Pediatric Coding Alert

Question: What are the rules governing multiple modifier sequencing?

Massachusetts Subscriber

Answer: The basic rule of modifier sequencing is to sequence payment, or level one, modifiers before informational, or level two, modifiers. Additionally, if you have a modifier that affects pricing, that will be sequenced before any payment eligibility modifier.

Here’s what that means:

Pricing modifiers affect the amount of money a payer will pay for a given procedure. For example, modifier 50 (Bilateral Procedure), when correctly appended to a unilateral procedure such as 69209 (Removal impacted cerumen using irrigation/ lavage, unilateral), should result in a payment that is the lower of either the total fee schedule amount for the procedure when performed on both sides (in this case, $28.88) or 150 percent of the fee schedule amount for the procedure (in this case, $21.66).

Coding caution: Use of the 50 modifier is dependent on payer guidelines. Some payers may require you to use informational modifiers such as RT (Right side) and LT (Left side) on two lines of the claim to indicate the procedure was performed bilaterally.

Pricing modifiers can also work in the opposite way. Modifiers such as 52 ( Reduced Services) or 53 (Discontinued Procedure) will alert payers that the provider did not, or could not, carry out the full service as defined by CPT^®. When this happens, the payer will reduce their fee to reflect what your provider actually performed.

Other pricing modifiers include modifiers 22, 26, 62, 80, 82, and P1-P6.

Payment eligibility modifiers communicate to the payer that the circumstances of the encounter necessitate overriding current billing and coding guidelines, such as those established by National Correct Coding Initiative (NCCI), when allowed.

In our above example, suppose your pediatrician had performed an unrelated procedure on the same patient prior to performing the impacted cerumen removal procedure, and the cerumen removal occurred during the global period of that unrelated procedure. In such a case, you would also append modifier 79 (Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period) to 69209, again according to payer guidelines. This means the modifiers in your claim would be sequenced as 69209-50-79 per the pricing/payment eligibility sequencing rule.

In addition to modifier 79, you can use other modifiers such as 24, 25, 51, 57, 58, 59, 76, 77, 78, 79, or 91, depending on circumstances and guidelines, to establish the eligibility of a given service or procedure.

Informational modifiers are sequenced last in multiple modifier scenarios. The most commonly used examples are the anatomical location modifiers, such as E1-E4, F1-F9, and T1-T9.