/M services, that are not normally reported together but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, or separate injury (or area in injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than CPT modifier 59. CPT modifier 59 should only be used if there is no other more descriptive modifier available and the use of CPT modifier 59 best explains the circumstances. 

Note: CPT modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see CPT modifi er 25.

 

CPT Modifier  :  78

Description :Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the Postoperative Period: It may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure).

 When this procedure is related to the first and requires the use of an operating room, it may be reported by adding CPT modifier 78 to the related procedure. (For repeat procedures, see CPT modifi er 76).

 CPT Modifier  :  79

Description :Unrelated Procedure by the Same Physician During the Postoperative Period: The physician may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. 

This circumstance may be reported by using the CPT modifier 79. (For repeat procedures on the same day, see CPT modifi er 76).

 

Cardiology Reimbursement Coding Fact Sheet

The information contained in this document is provided for informational purposes only and represents no statement, promise, or guarantee by Cordis Corporation concerning levels of reimbursement, payment, or charge. Similarly, all CPT, ICD-10 and HCPCS codes are supplied for informational purposes only and represent no statement, promise, or guarantee by Cordis that these codes will be appropriate to specific circumstances or products or services provided or that reimbursement will be made. Providers are ultimately responsible for exercising their independent clinical judgment to determine medical necessity for individual patients and the appropriate billing process according to the applicable payer’s current policy. CPT codes and descriptions are copyright 2016 American Medical Association. ICD-10 codes and descriptions are copyright 2016 World Health Organization; revised for use in the United States by the Centers for Medicare and Medicaid Services (CMS) and the Centers for Disease Control and Prevention’s (CDC) National Center for Health Statistics (NCHS) as ICD-10-CM / ICD-10-PCS. Healthcare Common Procedure Coding System (HCPCS) Level II codes and descriptions are maintained by the CMS HCPCS Workgroup. The information contained in this document is taken from various publicly available documents, is current at the date of publication and is subject to change at any time.

CPT® Codes and Physician Reimbursement

Medicare Part B pays for physician services based upon the Medicare Physician Fee Schedule (MPFS). Fee schedule amounts are calculated according to the Resource-Based Relative Value Scale (RBRVS), which is updated each year. Procedures are reported using CPT® codes. The 2017 CPT Professional Edition Manual also provides specific instructions for reporting particular families of codes. Individual payers may also have guidelines and coverage policies regarding certain services. The following table lists the most commonly used codes for coronary procedures

Diagnostic Procedures and Imaging

CPT® Code	Description	2017 Work RVUs	2017 Medicare Base Payment Rate2
			Non-Facility	Facility
93451	Right heart catheterization	2.47	$737	$136
93452	Left heart catheterization	4.50	$839	$248
93453	Right and left heart catheterization	5.99	$1,089	$332
93454	Coronary angiography	4.54	$851	$252
93455	Coronary angiography with bypass grafts	5.29	$995	$293
93456	Coronary angiography with right heart catheterization	5.90	$1,076	$327
93457	Coronary angiography and bypass grafts, with right heart catheterization	6.64	$1,220	$368
93458	Coronary angiography with left heart catheterization	5.60	$1,025	$310
93459	Coronary angiography and bypass grafts, with left heart catheterization	6.35	$1,137	$352
93460	Coronary angiography with right and left heart catheterization	7.10	$1,225	$394
93461	Coronary angiography with bypass grafts, right and left heart catheterization	7.85	$1,402	$435
+93462	Left heart access via transseptal or transapical puncture	7.85	$219	$219
+93463	Pharmacological agent administration with hemodynamic assessment	3.73	$101	$101
+93464	Physiologic exercise study with hemodynamic assessment	2.00	$259	$89
93503	Placement of flow directed catheter (eg, Swan-Ganz) for monitoring	1.80	$0	$132
93505	Endomyocardial biopsy	2.91	$712	$228
93530	Right heart catheterization for congenital cardiac anomalies	3.97	$0	$216
93531	Combined right & retrograde left heart cath for congenital cardiac anomalies	8.34	$0	$446
93532	Combined right & transseptal left heart cath through intact septum for congenital cardiac anomalies	9.99	$0	$556
93533	Combined right & transseptal left heart cath through intact septum for congenital cardiac anomalies	6.69	$0	$371
93561	Indicator dilution study with cardiac output (separate procedure)	0.25	$0	$13
93562	Indicator dilution study; subsequent measurement of cardiac output	0.01	$0	$1
+93563	Injection/imaging for coronary angiography with cath for congenital anomaly	1.11	$61	$61
+93564	Injection/imaging for bypass graft angiography with cath for congenital anomaly	1.13	$64	$64
+93565	Injection/imaging for left heart angiography with cath for congenital anomaly	0.86	$47	$47
+93566	Injection/imaging for right heart angiography with cath for congenital anomaly	0.86	$164	$48
+93567	Injection/imaging procedure for supravalvular aortography	0.97	$139	$55
+93568	Injection/imaging procedure for pulmonary angiography	0.88	$147	$50
+93571	Intravascular coronary flow reserve measurement, initial vessel	1.80	$0	$100
+93572	Intravascular coronary flow reserve measurement, each additional vessel	1.44	$0	$80
+92978	Coronary vessel or graft imaging with IVUS or OCT, initial vessel	1.80	$0	$100
+92979	Coronary vessel or graft imaging with IVUS or OCT, each additional vessel	1.44	$0	$80