H 1 cpt hcpcs lev ii mods-101511
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H 1 cpt hcpcs lev ii mods-101511 H 1 cpt hcpcs lev ii mods-101511 Document Transcript

  • PAYMENT POLICIES CPT and HCPCS Level II Modifiers1 For details on First Seniority Freedom, see the Product Portfolio section of this Provider Manual.Definition A Modifier provides the means by which the reporting physician/service can indicate that a service or procedure that has been performed has a specific circumstance but not changed in its definition or code. The use of modifiers eliminates the need for separate procedure listing that may describe the modifying circumstance. A modifier may be used to indi- cate whether: • A service or procedure has a professional component • A service or procedure has a technical component • A service or procedure was performed by more than one physician and/or in more than one location • Only part of a service was performed • A bilateral procedure was performed • A service or procedure was provided more than once • Unusual events occurred • A service or procedure was performed on a specific site • An add-on or additional service was performed The presence or absence of one of the following modifiers may affect claims payment or result in a claim denial. For a complete list of modifiers, refer to your CPT and HCPCS coding guideline manuals.Multiple Modifiers Harvard Pilgrim accepts up to two modifiers per line. Use of modifier will impact reimbursement when submitted as the primary or secondary modifier. For claim lines submitted with more than two modifiers, only the primary and secondary modifiers will be accepted. Harvard Pilgrim will not reject claims submitted with three or more modifiers.CPT Modifiers Modifier Description Reimbursement Impact • For claims processed as of 01/01/2012 antepartum E&M vis- its due to pregnancy complications that exceed the typical care (14 visits) will be given individual consideration when modifier is appended to the global obstetrical codes (CPT 22 Unusual procedural services codes 59400, 59510, 59610 or 59618) and supported by the medical documentation. • For other services after appropriate use of modifier is vali- dated, 120% of the fee schedule/allowable amount 23 Unusual anesthesia Modifier use will not impact reimbursement After appropriate use of modifier is validated, 100% of the Unrelated evaluation and management service by the fee schedule/allowable amount; E&M services billed with 24 same physician during a postoperative period modifier 24 when the diagnosis code is related to the surgi- cal service will be denied • Same day preventive & sick E&M: Lower valued E/M service reimbursed at 50% of the fee schedule/allowable amount • Effective 01/01/2011—Same day E&M and any service that 25 Significant, separately identifiable E&M service by the has a global period indicator as designated by CMS of 0, same physician on the same day of the procedure or 10, 90 or YYY. E&M reimbursed at 50% of the fee sched- service ule/allowable amount • Other separately identifiable E&M service, modifier use will not impact reimbursement Modifier is used for procedures subject to 26 modifier as 26 Professional component defined by CMS. Based on fee schedule/allowable amount Multiple outpatient hospital E&M encounters on the 27 same date Modifier use will not impact reimbursement 32 Mandated services (continued)Harvard Pilgrim Health Care—Provider Manual H.61 October 2011
  • PAYMENT POLICIES CPT and HCPCS Level II Modifiers (cont.) Modifier Description Reimbursement Impact No additional reimbursement is allowed for anesthesia by a 47 Anesthesia by surgeons surgeon, assistant surgeon, nursing staff or any other non- anesthesiologist professional during a procedure 50 Bilateral procedure (see Bilateral Services Policy) 150% of the fee schedule/allowable Primary procedure is reimbursed at 100% of the fee sched- 51 Multiple procedures ule/allowable, subsequent procedures reimbursed at 50% of the fee schedule/allowable amount Effective 01/01/2010—50% of the fee schedule/allowable 52 Reduced services amount 53 Discontinued procedure Effective 04/01/2010—25% of the fee schedule/allowable amount 54 Surgical care only 80% of the fee schedule/allowable amount 55 Postoperative management only 10% of the fee schedule/allowable amount 56 Preoperative management only 57 Decision for surgery Staged or related procedure or service by the same phy- Modifier use will not impact reimbursement 58 sician during postoperative period After appropriate use of modifier is validated, 100% of the fee schedule/allowable amount; claims submitted with operative/medical notes will be reviewed to determine whether procedure code is distinct or independent from 59 Distinct procedural service other services: - First time claim submissions can be submitted on paper with operative notes for consideration - Denied claims may be appealed with operative notes for consideration 62 Two surgeons 62.5% of the fee schedule/allowable amount 63 Procedure performed on infants less than 4 kg. Modifier use will not impact reimbursement Harvard Pilgrim will make a determination regarding reim- 66 Surgical team bursement after individual consideration and review of operative notes Discontinued outpatient procedure prior to 73 50% of the fee schedule/allowable amount anesthesia administration Discontinued outpatient procedure after 74 70% of the fee schedule/allowable amount anesthesia administration 76 Repeat procedure by same physician Modifier use will not impact reimbursement 77 Repeat procedure by another physician Return to the operating room for a related procedure 78 80% of the fee schedule/allowable amount during the postoperative period Unrelated procedures or service by the same 79 Modifier use will not impact reimbursement physician during the postoperative period 80 Assistant surgeon 81 Minimum assistant surgeon 16% of the fee schedule/allowable amount Assistant surgeon (when qualified resident 82 surgeon not available) 90 Reference (outside) laboratory Modifier use will not impact reimbursement 91 Repeat clinical diagnostic laboratory test Physician assistant, nurse practitioner or clinical nurse AS 16% of the fee schedule/allowable amount specialist services for assistant at surgery TC Technical component For procedures subject to TC modifier as defined by CMS (continued)Harvard Pilgrim Health Care—Provider Manual H.62 October 2011
  • PAYMENT POLICIES CPT and HCPCS Level II Modifiers (cont.)Common Modifiers for Anesthesia Claims Modifier Description Reimbursement Impact AA Anesthesia services performed personally by anesthesiologist 100% of Harvard Pilgrim anesthesia rate AD Medical supervision by a physician; more than four concurrent 100% of Harvard Pilgrim anesthesia rate (three anesthesia procedures base units) QZ CRNA service: without medical direction by a physician 100% of Harvard Pilgrim anesthesia rate QY Medical direction of one certified registered nurse Anesthetist 50% of Harvard Pilgrim anesthesia rate by an anesthesiologist Medical direction of two, three or four concurrent anesthesia QK procedures involving qualified individuals 50% of Harvard Pilgrim anesthesia rate QX CRNA service: with medical direction by a physician Monitored anesthesia care (MAC) provided by an Modifier use will not impact fee schedule QS anesthesiologist reimbursement P1–P6 Anesthesia Physical Status Modifiers No reimbursement is allowedHCPCS Modifiers The following modifiers are helpful when multiple surgical procedures are performed on different anatomical sites dur- ing the same operative session: Modifier Modifier Description Common Site-Specific Modifiers E1–E4 Eyelids FA–F9 Finger TA–T9 Toes RT Right LT Left LD, RC Coronary vessels Common DME Modifiers RT Right LT Left MS Maintenance and service fee NU Purchased new equipment RR Rental use Common Early Intervention Modifiers AH Clinical psychologist AJ Clinical social worker GN Outpatient speech language GO Outpatient occupational therapy GP Outpatient physical therapy HN Bachelor’s degree level TD Registered nurse (RN) TE Licensed practical nurse (LPN) TJ Program group child U1 Medicaid level of care 1 (defined by each state) U2 Medicaid level of care 2 (defined by each state) (continued)Harvard Pilgrim Health Care—Provider Manual H.63 October 2011
  • PAYMENT POLICIES CPT and HCPCS Level II Modifiers (cont.) Modifier Modifier Description Common Ambulance Modifiers GM Multiple patients on one trip QM Ambulance service provided under arrangement by a provider of services QN Ambulance service furnished directly by a provider of services E Residential, domiciliary, custodial facility Diagnostic or therapeutic site other than P or H, when these are used as D origin codes G Hospital based dialysis facility (hospital or hospital related) H Hospital I Site of transfer (e.g., airport or helicopter pad) J Non-hospital based dialysis facility N Skilled nursing facility P Physician’s office R Residence S Scene of accident or acute event Destination code only—intermediate stop at physician’s office on the X way to the hospital Physical and Occupational Therapy GP Services delivered under an outpatient physical therapy plan of care Modifiers GO Services delivered under an outpatient occupational therapy plan of care SL State-supplied vaccine Other Miscellaneous Modifiers Services performed in part by a resident under the direction of a teach- GC ing physician. Services are not reimbursable to a residentRelated Policies • Ambulance Payment Policy • Obstetrical/Maternity Care Payment Policy • Bilateral Services and CPT Modifier 50 Payment Policy • Physical, Occupational, and Speech Therapy • Durable Medical Equipment (DME) Payment Policy • Radiology Payment Policy • Early Intervention Payment Policy • Surgery Payment Policy • Evaluation and Management Payment PolicyPUBLICATION HISTORY 07/01/04 original documentation 07/01/05 policy update to modifiers 24 and 59 07/31/07 annual review 01/31/08 annual review; added multiple modifier information 07/31/08 policy update to bilateral procedure 01/31/09 annual coding update; removed mod 21 03/15/09 update to modifiers 78, 80, 81, 82, and AS 05/15/09 annual review: HCPC modifier tables updated, minor edit to modifier 59; added “Related Policies” 10/15/09 update to modifier 52 01/15/10 update to modifier 53, clarification of reimbursement impact for claims submitted with multiple modifiers 06/15/10 annual review; no changes 10/15/10 modifier 25 update–E&M’s with surgery/diagnostic procedure 11/15/10 modifier 25 minor edits for clarity 04/15/11 minor edits for clarity 06/15/11 annual review; added GO/GP modifiers 10/15/11 policy update to modifier 22, antepartum E&M visits due to complications will be given individual consideration; added Obstetrical/ Maternity Care to related policies1This policy is in reference to HPHC, HPHC-NE, and HPHC Ins. Co. products for services performed by contracted providers. Payment is based on memberbenefits and eligibility, medical necessity review, where applicable, and HPHC provider contractual agreement. Payment for covered services rendered bycontracted providers will be reimbursed at the lesser of charges or the contracted rate. (Does not apply to inpatient per diem, DRG, or case rates.) HPHCreserves the right to amend a payment policy at its discretion. CPT and HCPCS codes are updated annually. Always use the most recent CPT and HCPCScoding guidelines.Harvard Pilgrim Health Care—Provider Manual H.64 October 2011