What is a modifier in CPT coding? Give an example.

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A modifier in CPT coding is a two-character code (numeric or alphanumeric) added to a CPT code to provide additional information about the performed service or procedure without changing its definition. Modifiers help clarify circumstances that may affect reimbursement, billing, or reporting—such as if a procedure was altered, performed more than once, or only partially completed.

Purposes of Modifiers:

• Show that a service was altered in some way without changing its core nature.

• Indicate that procedures were bilateral, multiple, discontinued, or unusual.

• Help insurance payers understand why a service should be reimbursed differently.

Example:

Modifier -25: Significant, Separately Identifiable Evaluation and Management (E/M) Service

If a physician performs a procedure and, during the same visit, also provides a separate and significant evaluation of a new problem, you would use modifier -25.

Example scenario:
A patient comes in for a scheduled wart removal (CPT 17110), but during the visit, the physician also evaluates a new rash.

The -25 modifier tells the payer that the E/M service was distinct and medically necessary, not just part of the pre-procedure assessment.

Using modifiers appropriately ensures accurate claims processing and compliance with coding guidelines.

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