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Modifiers 1
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Modifiers 1

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  • Does any one know which is the correct modifier to be used for the code 11721 when the code used with in 60 days.

    Ashok
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  • To understand and know extensively about coding for Anesthesia services, visit the URL http://www.correctcodechek.com/reader/article_body/52664. You can also download the document from the URL http://www.slideshare.net/karna.indian/anesthesia-services
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  • Hi,

    Modifier AQ is used to indicate services provided in a Health Professional Shortage Area (HPSA). For more detailed info on HPSA and AQ modifier, please visit the CMS link http://www.cms.hhs.gov/hpsapsaphysicianbonuses/.

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    Karna
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  • 1. Modifiers for Medicare Billing For Medicare purposes, modifiers are two-digit codes appended to procedurecodes, to provide additional information about the billed procedure. In some cases, addition of a modifier may directly affect payment. Below is a list of modifiers including the modifier description. AMBULANCE CLAIM MODIFIERS Modifiers that are used on claims for ambulance services are created by combining two alpha characters. Each alpha character, with the exception of X, represents an origin (source) code or a destination code. The pair of alpha codes creates one modifier. The first position alpha code = origin; the second position alpha code = destination. Origin and destination codes and their descriptions are listed below: D Diagnostic or therapeutic site other than quot;Pquot; or quot;Hquot; when these are used as origin codes E Residential, domiciliary, custodial facility, nursing home G Hospital based dialysis facility (hospital or hospital related) H Hospital I Site of transfer (e.g., airport or helicopter pad) between modes of ambulance transport J Non-hospital based dialysis facility N Skilled nursing facility (SNF) (Medicare certified beds) P Physician’s office (includes HMO non-hospital facility, clinic, etc.) R Residence S Scene of accident or acute event X (Destination code only) Intermediate stop at physician’s office en route to the hospital (includes HMO non-hospital facility, clinic, etc.) QL Patient Pronounced dead after ambulance called The following modifiers are valid for Medicare; however, the services would be denied under Medicare Part B as a Part A expense. QM Ambulance service provided under arrangement by hospital QN Ambulance service furnished directly by hospital 1
  • 2. Billing indicators, listed below, can be used to further clarify the services provided. These billing indicators may be used as additional modifiers. 1A Bedridden 2A Accidental injury home/nursing home 3A Accidental injury car 4A Patient in shock 5A Oxygen used and/or heart monitor used 6A Transported by stretcher 7A Fracture to hip, leg, knee, trunk (same day as ambulance trip) 8A Hospital lacks facility (patient admitted to second hospital) 9A Rectal bleeding 1B Myocardial infarction 2B Possible cerebral vascular accident (CVA) 3B Black out, passed out 4B Laceration of head 5B Dead on Arrival (DOA) at hospital 6B Died in route to hospital 7B Unresponsive or coma 8B Quadriplegia 9B Stroke (same day as ambulance trip) 1C Paralysis 2C Mentally retarded 2
  • 3. ANCILLARY PERSONNEL MODIFIERS AH Clinical Psychologist (CP) AJ Clinical Social Worker (CSW) AK Nurse Practitioner, rural, team member AL Nurse Practitioner, non-rural, team member AM Physician, team member service AN Physician Assistant (PA) services, for other than assistant-at-surgery, non-team member AS PA, Nurse Practitioner, or Clinical Nurse Specialist services forassistant-at-surgery AU PA services, other than assistant-at-surgery, team member AV Nurse Practitioner, rural, non-team member AW Clinical Nurse Specialist, non-team member AY Clinical Nurse Specialist, team member GN Service delivered personally by a speech-language pathologist or under an outpatient speech-language pathology plan of care GO Service delivered personally by an occupational therapist or under an outpatient occuptional therapy plan of care GP Service delivered personally by a physical therapist or under an outpatient physical therapy plan of care GT Via interactive audio and video telecommunication systems GX Service not covered by Medicare ANESTHESIA (A.S.A.) CODE MODIFIERS AA Anesthesia services personally performed by anesthesiologist AD Medical supervision by a physician: More than 4 concurrent anesthesia procedures AE Direction of residents in furnishing not more than two concurrent anesthesia services - attending physician relationship met QK Medical direction of 2, 3, or 4 concurrent anesthesia procedures involving qualified individuals QS Monitored anesthesia care QX CRNA service with medical direction by physician QY Medical direction of one concurrent anesthesia procedure involving qualified individuals QZ CRNA service without medical direction by a physician 23 Unusual anesthesia - Used to report a procedure which usually requires either no anesthesia or local anesthesia; however, because of unusual circumstances must be done under general anesthesia 47 Anesthesia by surgeon - Used to report regional or general anesthesia provided by the surgeon (not for local anesthesia) 3
  • 4. AMBULATORY SURGICAL CENTER MODIFIERS 73 Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure prior to the administration of anesthesia 74 Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure after administration of anesthesia SG Ambulatory Surgical Center (ASC) Facility service DIAGNOSTIC PROCEDURES/PATHOLOGY MODIFIERS 26 Professional component only - Use to indicate that the physician component is reported separately from the technical component for the diagnostic procedure performed 90 Reference Lab - Used to indicate a lab test sent to an outside lab. e.g., lab procedure performed by a party other than the treating or reporting laboratory. NOTE: Outside lab name, address and UPIN must be included on the claim. Section 20 must be marked quot;yesquot; and your actual cost foreach test, net any discounts, must be included in the charges section. GH Diagnostic mammogram converted from screening mammogram on the same day. QP Documentation is on file showing that the laboratory test(s) was ordered individually or ordered as a CPT recognized panel other than automated profile codes QR Repeat clinical diagnostic laboratory test performed on the same day to obtain subsequent reportable test value(s) (separate specimens taken in separate encounters) QW CLIA waived test TC Technical component only - Used to indicate that the technical component is reported separately from the professional component for the diagnostic procedure performed EVALUATION/MANAGEMENT CODE MODIFIERS 21 Prolonged evaluation and management services - Use only with highest level of care code for the category when the face-to-face or floor/unit service provided is prolonged or otherwise greater than 4
  • 5. that usually required for the highest level code. 24 Unrelated E/M service during a post-op period - Use with E/M codes only to indicate that the E/M performed during a postoperative period for a reason(s) unrelated to the orig inal procedure. Modifier 24 applies to unrelated E/M services for either a MAJOR or MINOR surgical procedure. - Failure to use modifier when appropriate may result in denial of the E/M service 25 Separately identifiable service on same day as procedure - Use with E/M codes only to indicate that the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual pre- and postoperative care for the procedure performed - Failure to use modifier when appropriate may result in denial of the E/M service 57 Decision for surgery - Use with E/M codes billed by the surgeon to indicate that the E/M service resulted in the decision for surgery (E/M visit was NOT usual pre-operative care). For E/M visits prior to MAJOR surgery (90 day post-op period) only. - Failure to use modifier when appropriate may result in denial of the E/M service 5
  • 6. SURGICAL PROCEDURE MODIFIERS LC Left circumflex coronary artery LD Left anterior descending coronary artery LS FDA monitored Intraocular Lens Implant LT Left side - Used to identify procedures performed on the left side of the body RC Right Coronary Artery RT Right side - Used to identify procedures performed on the right side of the body 22 Unusual procedural services - Used only on surgery codes. An operative note should be submitted with the claim 50 Bilateral procedure - Used to indicate bilateral procedures performed during the same operative session. The code with modifier 50 should be billed only once on the claim. 51 Multiple procedures - not required for billing purposes. The carrier will assign the multiple procedure modifier as appropriate based on the services billed. 52 Reduced Services - Use for reporting services that were partially reduced or eliminated at the physician’s election. Documentation should be furnished explaining the reduction. 53 Terminated procedure without complications- for procedures terminated in respect to the patien ts condition 54 Surgical care only - Use with surgical codes when only the surgical service was performed (another physician is responsible for the pre- and/or postoperative management). 55 Post-operative care only - Use with surgical codes to indicate that only the post-operative care is performed (another physician performed the surgery) 56 Pre-operative care only - DO NOT USE FOR MEDICARE PURPOSES - Payment for this component is included in the allowable for surgery. If another physician performed the surgery, use an appropriate E/M code to bill the pre-op service. 58 Staged or related procedure or service during the postoperative period - This modifier should be used to permit payment for a surgical procedure during the postoperative period of another surgical procedure when (1) the subsequent procedure was planned prospectively at the time of the original procedure, (2) a less extensive procedure fails and a more extensive procedure is required or (3) a therapeutic surgical procedure follows a diagnostic procedure; e.g., a mastectomy follows a breast biopsy. - Failure to use modifier when appropriate may result in denial of subsequent surgery 59 Distinct Procedural Service - Use under certain circumstances where the physician may need to indicate that a procedure is distinct or independent from others services performed on the same day, same provider and are not normally reported together but are appropriate under the circumstances. 62 Two surgeons - When more than one surgeon performeda procedure, the modifier should be used by each surgeon to report his/her services. 66 Surgical team - The modifier should be used by each participating surgeon to report his services. 76 Repeat procedure by same physician -same day 6
  • 7. 77 Repeat procedure - same day, different physician 78 Return to the operating room for a related procedure during the postoperative period - Use on surgical codes only. - Failure to use modifier when appropriate may result in denial of the subsequent surgery 79 Return to the operating room for an unrelated procedure during the postoperative period - Use on surgical codes only. 80 Assistant surgeon 81 Minimum assistant surgeon 82 Assistant surgeon (when qualified resident surgeon not available) 7
  • 8. SURGICAL PROCEDURE EXPANDED MODIFIERS: HANDS - FEET - EYELIDS The following modifiers should be used in conjunction with procedures of the hands, feet and eyelids. The modifiers will not effect payment; however, failure to use these modifiers when appropriate could result in claim delay or denial. E1 Upper left, eyelid E3 Upper right, eyelid E2 Lower left, eyelid E4 Lower right, eyelid FA Left hand, thumb F5 Right hand, thumb F1 Left hand, second digit F6 Right hand, second digit F2 Left hand, third digit F7 Right hand, third digit F3 Left hand, fourth digit F8 Right hand, fourth digit F4 Left hand, fifth digit F9 Right hand, fifth digit TA Left foot, great toe T5 Right foot, great toe T1 Left foot, second digit T6 Right foot, second digit T2 Left foot, third digit T7 Right foot, third digit T3 Left foot, fourth digit T8 Right foot, fourth digit T4 Left foot, fifth digit T9 Right foot, fifth digit OTHER MODIFIERS FOR MEDICARE CLAIMS AT Acute treatment - this modifier should be used when reporting service A2000 foracute treatment CC Procedural code change - carrier use only. Used by carrier to indicate that the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed. The remittance statement will indicate the quot;submittedquot; code as well as the quot;newquot; code used by the carrier. EJ Subsequent claim for Epoetin Alfa-EPO- injection claim only EM Emergency reserve supply (for ESRD benefit only) ET Emergency treatment - Use to designate a dental procedure performed in an emergency situation GA Waiver of Liability statement on file - Use to indicate that the physician’s office has a signed advance notice retained in the patient’s medical record. The notice is for services that may be denied by Medicare - No effect on payment; however, potential liability determinations are based in part on the use of the modifier LR Laboratory Round Trip QA Investigational device or related procedure QB Physician service in a rural HPSA QC Single channel monitoring QD Recording and storage in sol d state memory by digital recorder i QT Recording and storage on tapeby an analog tape recorder 8
  • 9. QU Physician service in an urban HPSA Q3 Live Kidney Donor - Use for services associated with postoperative medical complications directly related to the donation Q4 Service for ordering/referring physician qualifies as a service exemption Q5 Service furnished by a substitute physician under a reciprocal billing arrangement Q6 Service furnished by a locum tenens physician 99 Multiple modifiers - Use only when more than two modifiers are needed to describe a service. File hard copy. - No effect on payment; however, the individual modifiers listed will apply, including any potential effect they may have on payment. ZX DMERC modifier to identify insulin-dependent beneficiary LOCALLY ASSIGNED MODIFIERS U2 Additional documentation attached U3 Prorated dialysis Monthly Capitation Payment (MCP) due to hospital admission U4 Prorated dialysis Monthly Capitation Payment (MCP) due to transient or temporary patient U5 Prorated dialysis Monthly Capitation Payment (MCP) due to patient death U6 Laparoscopic laser technique V2 Self dialysis training - complete V3 Self dialysis training - incomplete V4 Self dialysis training - subsequent V5 Patient controlled analgesia V6 Rechargeable batteries V7 Reusable electrodes WA Non-routine care for the sole purpose of determining the need/type of hearing aid WC Irreversible condition WD This procedure does not include photo plethysmographic or pulse digit wave form analysis WE Anesthesia Standby WH Special billing indicator: quot;I accept assignment on clinical lab procedurequot; WJ Procedure code related to routine foot care XF Radiation therapy final treatment, when 1 or 2 factions are left after multiples of 5 factions have been billed XT Radiation therapy services when the total treatment consists of 1 or 2 factions Y2 First repeat procedure, same date, same provider Y3 Second repeat procedure, same date, same provider Y4 Third repeat procedure, same date, same provider 9
  • 10. Y5 Fourth repeat procedure, same date, same provider Y6 Fifth repeat procedure, same date, same provider Y7 Sixth repeat procedure, same date, same provider Y8 Seventh repeat procedure, same date, same provider Y9 Eighth repeat procedure, same date, same provider Z2 Ninth repeat procedure, same date, same provider Z3 Tenth repeat procedure, same date, same provider Z5 No purchased diagnostic services on this claim Z6 Pre-anesthesia services up to and including induction when personally furnished by the physician. Payment is based on 3 units and 1 time unit. MODIFIERS FOR PET (POSITRON EMISSION TOMOGRAPHY) SCAN CODES Note: In addition to the standard modifiers ind icating whether the claim is for the professional component only or the technical component, a two-digit modifier should be used to indicate the results of the PET scan and the previous test. The modifier is not required for the technical component - only billings to the intermediary. The first alpha character is used to indicate the results of the PET scan while the second alpha character indicates the results of the prior test. The test result modifiers and their descriptions are listed below: N Negative E Equivocal P Positive, but not suggestive of extensive ischemia S Positive and suggestive of extensive ischemia (greater than 20% of the left ventricle) PODIATRY BILLING INDICATORS Billing indicators, listed below, can be used to further clarify the services provided. These billing indicators should be used as additional modifiers. Q7 One Class A finding Q8 Two Class A findings Q9 One Class B and two Class C findings 4P One Class D finding. This condition requires a referring physician 5P Documented mycosis of toenai l 10

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