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The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
The In's and Out's of Coding with Modifiers
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The In's and Out's of Coding with Modifiers

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Presentation of proper coding and usage of modifiers (Level I and Level II) …

Presentation of proper coding and usage of modifiers (Level I and Level II)

Have trouble knowing what modifier to use and how use will impact your claim? Take a look at the presentation "The In's and Out's of Coding with Modifiers", which explain modifiers for you! Hope you enjoy!

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  • 1. The ‘In’s and Out’s of Coding with ModifiersThe Key to Proper Reimbursement<br />Tara Ritter, CPC, CPC-H, CPC-I<br />Approved PMCC Instructor<br />Owner of A+ Coding Institute<br />(678) 684-8855<br />www.apluscodinginstitute.com<br />apluscodinginstitute@gmail.com<br />
  • 2. Today’s Agenda<br /> What are modifiers?<br /> Why are they used?<br />Modifier Categories<br /> Is your practice compliant?<br />
  • 3. What are Modifiers?<br />
  • 4. What are modifiers?<br />Modifiers are two digit codes appended to a CPT code that indicate that a service or procedure has been altered by a specific circumstance, but has not changed in its basic definition<br />
  • 5. Three Levels of HCPCS Codes and Modifiers(Healthcare Common Procedural Coding System) <br />Level 1 - CPT, Physician’s Current Procedural Terminology (Live in the CPT Manual)<br />Level 2 - HCPCS National Codes (Live in the HCPCS Manual)<br />Level 3 - Local Codes assigned and maintained by individual state Medicare Carriers<br />Eliminated by HIPAA as of Dec 31, 2003<br />
  • 6. Modifiers denote that…<br />A service or procedure has both a professional and technical components<br />A service or procedure was performed by more than one physician<br />A service or procedure has been increased or reduced<br />Only part of a service was performed<br />A service or procedure was provided more than once<br />A bilateral procedure was performed<br />Unusual events occurred<br />
  • 7. Examples:<br /> 31237-50 (procedure done bilaterally)<br /> 99214-25 (office visit and procedure on same day)<br /> 33208-62 (two surgeons of differing specialties doing same procedure together)<br />
  • 8. Why Do We Use Them?<br />
  • 9. Modifiers are used for a variety of reasons, including:<br /> Claims can be incomplete or inaccurate without a modifier<br /> Coding to the highest level of specificity requires modifier use<br /> Appropriate use of modifiers get services reimbursed that might otherwise be denied<br />Allows for proper reimbursement (increased or decreased) based on the procedure/service circumstances<br />…and to avoid hearing your physicians say….<br />Why Do We Use Them?<br />
  • 10. Why aren’t my claims getting paid?<br />
  • 11. Modifier Categories<br />When decisions are not based on information, it’s called gambling!<br />
  • 12. MODIFIER CATEGORIES<br /> Global Package Modifiers<br /> CCI or Bundling Modifiers<br /> Evaluation and Management Only Modifiers<br /> Number of Surgeon Modifiers<br /> “Other” Modifiers<br />
  • 13. Global Surgery Modifiers<br />
  • 14. What is the “Global” Period?<br />Also known as the global surgical package<br />CMS and AMA have the same definition<br />Per CPT Guidelines, the following services are always included in addition to the operation per se:<br />local or topical anesthesia<br />subsequent to the decision for surgery, one related E/M encounter on the date immediately prior to or on the date of procedure (including history and physical)<br />immediate postoperative care<br />writing orders<br />evaluating the patient in the post-anesthesia recovery area<br />typical postoperative follow-up care<br />
  • 15. Examples of Services Included in the Global Period<br />Removal of staples 10 days after a surgical procedure<br />A visit with a patient prior to surgery to answer any last minute questions<br />A post-operative visit in the office to check on wound healing<br />
  • 16. Services NOT Included in Global Package:<br />Initial consultation or evaluation by the surgeon to determine the need for surgery<br />Services of other physicians unless a transfer of care has been arranged<br />Visits unrelated to patient’s surgical diagnosis<br />Treatment for the underlying condition or an added course of treatment that is not part of normal recovery from surgery<br />
  • 17. Services NOT Included in Global Package:<br />Diagnostic tests and procedures<br />Staged or clearly distinct surgical procedures during the post-op period<br />Treatment for post-op complications requiring a return to the OR<br />A more extensive procedure when a less extensive procedure fails<br />
  • 18. Services NOT Included in Global Package:<br />Supplies, such a surgical trays, splints and casting materials when certain surgical services are performed in the physician’s office<br />Immunosuppresive therapy for organ transplants<br />Critical Care services unrelated to the surgery for a critically injured patient<br />Pre-op evaluations outside of the global surgical period<br />Without a modifier, these service will not get paid!!!!!!!<br />
  • 19. &quot;Let&apos;s hope there‘re no post-op problems-it complicates the billing.&quot; <br />
  • 20. Modifier -24 Unrelated E/M Service by Same Physician During a Postoperative PeriodAppend to E&amp;M Code Only<br />Used when a physician provides a surgical service related to one problem and then during the postoperative period provides an E&amp;M service unrelated to the problem requiring the surgery <br />Diagnosis code selection is critical to indicate the reason for the additional E&amp;M service.<br />Modifier Category: E/M Only and Global Package <br />
  • 21. Modifier -24<br />Example: Patient came in for post-operative visit. He is 12 weeks s/p diskectomy. During the exam, pt c/o severe headaches with visual changes, preceded by an aura. The physician performs an expanded problem focused exam. His impression is migraine with medical decision making of low complexity.<br /> Report: <br /> CPT Code 99213 [24] Level 3, established patient office visit<br />
  • 22. Clinical Examples for Modifier -24<br />Appropriate Use:<br />Patient 80 - days s/p TURP. Reports to the office of the surgeon who performed the procedure complaining of right flank pain and abdominal pain. Diagnostic work-up reveals a kidney stone.<br />Report 992XX-24 with diagnosis code for the kidney stone<br />Inappropriate Use:<br />Patient returns for complaining of fever and wound tenderness in the global period of her C-Section<br />Report 99024 post-op visit<br />
  • 23. Modifier -25Significant, Separately Identifiable E/M by the Same Physician on the Same Day of the Procedure or Other ServiceAppend to E&amp;M Code Only<br />Indicates that on the day of a procedure or other service, the patients condition required an additional E&amp;M service above and beyond the usual pre and post-op care associated with the procedure performed.<br />E&amp;M Service elements must be clearly documented to justify that a visit took place beyond the elements necessary to perform the procedure<br />Modifier Category: E/M Only, Global Package and CCI <br />
  • 24. Modifier -25<br />EXAMPLE: <br />An established patient is seen by the physician to evaluate his general osteoarthritis, benign HTN and NIDDM. While examining the patient, the physician determines that an arthrocentesis of the patient’s knee joint needs to be performed.<br />REPORT: <br />CPT Codes 9921X-25 &amp; 20610<br />
  • 25. Clinical Example for Modifier -25<br />Appropriate Use:<br />Procedure: Excision, rt. arm lesion<br />Visit- Established Pt concerned about changes to a lesion on right arm. History taken, examination of arm and additional body areas for new and suspicious lesions performed. Physician decides to remove lesion. <br />Inappropriate Use:<br />Patient presents for scheduled removal of lesion on right arm. Exam of arm to determine status of lesion performed and a general determination of the patient’s status prior to excision.<br />
  • 26. Modifier -26Professional ComponentAppend to procedure code<br />Certain procedures are a combination of a physician component and a technical component. When physician component is reported separately, add -26 to the CPT code to identify that the physician’s component only is being billed.<br />EXAMPLE: A 72 year old woman comes to the Emergency Room complaining of chest discomfort. The physician orders a complete 2D echocardiography using the hospital equipment. The physician provides the written interpretation.<br />REPORT: CPT Codes: 93307-26<br />Modifier Category: Global Package <br />
  • 27. Modifier -26<br />For use by physicians when utilizing equipment owned by a hospital/facility<br />Interpretations must be separate, distinct, written and signed<br />Not all procedures have a professional/technical split!<br />Refer to Medicare Fee Schedule to determine what procedures are eligible for this modifier<br />Common Services billed with -26:<br />Radiology, Stress Tests, Heart Catheterizations<br />
  • 28. Modifier -54Surgical Care OnlyAppend to Procedure Code<br />Physician service to the patient was only the intra-operative procedure. The physician is paid a portion of the global package. Another physician(s) will perform the Pre-operative and Post operative care<br />There should be an agreement for the transfer of care between physicians<br />Do not use with procedure codes having a zero day global period<br />Do not use -54 if physician is a covering physician (locum tenens) or part of the same group as the surgeon who performed the procedure<br />Modifiers 54 should only be appended to the surgical procedure codes <br />Procedure codes with modifier 54 will be paid a percentage of the allowable charge. The percentage paid is variable and based on the Medicate Physician Fee Schedule<br />See Intra-op column, by CPT code, for the percentage of the allowed amount to expect for reimbursement<br />Modifier Category: Global Package <br />
  • 29. Modifier -55Post Operative Management OnlyAppend to Surgical Procedure Code<br />Modifier 55 is reported when one physician performed the postoperative management only; another physician performed the surgical procedure. Modifier 55 is appended to the surgical code. The physician is paid a portion of the global package<br />Modifiers 55 should only be appended to the surgical procedure codes <br />Procedure codes with modifier 55 will be paid a percentage of the allowable charge. The percentage paid is variable and based on the Medicate Physician Fee Schedule<br />See Post-op column, by CPT code, for the percentage of the allowed amount to expect for reimbursement<br />Modifier Category: Global Package <br />
  • 30. Modifier -56 Pre Operative Management OnlyAppend to Surgical Procedure Code<br />Modifier 56 is reported when one physician performed the preoperative care and evaluation and another physician performed the surgical procedure. Modifier 56 is appended to the surgical code. The physician is paid a portion of the global package<br />Modifiers 56 should only be appended to the surgical procedure codes <br />Procedure codes with modifier 56 will be paid a percentage of the allowable charge. The percentage paid is variable and based on the Medicate Physician Fee Schedule<br />See Pre-op column, by CPT code, for the percentage of the allowed amount to expect for reimbursement<br />Modifier Category: Global Package <br />
  • 31. Split Surgical Care Clinical Examples<br />-54 Surgical Care Only<br />A neurosurgeon travels to a rural location to perform a craniotomy for drainage of an intracranial abscess. He assessed the patient the day before surgery, and performed the procedure. Follow-up care was performed by a local surgeon.<br />The neurosurgeon would report 61321-54<br />-55 Pre Operative Care Only<br />Pre operative evaluation was performed and decision was made to have the intra-operative procedure and post operative care done else where.<br />Internist does pre-op work-up on a patient having a laporoscopic cholecystectomy by a general surgeon who travels to the area monthly. Internist would bill 47562-56<br />-56 Post Operative Care Only<br />While on vacation in Vail, Anna had a skiing accident. A local Orthopedist in Vail did the Pre operative and Intra-operative procedure and the patient went home. NYU physician provides all post-op care, and bills by adding a -55 to the surgical procedure code.<br />
  • 32. MODIFIER -57DECISION FOR SURGERYAppend to E/M Code Only<br />The purpose of this modifier is to report an E/M service on the day before or on the day of major surgery (90 day global period) which results in the initial decision to perform the surgery. NOTE: For minor surgical procedures, see -25 vs. -57<br />Modifier 57 is appended to the appropriate level of E/M CPT code<br />Modifier 57 should not be appended to any code other than an E/M code<br />Without using this modifier on the E/M code the E/M will be denied as “included in the Global period of the surgical procedure <br />EXAMPLE: Patient comes to the emergency department with sudden onset of acute abdominal pain. Gyn physician evaluates patient &amp; determines that patient has twisted ovarian cyst. Physician admits patient to OR for right salpingo-oophorectomy.<br />REPORT: CPT Code 99223-57 &amp; 58720<br />Modifier Category: E/M Only and Global Package <br />
  • 33. Modifier -58Staged or Related Procedure by the Same Physician during the Postoperative PeriodAppend to Surgical Procedure Code <br />The purpose of this modifier is to report the performance of a procedure or service during the postoperative period for one of the following circumstances: <br />planned or staged <br />more extensive than the original procedure <br />therapy following a surgical procedure <br />This modifier is used to report a staged or related procedure by the same physician during the postoperative period of the first procedure <br />Modifier 58 is used only during the global surgical period for the original procedure<br />Modifier Category: Global Package <br />
  • 34. Modifier -58<br /> Modifier 58 should not be reported when treatment of a problem requires return to the operating room<br /> Modifier 58 should not be used for staged procedures when the code description indicates “one or more visits or one or more sessions.” <br /> Without the modifier, the third-party payer could reject the claim because the surgery occurred during the post-op period<br />
  • 35. Modifier -58 Clinical Examples<br />Example #1: 32 year old woman with breast cancer undergoes a mastectomy one week ago. Today, she is scheduled to have breast implants placed<br />Report: 19342-58<br />Example #2: Sternal debridement performed for mediastinitis and it is noted that a muscle flap repair will be needed in a few days to close the defect<br />Report: 15734-58 since muscle flap planned at time of initial surgery<br />
  • 36. Modifier -76Repeat Procedure by same physicianAppend to Procedure Code<br />Repeat Procedure by the Same Physician; use when it is necessary to report repeat procedures performed on the same day<br />Appropriate Usage:<br />• On procedure codes that cannot be quantity billed<br />• Report each service on a separate line, using a quantity of one and append 76 to the subsequent procedures<br />• The same physician performs the services<br />Inappropriate Usage:<br />• Appending to a surgical procedure code<br />• Appending to each line of service<br />• Repeat services due to equipment or other technical failure<br />• For services repeated for quality control purposes<br />Modifier Category: Global Package<br />
  • 37. Modifier -76<br />Medicare considers two physicians, in the same group with the same specialty performing services on the same day as the same physician<br />For all procedure codes that cannot be quantity billed always use a quantity of “1”<br />To avoid denials, bill all services performed on one day on the same claim<br />For repeat clinical diagnostic laboratory tests, use modifier 91 if the service can not be quantity billed<br />
  • 38. Example: <br />A second radiology service performed on the same day<br />Two subsequent services, with no original service<br />
  • 39. Modifier -77Repeat Procedure by Another PhysicianAppend to Procedure Code<br />Repeat Procedure by a Different Physician; use when it is necessary to report repeat procedures performed on the same day<br />Appropriate Usage:<br />• A different physician performs the repeat services<br />Inappropriate Usage:<br />• Appending to a surgical procedure code<br />• Appending when the repeat procedure is performed by the same physician<br />• Appending to E/M codes<br /> Example: <br />A PCP performs a chest x-ray in his office and observes a suspicious mass. He sends the patient to a Pulmonologist who, on the same day, repeats the CXR.<br /> The Pulmonologist should submit their claim with the and provide documentation to support the need for a repeat CXR. <br />Modifier Category: Global Package<br />
  • 40. Modifier -78Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postop period Append to Procedure Code<br />The purpose of this modifier is to report a related procedure performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure) and requires use of the operating/procedure room. <br />Modifier 78 should not be used if a complication does not require use of the operating/procedure room. <br />Modifier 78 may be used to report procedures performed on the same day (usually in emergency situations)<br /> Example: Pt. brought to recovery room S/P abdominal surgery. Dressings became saturated, vital signs were unstable. Pt. brought back to OR for exploration post-op hemorrhage.<br /> Report: CPT Codes 35840 [78]<br />Modifier Category: Global Package<br />
  • 41. Modifier -79Unrelated Procedure/Service by same MD during the post-op periodAppend to Procedure Code<br />The purpose of this modifier is to report services during the postoperative period that are unrelated to the original procedure. <br />The procedure must be performed by the same physician, and modifier 79 is appended to the procedure code<br />Claim should be submitted with a different diagnosis and documentation should the different diagnosis and support medical necessity<br /> Example:<br /> A repair of femoral hernia [49550 (90 day global)] is performed on Jan. 5th. On Feb. 12th, the same physician performs an appendectomy.<br /> Report:<br /> CPT Code: 44950 [79]<br />Modifier Category: Global Package<br />
  • 42. “Other” Modifiers<br />
  • 43. Modifier -22Unusual Procedural ServicesAppend to procedure code <br /> Indicates that procedure was more complicated or complex<br /> Alerts payers to unusual circumstances or complications during a procedure<br /> Increased work effort of 30-50%<br />Must be accompanied by an Operative Report with letter explaining additional time required to support modifier -22 use<br />Modifier Category: “Other”<br />
  • 44. Modifier -22<br />Operative/Procedure Note Key Terms:<br />Increased risk; difficult; extended; complications; prolonged; unusual findings; unusual contamination controls; hemorrhage, blood loss over 600cc, unusual findings, etc.<br /> Additional physician work due to complications or medical emergencies may warrant use of -22<br /> Documentation must support the substantial additional work and the reason for the additional work (i.e., increased intensity, time, technical difficulty of procedure, severity of patient’s condition, physical and mental effort required)<br /> Overuse can trigger an audit, if you find yourself consistently using modifier -22, chances are you are using the wrong CPT<br />
  • 45. Use of Modifier -22<br />
  • 46. Modifier -23Unusual AnesthesiaAppend to Anesthesia Code Only<br /> Used to report a procedure which normally requires either local or no anesthesia, must be done under general anesthesia due to unusual circumstances<br /> Reserved for use by Anesthesiologists Only<br /> Example:<br /> Child or adult unable to cooperate with procedure - requires anesthesia i.e. CT, MRI, XRT. The anesthesiologist should report the appropriate anesthesia code (00010-01999) with modifier -23<br />Modifier Category: “Other”<br />
  • 47. -23 Unusual Anesthesia<br /> Use the code once on the basic service procedure code<br /> Claim must be accompanied by documentation and cover letter by physician explaining the need for general anesthesia<br /> Not for use by the Anesthesiologist<br /> Do not use for local anesthesia<br />
  • 48. Modifier -32Mandated ServicesAppend to Procedure Code<br /> Attach modifier 32 to mandated consultation &amp;/or other services<br /> Usually mandated by courts, government agencies or an insurance entity<br />Modifier Category: “Other” <br />
  • 49. Modifier -47Anesthesia by SurgeonAppend to Surgical Procedure Code Only<br /> Regional or general anesthesia provided by surgeon may be reported by adding -47. Not to be used with local anesthesia<br />Do not use CPT modifier 47 on anesthesia procedures codes 00100 through 01999, or 99143 through 99145 <br />CPT codes for use with CPT modifier 47 are 10021 through 69990<br />Not for use an Anesthesiologist <br />Not covered by Medicare<br />Modifier Category: “Other” <br />
  • 50. Modifier -50Bilateral ProcedureAppend to Procedure Code<br />Used to report bilateral procedures that are performed at the same operative session <br />Bilateral means: (bi = two, lateral = side; both sides) <br />Modifier 50 is used to report diagnostic, radiology and surgical procedures<br />Modifier 50 should only be applied to services and/or procedures performed on identical anatomic sites, aspects, or organs (arms, legs, eyes, breasts)<br />Modifier Category: “Other” <br />
  • 51. Modifier -50<br /> Modifier -50 is not applicable to:<br />Procedures that are bilateral by definition.<br />Procedures with descriptions including the terminology as “bilateral” or “unilateral”<br />When removing a lesion on the right arm and one on the left arm (RT/LT should be used)<br /> Modifier -50 can be appended to codes with a bilateral indicator of “1” or “3” on the Medicare Physician Fee Schedule<br />
  • 52. Modifier -50Reporting Bilateral Procedures on the Claim Form<br />Medicare requires the bilateral procedure to be reported on a single line with -50; however, private payers may require the procedure to be reported on two separate lines, appending -50 on the 2nd line (check with the individual payer for their bilateral billing policy)<br />Reimbursement is subject to 100% of the allowable charge for the first side and 50% of the allowable charge for the second side (150% of allowed amount)<br />Example: Physician removes a foreign body from each of a patient’s ears without anesthesia<br />
  • 53. Modifier -50Reporting Bilateral Procedures on the Claim Form<br />Do not report modifier -50 on the same line with modifiers RT/LT<br />Example: Correctly billed for bilateral procedure<br />Submit either Modifier 50 orModifiers LT and RT<br />
  • 54. Modifier -51Multiple ProceduresAppend to Procedure Code<br /> Used when multiple procedures, other than E/M services, performed at the same session by the same provider<br />Reimbursement is subject to 100% of the allowable charge for the primary code and 50% of the allowable charge for each additional surgery code<br />EXAMPLE: Patient presents for removal of a malignant lesion on the face with complex repair of the defect<br />REPORT: Line 1: 11641 Paid at 100% of Allowed<br /> Line 2: 13152-51 Paid at 50% of Allowed<br />Modifier Category: “Other” <br />
  • 55. Modifier -51<br />The surgical procedure with the highest allowable amount is considered the primary (first) procedure. Medicare uses the RVU for this determination, which can be found on the Physician Fee Schedule <br />Do not use -51 on the primary procedure, only on the secondary procedures (order procedures by RVU; highest to lowest)<br />Do not use -51 on procedures with a “+” or “Ø” symbol indicated in the CPT Manual (See Appendix D and E)<br />These codes can also be identified on the Medicare Physician Fee Schedule with a Multiple Procedure Indicator of “3”<br />
  • 56. Modifier -52Reduced ServicesAppend to Procedure Code<br />This modifier is used to report a service or procedure that is partially reduced or eliminated at the physician’s election<br />Modifier 52 is not used to report an elective cancellation of a procedure before surgical preparation in the operating suite <br />Modifier 52 should not be used if the procedure is discontinued after administration of anesthesia<br />The presence of modifier -52 will reduce the payment of the service. Depending upon the payer, the payment reduction percentage can vary, usually, the payment reduction is 50%<br />Modifier Category: “Other” <br />
  • 57. Modifier -53Discontinued ProcedureAppend to Procedure Code<br />Used to indicate that a surgical or diagnostic procedure was started but discontinued, due to extenuating circumstances that threaten the patient’s well-being<br />This modifier is used to report services or procedures when discontinued after anesthesia is administered to the patient<br />This modifier is not used to report an elective cancellation of a procedure or prior to the patient’s anesthesia induction and/or surgical preparation in the operating suite; including situations where cancellation is due to patient instability<br />Modifier 53 should not be used when a laparoscopic or endoscopic procedure is converted to an open procedure. <br />Modifier 53 should not be appended to E/M codes. <br />Modifier Category: “Other” <br />
  • 58. Modifier -53<br />Differs from modifier -52 because in that a life-threatening condition precipitates the terminated procedure when modifier -53 is reported<br />EXAMPLE:<br />A 50 year old woman complaining of acute rectal bleeding. She was given a bowel prep, administered at home, and returned for a total diagnostic colonoscopy. The procedure proceeds in the normal fashion, however the patient suddenly develops an erratic heart beat and the physician elects to discontinue the procedure<br />
  • 59. Modifier -63Procedure Performed on Infants less than 4kgAppend to Specific Surgical Procedure Codes Only<br />Procedures performed on neonates and infants up to a present body weight of 4kg may involve significantly increased complexity and physician work<br />Unless otherwise designated, should only be appended to services in 20000-69999 code series. Should not be appended to E&amp;M, Anesthesia, Radiology, Path/Lab, Medicine sections<br />WARNING:CPT lists, in Appendix F, codes that are exempt from use of modifier -63. There is not a used symbol for modifier -63 exempt codes, like there is for modifier -51 exempt codes (Ø). Check parenthetical notes under CPT codes for “patients under the age of 1 year”, as well as Appendix F, before appending modifier -63.<br />Modifier Category: Other<br />
  • 60. CCI or Bundling Modifiers<br />
  • 61. What is CCI or NCCI?<br />CMS developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims. The CMS developed its coding policies based on coding conventions defined in the American Medical Association&apos;s CPT manual, national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practices, and a review of current coding practices<br />NCCI (National Correct Coding Initiative) edits, which are released by CMS quarterly, define when two procedure HCPCS/CPT codes may not be reported together except under special circumstances. If an edit allows use of NCCI-associated modifiers, the two procedure codes may be reported together if the two procedures are performed at different anatomic sites or different patient encounters<br />Edits can be viewed @: <br />http://www.cms.gov/NationalCorrectCodInitEd/01_overview.asp<br />
  • 62. Modifier -59Distinct Procedural ServiceAppend to Procedure Code<br />The purpose of this modifier is to identify procedures or services that are not usually reported together but appropriate under the circumstances. This may represent the following: <br />A different session or patient encounter <br />A different procedure or surgery <br />A different site or organ system <br />A separate incision or excision <br />A separate lesion <br />A separate injury (or area of injury in extensive injuries) <br />Modifier -59 should only be used if no other modifier more appropriately describes the relationships of the two or more procedure codes (i.e. RT/LT, T1-T0, etc.)<br />Modifier 59 should not be appended to an E/M code <br />Modifier Category: CCI <br />
  • 63. Modifier -59 and NCCI <br />Modifier -59 is an important NCCI associated modifier that is often used incorrectly. For the NCCI its primary purpose is to indicate that two or more procedures are performed at different anatomic sites or different patient encounters<br />From an NCCI perspective, the definition of different anatomic sites includes different organs or different lesions in the same organ. However, it does not include treatment of contiguous structures of the same organ. For example, treatment of the nail, nail bed, and adjacent soft tissue constitutes a single anatomic site. Treatment of posterior segment structures in the eye constitute a single anatomic site <br />
  • 64. Modifier -59 and NCCI <br />Use of modifier -59 to indicate different procedures or surgeries does not require a different diagnosis for each HCPCS/CPT coded procedure/surgery<br />Example: An arthroscopic synovectomy was performed on the right knee for localized synovitis and a diagnostic arthroscopy was performed on the left knee for chronic pain syndrome<br />Report: 29875 &amp; 29870 – 59<br /> Note: The diagnosis for both CPT codes will be “chronic pain syndrome<br />CMS issued an article on modifier -59 which can be found at:<br />http://www.cms.gov/NationalCorrectCodInitEd/Downloads/modifier59.pdf<br />
  • 65. Modifier -59 Clinical Examples<br />Example #1: Column 1 Code/Column 2 Code 11055/11720 <br />CPT Code 11055 - Paring or cutting of benign hyperkeratotic lesion; single lesion <br />CPT Code 11720 – Debridement of nail(s) by any method(s); 1-5<br />Modifier -59 is: <br />1) Only appropriate if procedures are performed for lesions anatomically separate from one another or if procedures are performed at separate patient encounters<br />2) Don’t report CPT codes 11055-11057 for removal of hyperkeratotic skin adjacent to nails needing debridement<br />Example #2: Column 1 Code/Column 2 Code 17000/11100 <br />CPT Code 17000 – Destruction, all benign or premalignant lesions other than skin tags or cutaneous vascular proliferative lesions; first lesion <br />CPT Code 11100 – Biopsy of skin, subcutaneous tissue and/or mucous; single lesion <br />Modifier -59 is: <br />1) Only appropriate if procedures are performed on separate lesions or at separate patient encounters<br />
  • 66. Modifier -59 Clinical Examples<br />Example #3: Column 1 Code/Column 2 Code 38221/38220 <br />CPT code 38221 - Bone marrow; biopsy, needle or trocar <br />CPT code 38220 - Bone marrow; aspiration only <br />Use of -59 modifier should be uncommon but appropriate for these circumstances: <br />1) Different sites - contralateral iliac crests; iliac crest and sternum <br />2) Different incisions - same iliac crest <br />3) Different encounters<br />Example #4: Column 1 Code/Column 2 Code 93529/76000 <br />CPT Code 93529 – Combined right heart catheterization and left heart catheterization through existing septal opening (with or without retrograde left heart catheterization) <br />CPT Code 76000 – Fluoroscopy (separate procedure), up to one hour physician time, other than 71023 or 71034 (e.g., cardiac fluoroscopy) <br />Modifier -59 is: <br />1) Only appropriate if the fluoroscopy service 76000 is performed for a procedure done unrelated to the cardiac catheterization procedure.<br />
  • 67. Number of Surgeon Modifiers<br />
  • 68. How to Determine if Multiple Surgeons Are Allowed<br />To determine whether the services of more than one surgeon may be submitted to Medicare with CPT Modifiers 62, 66, 80, 81, 82 or AS, refer to the Medicare Physician Fee Schedule database (MPFSDB):<br />Access the database directly from the CMS Web Site at www.cms.gov/apps/physician-fee-schedule/overview.aspx/<br />Select Physician Fee Schedule Search from the left area of the Web page <br />Screen defaults to current year. Under Type of information, select Payment Policy Indicators, then ‘next’ <br />On the ‘select field options’ screen, select ‘Next’ <br />Enter the procedure code and select ‘All Modifiers’, then click ‘Submit’ <br />Refer to the column heading applicable:<br />‘Co Surg’, ‘Team Surg’ or ‘Asst Surg’ <br />
  • 69. Modifier -62Two surgeonsAppend to Surgical Procedure Code<br />Two surgeons (each in a different specialty) work together to perform a specific procedure <br />If two surgeons (each in a different specialty) are required to perform a specific procedure, each surgeon bills for the procedure, and both surgeons need to report the same surgery code with the modifier 62. <br />Example: Transphenoidal Hypophesectomy<br />Neurosurgeon and ENT both report 61548-62<br />WARNING: If one surgeon bills with a modifier “-62,” and one surgeon bills with no modifier, the payer may deny or suspend the claim with the modifier for review. Coordination of billing is key to proper reimbursement for each surgeon!<br />Modifier Category: # of Surgeons <br />
  • 70. Modifier -62<br />Global surgery rules apply to each of the physicians participating in a co-surgery<br />Documentation of the medical necessity for two surgeons is required for certain services identified in the Medicare Physician Fee Schedule<br />Reimbursement is at 62.5% of the global surgery fee schedule amount for each co-surgeon <br />The following Co-Surgeon indicators found on the Medicare Physician Fee Schedule identify services for which two surgeons, each in a different specialty, may be paid: <br />0 = Co-surgeons not permitted for this procedure<br />1= Co-surgeons may be paid if supporting documentation is supplied to establish medical necessity<br />2 = Co-surgeons permitted. No documentation is required if two- specialty requirement is met<br />
  • 71. Modifier -62 <br />Appropriate Use:<br /> Arthrodesis using<br /> anterior interbody technique, thoracic level.<br /> Thoracic surgeon performs a thoracotomy, exposes and later closes the site<br /> Orthopaedic surgeon performs the arthrodesis<br /> Both surgeons should use CPT Code: 22556-62<br />Inappropriate Use:<br />Oncology surgeon performs a radical mastectomy. At same operative session the plastic surgeon then performs breast reconstruction. <br /> In this case, the surgeons are performing 2 distinct services and each uses separate CPT codes and -62 is not required<br />
  • 72. Modifier -66Surgical TeamAppend to Surgical Procedure Codes Only<br />Highly complex procedures requiring concomitant services of several physicians, often of different specialties plus other highly skilled, specially trained personnel, various types of complex equipment<br />Example:<br />Transplants<br />Separation of conjoined twins<br />Each participating physicians uses the -66 modifier <br />Modifier Category: # of Surgeons <br />
  • 73. Modifier -66<br />Global surgery rules apply to each of the physicians participating in a team surgery. <br />The Medicare Physician Fee Schedule identifies certain services submitted with a “-66” modifier, which must be sufficiently documented to establish that a team was medically necessary. All claims for team surgeons must contain sufficient information to allow pricing “by report.” <br />The following indicators, according to the Medicare Physician Fee Schedule, identify services for which team surgeons may be paid: <br />0 = Team surgeons not permitted for this procedure. <br />1 = Team surgeons may be paid if supporting documentation is supplied to establish medical necessity of a team. Paid by report. <br />2 = Team surgeons may be paid. Paid by report. <br />Reimbursement is typically determined “By Report.” <br />
  • 74. Modifier -80Assistant SurgeonAppend to Surgical Procedure Codes Only<br /> Submit CPT modifier 80 to identify the services of a surgical assistant<br /> This modifier may only be submitted with surgery codes <br /> Physician assistants, nurse practitioners and clinical nurse specialists must not submit this modifier. See HCPCS Modifier AS<br /> Use of the modifier will result in a payment of 16% of the allowed amount <br />Global surgery rules do not apply<br />Modifier Category: # of Surgeons <br />
  • 75. Modifier -81Minimal Assistant SurgeonAppend to Surgical Procedure Codes Only<br />Modifier -81 specifies “minimal” assistant surgeon, but neither CPT nor CMS provides definitive guidelines to help physicians and coders distinguish a minimum assistant from a “regular” assistant as described by modifier -80. This absence of clarity causes payers to interpret modifier -81 differently<br /> This modifier may only be submitted with surgery codes <br /> Physician assistants, nurse practitioners and clinical nurse specialists must not submit this modifier. See HCPCS Modifier AS<br /> Use of the modifier will result in a payment of 16% of the allowed amount <br />Global Surgery rules do not apply<br />Modifier Category: # of Surgeons <br />
  • 76. Modifier -82Assistant surgeon (when qualified resident surgeon not available)Append to Surgical Procedure Codes Only<br /> Submit CPT modifier 82 when the assistant at surgery service was provided by an MD and there was not a qualified resident available <br /> This modifier may only be submitted by teaching hospitals<br /> Payment is not made for a first assistant when the service is provided in a teaching hospital that has a training program related to the particular surgical procedure and a qualified resident is available. But if the teaching hospital has no qualified resident available or no teaching program related to the particular medical specialty required for the procedure, or if the primary surgeon has an across-the-board policy of not using residents, Medicare will cover the services of a PA first assistant<br />Modifier Category: # of Surgeons <br />
  • 77. Modifier -ASPhysician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgeryAppend to Surgical Procedure Codes Only<br />Modifier “AS” is for assistant at surgery services provided by a Physician Assistant (PA) or Nurse Practitioner (NP)<br /> This modifier may only be submitted with surgery codes <br /> Not for use by Physicians<br /> Use of the modifier will result in an 85% payment of 16% of the allowed amount <br />Modifier Category: # of Surgeons <br />
  • 78. Modifiers -80, -81, 82 and -AS<br />The following indicators, according to the Medicare Physician Fee Schedule, identify services for which assistant surgeons may be paid: <br />Indicator 0 = Payment restriction for assistants at surgery applies to this procedure. Supporting documentation describing the medical necessity for an assistant must be submitted with the claim<br />Indicator 1 = Statutory payment restriction for assistants at surgery applies to this procedure. Assistants at surgery will not be paid<br />Indicator 2 = Payment restriction for assistants at surgery does not apply to this procedure. Assistants at surgery may be paid<br />Indicator 9 = Concept does not apply (the most likely explanation is that the procedure is not a surgery) <br />
  • 79. Assistant Surgeon Modifiers Which One Do I Use?<br />Quick Reference for Choosing Assistant Surgeon Modifier<br />CPT Modifier -80, assistant at surgery:This includes MD, DO, and DPM provider types and is an assistant surgeon providing full assist to the primary surgeon <br />CPT Modifier -81, minimal assistant at surgery:This includes MD, DO, and DPM provider types and is an assistant surgeon providing minimal assistance to the primary surgeon. This modifier may be used when more than one assistant is involved or if one person assists during a portion of the surgery. This modifier is not intended for use by non-physician assistants (e.g., RN, PA)<br />CPT Modifier -82, assistant at surgery when a qualified resident surgeon is not available to assist the primary surgeon:This used by teaching hospitals and includes MD, DO, and DPM provider types <br />HCPCS Level II modifier -AS, a non-physician assistant at surgery:This would include PA, CNS, CRNFA, RNFA, NP, LPN, DDS, DMD, and surgical technician provider types, subject to contract eligibility<br />
  • 80. -RR<br />-AA<br />-F1<br />-LT<br />-TC<br />HCPCS LEVEL II MODIFIERS<br />-KX<br />-GA<br />
  • 81. HCPCS Level II Modifiers<br /> Alpha or alphanumeric<br /> Provide additional information just like CPT modifiers<br />Found in HCPCS Manual<br /> Can be used on Level I CPT codes and/or Level II HCPCS codes<br />
  • 82. HCPCS Level II Modifiers<br />HCPCS Modifiers are very descriptive and should be reviewed for applicability before assigning modifier -59<br />Example:<br /> A patient has a lesion removed from the left breast and a biopsy of a lesion of the right breast<br />In this instance, assign 19120 with modifier -LT and 19100 with modifier -RT. This is because, according to CMS, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available should modifier 59 be used<br />
  • 83. Examples of HCPCS Modifiers<br />-LT: LEFT SIDE (USED TO IDENTIFY PROCEDURES PERFORMED ON THE LEFT SIDE OF THE BODY)<br />-RT: RIGHT SIDE (USED TO IDENTIFY PROCEDURES PERFORMED ON THE RIGHT SIDE OF THE BODY)<br />-GA: WAIVER OF LIABILITY STATEMENT ON FILE<br />-RR: RENTAL (USE THE &apos;RR&apos; MODIFIER WHEN DME IS TO BE RENTED)<br />
  • 84. Is your practice in compliance?<br />QUICK SELF TEST FOR COMPLIANCE PRACTICES IN YOUR OFFICE<br />
  • 85. A Quick Self-Test for Compliance Practices in Your Office<br /> Does your office review all pertinent documentation prior to appending a modifier?<br /> Do you monitor the activities of your billing office or service with respect to modifier usage?<br /> Do you randomly cross-check all billings performed by your office or service to be certain that claims submitted with modifiers are accurate and appropriate?<br />
  • 86. Compliance Test cont..<br /> Do you make sure the staff is educated and updated on Medicare and Medicaid program changes?<br /> Are services billed to Medicare and Medicaid thoroughly documented?<br /> Are new billing employees and new physicians oriented on modifier reporting policies?<br />
  • 87. The Answer to all those questions should be YES!<br />
  • 88. A Quick Self-Test for Complaint Practices in Your Office<br /> Do you allow your billing office or service to assign modifiers and subsequently report services on claims without conducting an intermittent review of claims?<br /> Does your billing office or service have carte blanche permission to correct and/or change codes for services that you have performed?<br />
  • 89. Is there evidence of inappropriate overpayment by the payer when a modifier is used?<br /> Does your billing office or service answer all Medicare and Medicaid inquiries regarding your services and claims on your behalf without your knowledge?<br />Compliance Test cont..<br />
  • 90. The Answer to These Questions Should be NO!!!!!!!!<br />
  • 91. Remember, modifiers mean real money for your practice!!!<br />
  • 92. QUESTIONS???<br />

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