JustCoding's Guide to Modifiers: Hospital Outpatient Edition

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JustCoding’s Guide to Modifiers: Hospital Outpatient Edition

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JustCoding’s Guide to Modifiers: Hospital Outpatient Edition

Susan E. Garrison, CHCA, CHCA-S, CHC, CPC, CCS-P, CPAR, COC

Modifiers are intended to communicate specific information that is not contained in the code definition itself, but their proper reporting can sometimes be vague or confusing. This has resulted in many modifiers, in particular -25 and -59, being frequently targeted for audit by CMS and the Office of Inspector General.

Healthcare professionals must stay up-to-date with guidance for reporting modifiers or risk repeated audits and lost revenue. JustCoding’s Guide to Modifiers: Hospital Outpatient Edition provides detailed information on the latest guidelines surrounding CPT®/HCPCS modifiers. This book features comprehensive explanations of when to report each modifier, including coding tips and detailed examples.

Each chapter is jam-packed with exercises that provide an opportunity for readers to use real-life documentation, including operative reports and case studies, to test their knowledge for applying each modifier. Flowcharts and tables will also be included to help readers gain a better understanding of when a modifier should be applied.


Sample documentation and case studies—Clear, specific examples will show you exactly how CMS expects to see codes and modifiers on the claim.

  • Most problematic modifiers—From new modifiers like -JW, -96, and -97, to the perpetually confounding -59, readers will feel more confident in the application of modifiers.
  • Answers to all those “what-if’s” —You and your team can put your mind at ease as you’ll learn when (and how) to apply modifiers in the proper situations.

What's New:

  • Guidance for reporting outpatient modifiers is continually updated and revised. Some notable updates that coders need to be aware of are listed below: 
  • CMS created modifier -PN for providers to append to every single HCPCS code provided in non-excepted off-campus provider-based departments. 
  • The reporting of modifier -JW is no longer optional. Modifier -JW must be reported if providers are seeking payment for drugs they have to discard or waste.
  • CMS established two HCPCS Level II modifiers to identify 340B-acquired drugs. 
  • OPPS payments for x-rays using film were reduced by 20% in 2017. To identify these services, providers must add modifier -FX to claims for x-ray services. 
  • Effective in 2018, modifiers -96 and -97 will be used to describe services that are either habilitative or rehabilitative in nature.

About the Author

Susan E. Garrison, CHCA, CHCA-S, CHC, CPC, CCS-P, CPAR, COC, serves as executive vice president of Med Law Advisors. She is also executive director of the Association of Health Care Auditors and Educators, an international professional membership organization.

As a consultant to hundreds of healthcare providers, legal teams, accountants, and related organizations, Garrison assists clients in all facets of documentation, coding, billing, compliance, and litigation needs. She is a nationally acclaimed and highly sought-out speaker who has presented hundreds of educational sessions for professional organizations (such as AAPC, the Healthcare Financial Management Association, the American Health Information Management Association, and the Medical Group Management Association), teaching university health systems, healthcare providers, and payers. Her audiences include physicians, nonphysician providers, residents, chief executive and financial officers, coding professionals, and attorneys. Garrison’s areas of expertise include documentation, coding, billing, compliance, litigation support, revenue enhancement, revenue cycle operations, and professional communications.

With more than 25 years of experience in healthcare management, Garrison has held the positions of senior manager of outpatient consulting services with the 3M Company, vice president of accounts receivable management with MedPartners, vice president of outpatient consulting services with Healthcare Management Advisors, and fair hearing officer for Georgia’s Medicare Carrier. She also served as past president of the American Academy of Professional Coders’ National Advisory Board.

Published: September 2018

Page count: 158
Dimensions: 8.5x11
ISBN: 978-1-68308-821-9

Table of Contents

Chapter 1: Introduction
Chapter 2: NCCI Modifiers (-59, -X{EPSU}, -58, -78, -79) 

  • Section I: Overview of NCCI
  • Section II: NCCI Modifiers
  • Section III: Modifier -59
  • Section IV: Modifiers -X{EPSU}
  • Section V: Modifier -58
  • Section VI: Modifier -78 
  • Section VII: Modifier -79 
  • Section VIII: Final Thoughts on Modifiers -58, -59, and -79

Chapter 3: E/M Modifiers (-25, -27)

  • Section I: Overview of Modifiers -25 and -27
  • Section II: Modifier -25
  • Section III: Modifier -27 

Chapter 4: Anatomical Modifiers (Eyelids, Fingers, Toes, Coronary Arteries)

  • Section I: Overview of Anatomical Modifiers
  • Section II: Eyelid Modifiers (-E1, -E2, -E3, and -E4)
  • Section III: Finger Modifiers (-FA, -F1, -F2, -F3, -F4, -F5, -F6, -F7, -F8, and -F9)
  • Section IV: Toe Modifiers (-TA, -T1, -T2, -T3, -T4, -T5, -T6, -T7, -T8, and -T9)
  • Section V: Coronary Artery Modifiers (-LC, -LD, -LM, -RC, and -RI)

Chapter 5: Drug Modifiers (-JG, -JW, -TB)

  • Section I: Overview of Drug-Related Modifiers
  • Section II: Drugs Acquired Through 340B Program (Modifiers -JG and -TB)
  • Section III: Discarded Drugs Modifier -JW

Chapter 6: Laterality Modifiers (-50, -RT, -LT)

  • Section I: Overview of Laterality Modifiers
  • Section II: Modifier -50
  • Section III: Modifiers -RT and -LT
  • Section IV: Additional Information on Reporting Laterality Modifiers

Chapter 7: Reduced and Discontinued Services Modifiers (-52, -73, and -74)

  • Section I: Overview of Reduced and Discontinued Modifiers
  • Section II: Reduced Services Modifier -52
  • Section III: Discontinued Services (Modifiers -73 and -74)

Chapter 8: Inpatient-Only Services Modifier -CA

  • Section I: Overview of Inpatient-Only Services Modifier -CA
  • Section II: General Guidelines

Chapter 9: Screening Services Modifiers (Modifiers -GG, -33, and -PT)

  • Section I: Overview of Screening Service Modifiers -GG, -33, and -PT
  • Section II: Modifier -GG on the Same Patient, Same Day
  • Section III: Modifiers -33 and -PT

Chapter 10: Non-Covered Services (Modifiers -GA, -GX, -GY, and -GZ)

  • Section I: Overview of Non-Covered Services Modifiers
  • Section II: Background on Waiver of Liability (Advance Beneficiary Notice or ABN)

Chapter 11: Blood and Blood Products Modifier (-BL) 

  • Section I: Overview of Modifier -BL

Chapter 12: Radiology-Specific Modifiers (-CT, -FX, and -FY) 

  • Section I: Overview of Radiology-Specific Modifiers (-CT, -FX, -FY)
  • Section II: Modifier -CT, Computed Tomography (CT) Services Furnished With Equipment Not Meeting NEMA standards
  • Section III: Modifier -FX, X-Rays Taken Using Film
  • Section IV: Modifier -FY, X-Ray Using Computed Radiography/Cassette-Based Imaging
  • Section V: Scrutiny of Radiology-Specific Modifiers

Chapter 13: Repeat Procedures: Modifiers -76, -77, and -91

  • Section I: Modifiers -76 and -77
  • Section II: Modifier -91

Chapter 14: Modifiers -QM and -QN