Coding and Billing Basics

Modifier 26 – The professional component of a code. This modifier indicates only the professional component of the code is being reported. The technical component may be reported by a different entity. 

Modifier 59 – Distinct procedural services. This modifier is to be used only for procedural services. It indicates a need to report separate non-E/M services individually when normally they are bundled into one code. The most common coding bundling edits are published byCMS asCorrectCoding Edits. Many third party payers follow these guidelines or modify these guidelines to support the payment policies. A common example for the allergist would be when the patient has had a bronchodilation responsiveness test performed (94060) and a separate instruction is given to the patient for a different bronchodilator that the patient will be using at home. Included in the 94060 code is the instruction on the bronchodilator to accurately have a good test. However, if the patient needs a different bronchodilator at home and needs to be instructed on the appropriate technique, then it would be appropriate to code both the 94060 and the 94664 with the 59 modifier attached to the 94664. Modifier 59 is not to be used if another HCPCS modifier best describes the scenario; it is to be used only if no other modifier is appropriate.

Modifier 76 – Repeat procedure by the same physician or other qualified healthcare provider. 

This modifier indicates two exact same services were provided on the same calendar day. The second service received the 76 modifier to indicate the necessity of the repeat services. This is not a modifier to be used on E/M services, but it would be appropriate if two nebulizer treatments were performed on the same calendar day. The appropriate reporting would be 94640, and then 9464076. 

Modifier 77 – If a different provider under the same tax ID provided the repeat service, then the appropriate modifier would be modifier 77. 

If any surgical procedures are performed by the allergist and the procedures have global days associated with the procedures, there would be a need to use additional modifiers for payment of services within the global period. All modifiers are listed with explanations in the appendix of the CPT book and are listed in numerical order for easy reference and understanding.