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Surgical Modifiers

 

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Modifier 22 – Increased Procedural Services

When to Use Modifier 22

  •  The procedure required substantially more work than usual.  There was excessive scarring, abnormal anatomy, or unexpected complexity.

  • Operative time was significantly longer than normal.

Examples of Correct Use

  •  Surgeon encounters dense adhesions requiring extensive dissection. • Abnormal anatomy forces the surgeon to modify the approach. • A procedure takes twice as long due to unexpected complexity.

When NOT to Use Modifier 22

  • Routine difficulty or minor complications. 

  • The surgeon simply felt the case was challenging.

  • No clear documentation of increased work.

Documentation Requirements Explain what made the procedure more complex and compare it to the standard version.

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Modifier 50 – Bilateral Procedure

When to Use Modifier 50

  • The same procedure is performed on both sides of the body in one session. 

  • The CPT code does not already describe bilateral work.

Examples of Correct Use 

  • Bilateral ear tube placement. 

  • Bilateral carpal tunnel release. 

  • Bilateral knee injections (if payer accepts modifier 50).

When NOT to Use Modifier 50

  •  The code is inherently bilateral.

  • The payer requires separate line items with RT/LT instead.

Documentation Requirements Clearly state the procedure was performed on both sides.

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Modifier 51 – Multiple Procedures

When to Use Modifier 51

  • Two or more procedures are performed in the same session. 

  • Procedures are not bundled under NCCI edits.

Examples of Correct Use 

  • Excision of a lesion plus a separate repair.

  • Multiple endoscopic procedures performed in one session.

When NOT to Use Modifier 51

  • Procedures are bundled.

  • The payer automatically applies multiple procedure reductions.

Documentation Requirements Show that each procedure was distinct and medically necessary.

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Modifier 52 – Reduced Services

When to Use Modifier 52 

  • A procedure is partially reduced or not fully completed. 

  • The reduction is intentional and not due to patient instability.

Examples of Correct Use

  •  Only part of a diagnostic test is completed. 

  • A procedure is shortened due to patient tolerance but not emergency risk.

When NOT to Use Modifier 52

  • The procedure is discontinued due to patient instability (use 53).

  • The procedure was never started.

Documentation Requirements Describe what portion was completed and why it was reduced.

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Modifier 53 – Discontinued Procedure

When to Use Modifier 53

  • The procedure is started but must be stopped due to patient risk.

  • Complications or instability prevent safe completion.

Examples of Correct Use 

  • Patient becomes unstable under anesthesia. 

  • Unexpected bleeding forces the surgeon to stop.

When NOT to Use Modifier 53 

  • The procedure was never started. 

  • The reduction was planned (use 52).

Documentation Requirements Explain why the procedure was stopped and at what point.

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Modifier 54 – Surgical Care Only

When to Use Modifier 54

  • The provider performs only the surgical portion of care. 

  • Pre‑op and post‑op care are handled by other providers.

Examples of Correct Use

  • A surgeon performs the operation but another provider handles follow‑up. 

  • Shared care arrangements between facilities.

When NOT to Use Modifier 54 

  • The same provider performs all components of care.

Documentation Requirements Identify which portions of care were provided.

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Modifier 55 – Postoperative Management Only

When to Use Modifier 55

  • The provider furnishes only postoperative care.

  • Post‑op management is formally transferred.

Examples of Correct Use 

  • A surgeon in another state performs the surgery; local provider handles follow‑up. 

  • Shared care agreements.

When NOT to Use Modifier 55 

  • The provider also performed the surgery.

Documentation Requirements Include transfer‑of‑care details and start date of post‑op care.

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Modifier 56 – Preoperative Management Only

When to Use Modifier 56

  •  The provider performs only preoperative evaluation and preparation. 

  • The surgery and post‑op care are handled by others.

Examples of Correct Use 

  • Pre‑op clearance and planning performed by a specialist involved in surgical prep.

When NOT to Use Modifier 56

  • • Routine consultations not tied to surgical planning.

Documentation Requirements Support that the care was specifically preoperative.

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Modifier 58 – Staged or Related Procedure

When to Use Modifier 58 

  • The subsequent procedure is planned, staged, or more extensive.

  • The procedure is part of the original treatment plan.

Examples of Correct Use 

  • Planned second‑look surgery. 

  • Staged wound closure.

  • More extensive follow‑up procedure documented in the plan.

When NOT to Use Modifier 58

  • The procedure is due to a complication (use 78). 

  • The procedure is unrelated (use 79).

Documentation Requirements Show that the procedure was planned or expected.

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Modifier 59 – Distinct Procedural Service

When to Use Modifier 59 

  • Procedures are separate by site, session, incision, or purpose. 

  • Needed to override NCCI bundling edits.

Examples of Correct Use 

  • Two procedures on different anatomical sites. 

  • Separate sessions on the same day.

When NOT to Use Modifier 59 

  • To bypass edits without documentation.

  • When an X‑modifier provides more specific detail.

Documentation Requirements Clearly establish distinctness.

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Modifier 62 – Two Surgeons

When to Use Modifier 62

  • Two surgeons act as primary surgeons.

  • Each performs a distinct, critical portion of the procedure.

Examples of Correct Use

  • Complex spine surgery requiring two specialists. 

  • Multi‑disciplinary tumor resections.

When NOT to Use Modifier 62 

  • Assistant surgeons (use 80/81/82/AS).

Documentation Requirements Both surgeons must document their roles.

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Modifier 66 – Surgical Team

When to Use Modifier 66 

  • A highly complex procedure requires a full surgical team.

  • Multiple surgeons are needed due to extraordinary circumstances.

Examples of Correct Use 

  • Transplant surgeries.

  • Major trauma requiring multiple specialists.

When NOT to Use Modifier 66

  • Routine multi‑provider surgeries.

Documentation Requirements Explain why a team approach was necessary.

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Modifier 78 – Unplanned Return to the Operating Room

When to Use Modifier 78

  • Patient returns to the OR due to a complication. 

  • Occurs during the global period.

Examples of Correct Use

  • Post‑op bleeding requiring return to OR.

  • Infection requiring surgical intervention.

When NOT to Use Modifier 78 

  • Planned procedures. 

  • Unrelated procedures.

Documentation Requirements Describe the complication and reason for return.

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Modifier 79 – Unrelated Procedure During the Postoperative Period

When to Use Modifier 79

  • A completely unrelated procedure is performed during the global period. 

  • The diagnosis is different from the original surgery.

Examples of Correct Use

  • Patient had knee surgery but later needs a skin lesion excision.

  • Patient had cataract surgery but later requires a colonoscopy.

When NOT to Use Modifier 79

  • Staged or related procedures (use 58). 

  • Complication‑related procedures (use 78).

Documentation Requirements Support that the new procedure is unrelated.

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