A medical assistant is reviewing a superbill for a patient who had a routine office visit. During the visit, the physician also performed a distinct, minor surgical procedure on the patient's left arm. To ensure both the office visit and the surgical procedure are billed correctly to the insurance payer without being improperly denied, what should be appended to the CPT code for the surgical procedure?
Modifiers are two-character codes appended to a CPT or HCPCS code to provide additional information about a service without changing the code's definition. In this scenario, a modifier is necessary to indicate that a significant, separately identifiable service was performed on the same day as another service by the same physician. Upcoding is the illegal practice of billing for a higher-level service than what was provided. Bundling and unbundling refer to the grouping or separating of services under codes, not an element appended to a code.
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