Hi Guest!
There is no standard modifier i am aware of for this combination of services. Modifiers are 2-character codes that you basically add on to procedure and equipment codes in medical billing, on the medical claim CMS1500 in field 24 D. Modifiers provide additional information regarding the service or equipment to the medical insurer. For example, a standard modifier to use when billing medical insurance for a custom made oral appliance for Obstructive Sleep Apnea (OSA)(HCPCS code E0486) is the modifier "NU", which stands for "new equipment".
You may consider using the JP qualifier to indicate the tooth number(s) being extracted.
The JO & JP qualifiers represent tooth numbers and areas of the oral cavity for medical claims.
The following are the codes for tooth numbers, reported with the JP qualifier:
• 1 –32: Permanent dentition
• 51 –82: Permanent supernumerary dentition
• A –T: Primary dentition
• AS –TS: Primary supernumerary dentition
The following are the codes for areas of the oral cavity, reported with the JO qualifier:
• 00 : Entire oral cavity
• 01 : Maxillary arch
• 02 : Mandibular arch
• 10 : Upper right quadrant
• 20 : Upper left quadrant
• 30 : Lower left quadrant
• 40: Lower right quadrant
Examples of how this would look on the medical claim can be found in the NUCC's CMS 1500 claim form manual here, starting on page 46 & 47:
http://www.nucc.org/images/stories/PDF/1500_claim_form_instruction_manual_2012_02-v5.pdfHope this helps!