Modifier th

Misunderstood Modifiers

Modifiers are two-digit representations used in conjunction with a service or procedure code (e.g., 99233-25) during claim submission to alert payors that the service or procedure was performed under a special circumstance. Modifiers can:

  • Identify body areas;
  • Distinguish multiple, separately identifiable services;
  • Identify reduced or multiple services of the same or a different nature; or
  • Categorize unusual events surrounding a particular service.1

Many questions arise over appropriate modifier use. Hospitalist misconceptions typically involve surgical comanagement or multiple services on the same day. Understanding when to use modifiers is imperative for proper claim submission and reimbursement.

Multiple Visits

Most hospitalists know payors allow reimbursement for only one visit per specialty, per patient, per day; however, some payors further limit coverage to a single service (i.e., a visit or a procedure) unless physician documentation demonstrates a medical necessity for each billed service. When two visits are performed on the same date by the same physician, or by two physicians of the same specialty within the same group, only one cumulative service should be reported.2

Consideration of two notes during visit-level selection does not authorize physicians to report a higher visit level (e.g., 99233 for two notes instead of 99232 for one note). If the cumulative documentation does not include the necessary elements of history, exam, or medical decision-making that are associated with 99233, the physician must report the lower visit level that accurately reflects the content of the progress note (for more information on documentation guidelines, visit

One exception to this “single cumulative service” rule occurs when a physician provides a typical inpatient service (e.g., admission or subsequent hospital care) for chronic obstructive bronchitis with acute exacerbation (diagnosis code 491.21) early in the day, and later the patient requires a second, more intense encounter for acute respiratory distress (diagnosis code 518.82) that meets the definition of critical care (99291). In this scenario, the physician is allowed to report both services on the same date, appending modifier 25 to the initial service (i.e., 99233-25) because each service was performed for distinct reasons.

If different physicians in the same provider group and specialty provided the initial and follow-up services, each physician reports the corresponding service in their own name with modifier 25 appended to the subsequent hospital care service (as above). Please note that physicians may not report both services if critical care is the initial service of the day. In this latter scenario, the physician reports critical-care codes (99291, 99292) for all of his or other group members’ encounters provided in one calendar day.3

Visits and Procedures

When a physician bills for a procedure and a visit (inpatient or outpatient) on the same day, most payors “bundle” the visit payment into that of the procedure. Some payors do provide separate payment for the visit, if the service is separately identifiable from the procedure (i.e., performed for a separate reason). To electronically demonstrate this on the claim form, the physician appends modifier 25 to the visit. Although not required, it is strongly suggested that, when possible, the primary diagnosis for the visit differs from the one used with the procedure. This will further distinguish the services. However, different diagnoses may not be possible when the physician evaluates the patient and decides, during the course of the evaluation, that a procedure is warranted. In this case, the physician may only have a single diagnosis to list with the procedure and the visit.

Payors may request documentation prior to payment to ensure that the visit is not associated with the required preprocedure history and physical. Modifier 57 is not to be confused with modifier 25. Modifier 57 indicates that the physician made the decision for “surgery” during the visit, but this modifier is used with preprocedural visits involving major surgical procedures (i.e., procedures associated with 90-day global periods). Since hospitalists do not perform major surgical procedures, they would not use this modifier with preprocedural visits.

Keep in mind that this “bundling” concept only applies when same-day visits and procedures are performed by the same physician or members of the same provider group with the same specialty designation. In other words, hospitalist visits are typically considered separate from procedures performed by a surgeon, and there is no need to append a modifier to visits on the same day as the surgeon’s procedure. The surgeon’s packaged payment includes preoperative visits after the decision for surgery is made beginning one day prior to surgery, and postoperative visits by the surgeon related to recovery from surgery, postoperative pain management, and discharge care.4 The surgeon is entitled to the full global payment if he provides the preoperative, intraoperative, and postoperative management.

If the surgeon relinquishes care and formally transfers the preoperative or postoperative management to another physician not associated with the surgical group, the other physician may bill for his portion of the perioperative management by appending modifier 56 (preop) or 55 (postop) to the procedure code. Unfortunately, the hospitalist is subject to the surgeon’s claim reporting. If the surgeon fails to solely report his intraoperative management (modifier 54 appended to the procedure code), the surgeon receives the full packaged payment. The payor will deny the hospitalist’s claim.

The payor is unlikely to retrieve money from one provider to pay another provider, unless a pattern of inappropriate claim submission is detected. Surgical intraoperative responsibilities are not typically reassigned to other provider groups unless special circumstances occur (e.g., geographical restrictions). Therefore, if the surgeon does not relinquish care but merely wants the hospitalist to assist in medical management, the hospitalist reports his medically necessary services with the appropriate inpatient visit code (subsequent hospital care, 99231-99233). TH

Carol Pohlig is a billing and coding expert with the University of Pennsylvania Medical Center, Philadelphia. She is on the faculty of SHM’s inpatient coding course.


1. Holmes A. Appropriate Use of Modifiers In: Coding for Chest Medicine 2009. Northbrook, Ill.: American College of Chest Physicians; 2008:273-282.

2. Centers for Medicare and Medicaid Services. Medicare claims processing manual. CMS Web site. Available at: Accessed Feb. 10, 2009.

3. Centers for Medicare and Medicaid Services. Medicare claims processing manual. CMS Web site. Available at: Accessed Feb. 10, 2009.

4. Pohlig, C. Sort out surgical cases. The Hospitalist. 2008;12(8):19.


Hand and Foot Modifier FA -F9 and T1 – T9, TH

E1 – E4,   FA – F9,  TA – T9 Level II Modifier

E1-E4 Anatomic modifiers which are associated with the eyelid

FA, F1- F9 Anatomic modifiers which are associated with the fingers

TA, T1- T9 Anatomic modifiers which are associated with the toes

Description :

E1   Upper left, eyelid
E2   Lower left, eyelid
E3   Upper right, eyelid
E4   Lower right, eyelid

FA  Left hand, thumb
F1  Left hand, second digit
F2  Left hand, third digit
F3  Left hand, fourth digit
F4  Left hand, fifth digit
F5  Right hand, thumb
F6  Right hand, second digit
F7  Right hand, third digit
F8  Right hand, fourth digit
F9  Right hand, fifth digit

FA Left hand, thumb

LC Left circumflex coronary artery

LD Left anterior descending coronary artery

LM Left main coronary artery

LT Left side

RC Right coronary artery

RI Ramus intermedius coronary artery

RT Right side

Feet Modifiers

ModifierModifier Description

TA  Left foot, great toe
T1   Left foot, second digit
T2   Left foot, third digit
T3   Left foot, fourth digit
T4   Left foot, fifth digit
T5   Right foot, great toe
T6   Right foot, second digit
T7   Right foot, third digit
T8   Right foot, fourth digit
T9   Right foot, fifth digit

Modifiers TA and T1-T9

When billing toe or toenail surgeries, Modifiers TA and T1-T9 are necessary to ensure services are processed and paid correctly.

HCPCS Level II toe Modifiers TA and T1-T9 are anatomical modifiers that describe procedures performed on the right and left foot digits. It is incorrect to additionally append Modifiers LT and/or RT. It is also incorrect to use modifier 59 and/or modifier 59 subset “X modifiers” (XE, XS, XP, XU).

Failure to use these modifiers appropriately may result in claims denial. Additionally, post audits will be performed and will result in recoupments if documentation reviewed supports unbundling by incorrect use of modifiers 59, XE, XS, XP, XU, LT and RT.

Required for Claims : Hospital Outpatient Prospective Payment System

Type of Bill :

Coding Guidelines : Generally applied to surgical (CPT 10000-69990) and other diagnostic services
(CPT 90281-99569)

General Guidelines :

*  Apply the appropriate modifiers for procedures involving eyelids, fingers and toes.  Use the most specific modifier available.

* If more than one level II modifier applies, repeat each line item with the appropriate level II modifiers

*  Do not use if CPT/HCPCS code indicates multiple occurrences.

*  Do not use if the code indicates the procedure applies to different body parts.

Patient comes to the hospital for drainage of an abscess on the fifth digit on the right hand.


26010 Drainage of finger abscess; simple (Use appropriate modifier to identify the fifth digit on the right hand)

Billing Guide to Avoid Medically unlikely Edit

some instances, it may be appropriate for a provider to report medically reasonable and necessary units of service in excess of a MUE value. Since each line of a claim is adjudicated separately against the MUE value for the code on that line, appropriate CPT modifiers should be used to report medically reasonable and necessary units of service in excess of an MUE value. CPT modifiers such as -76 (repeat procedure by same physician), -77 (repeat procedure by another physician), anatomic modifiers (e.g. RT, LT, F1, F2), -91 (repeat clinical diagnostic laboratory test), and -59 (distinct procedural service) will accomplish this purpose. Modifier -59 should be utilized only if no other modifier describes the service

The current NCCI-associated modifiers are: E1, E2, E3, E4, FA, F1, F2, F3, F4, F5, F6, F7, F8, F9, LC, LD, RC, LT, RT, TA, T1, T2, T3, T4, T5, T6, T7, T8, T9, 25, 27, 58, 59, 78, 79, and 91. Additional modifiers shall be added to the above list of NCCI-associated modifiers that will allow an edit with modifier indicator of “1” to be bypassed when the modifier is utilized correctly. These modifiers are LM (left main coronary artery), RI (ramus intermedius coronary artery), 24 (unrelated evaluation and management service by the same physician during a postoperative period), and 57 (decision for surgery).

*  Procedure codes that do not specify right or left require an anatomical modifier. If an anatomical modifier is necessary to differentiate right or left and is not appended, the claim will be denied.

* Likewise, if a modifier is appended to a procedure code that does not match the appropriate anatomical site, the claim will be denied.

* Please append the modifier in 24D of the CMS 1500 claim form, or electronically report the first modifier in SV101-3; use the additional fields SV101-4, SV101-5 or SV101-6 if needed for additional modifiers relevant to the procedure code on the service line.

Would the Maximum Frequency Day value for hand or foot bilateral procedures remain at “1” unit if it is possible to perform the procedure on multiple digits such as fingers or toes?

The MFD value would remain at 1 unit, however, HCPCS modifiers FA or F1-9 may be used to report specific fingers; TA or T1-9 may be used to report specific toes.

Modifier TH – Obstetrical treatment/services

Policy The Plan recognizes Modifier TH appended to a An Evaluation and Management (E&M) service to indicate the first, second or third routine antepartum visit when a p
rovider renders  less than the  number of antepartum visits designated in code  59425 – Antepartum care only; 4-6 visits or code  59426- Antepartum care only; 7 or more visits.

Modifier TH is appropriate  only  when added to an E&M code to represent three or less visits for routine antepartum care
Modifier TH should notbe billed on any post – partum E&M  visit code

Violations of Policy

Violations of this policy by any party that enters into a written arrangement with the  Plan may result in increased auditing and monitoring, performance guarantee contractual penalties and/or termination of the contract.   Disciplinary actions will be appropriate to the seriousness of the violation and shall be determined in Plan’s sole discretion.

Violations of this policy may be grounds for corrective action, up to and including  termination of employment.

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Effective May 1, 2019, Missouri Care will transition from allowing global billing to allowing only “per visit” billing for each obstetrical service. The “per visit” information will improve our ability to track and evaluate prenatal and postpartum care for our members.

Prenatal visits should be billed with the appropriate E&M code with modifier-TH. Postpartum visits within 21 to 56 days of delivery should be submitted using code 59430 with modifier-TH. Postpartum visits outside of the 21 to 56 day time period should be submitted using the appropriate E&M code or 59430 without the modifier.

Examples of codes that should be used to bill obstetrical services under the new guidelines are shown below:

Prenatal Care

99213-TH Use appropriate E&M code with –TH modifier (99213 is illustrative only)


59409 Vaginal Delivery Only
59514 C-Section Delivery Only
59612 VBAC – Vaginal Delivery after Previous Cesarean
59620C-Section Delivery Only after attempted VBAC
59622 C-Section following attempted Vaginal Delivery after prior C-Section

Global codes will be denied.

Postpartum Care

59430-TH Postpartum Care performed 21 to 56 days from delivery
99213 or Use appropriate E&M code (99213 is illustrative only) or 59430 without
59430 the TH modifier for postpartum care performed less than 21 or more than
56 days from delivery

If you have a Missouri Care patient that is currently receiving prenatal care and you intended to bill using a global or bundled code, please submit claims for any prenatal visits already provided with the appropriate coding outlined above. Any global or bundled codes with a date of service on or after May 1, 2019 will be denied.


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Th modifier

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