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A Facility-Focused Guide to Applying Modifiers Corectly.pptx

Health Catalyst
Health Catalyst
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This webinar is a review of how to appropriately assign frequently misapplied CPT and HCPCS modifiers. Older modifiers and newly added modifiers, that were effective January 1, 2023, will be covered. This webinar is focused on modifiers that should be used on the facility side. While some of these modifiers can also be used on the professional side, this presentation does not focus on assigning modifiers on the professional side. For information regarding applying modifiers on the professional side, please see part one of this series--A Physician-Focused Guide to Applying Modifiers Correctly.

A Facility-Focused Guide to Applying Modifiers Corectly.pptx

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© Health Catalyst. Confidential and Proprietary.
A Facility-Focused Guide to
Applying Modifiers Correctly
Mikki Fazzio, RHIT, CCS, Principal Content Integrity Consultant
© Health Catalyst. Confidential and Proprietary.
Disclaimer Statement
This presentation was current at the time it was published or provided via the
web and is designed to provide accurate and authoritative information regarding
the subject matter covered. The information provided is only intended to be a
general overview with the understanding that neither the presenter nor the
event sponsor is engaged in rendering specific coding advice. It is not intended
to take the place of either the written policies or regulations. We encourage
participants to review the specific regulations and other interpretive materials,
as necessary.
All CPT® codes are trademarked by the American Medical Association (AMA) and
all revenue codes are copyrighted by the American Hospital Association (AHA).
Agenda
• Brief Facts on Modifiers
• Evaluation and Management (E/M) Modifiers
• Anatomic Modifiers
• Discontinued or Reduced Services Modifiers
• Separate, Distinct Service Modifiers
• Repeat Procedures Modifiers
• Return to Surgery Modifiers
• Newer Modifiers
• Questions
© Health Catalyst. Confidential and Proprietary.
Level I Modifiers Level II Modifiers
• Developed by the American Medical
Association (AMA)
• Numeric modifiers
• Indicates a change in the description of the
code without a change in meaning
• See Appendix A of CPT book for complete
listing
• Developed by CMS (HCFA)
• Alpha-numeric modifiers
• Used to explain various circumstances that
apply to provided services
• See Appendix B of HCPCS Manual for
complete listing
Brief Facts on Modifiers
© Health Catalyst. Confidential and Proprietary.
Brief Facts on Modifiers
• Rules for assigning modifiers vary from payer
to payer and between the different Medicare
Administrative Contractors (MACs).
• Modifier usage does not guarantee payment.
• Certain modifiers can be used to override National Correct Coding Initiative (NCCI)
edits [aka Procedure to Procedure (PTP) edits].
• Use of certain modifiers will impact reimbursement. Use of “informational”
modifiers will provide information that will ease claim processing to avoid delays.
© Health Catalyst. Confidential and Proprietary.
• Anatomic modifiers: E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, LM, RI.
• Global surgery modifiers: 24, 25, 57, 58, 78, 79.
• Other modifiers: 27, 59, 91, XE, XS, XP, XU.
Modifiers that are NCCI Eligible
Brief Facts on Modifiers

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A Facility-Focused Guide to Applying Modifiers Corectly.pptx

  • 1. © Health Catalyst. Confidential and Proprietary. A Facility-Focused Guide to Applying Modifiers Correctly Mikki Fazzio, RHIT, CCS, Principal Content Integrity Consultant
  • 2. © Health Catalyst. Confidential and Proprietary. Disclaimer Statement This presentation was current at the time it was published or provided via the web and is designed to provide accurate and authoritative information regarding the subject matter covered. The information provided is only intended to be a general overview with the understanding that neither the presenter nor the event sponsor is engaged in rendering specific coding advice. It is not intended to take the place of either the written policies or regulations. We encourage participants to review the specific regulations and other interpretive materials, as necessary. All CPT® codes are trademarked by the American Medical Association (AMA) and all revenue codes are copyrighted by the American Hospital Association (AHA).
  • 3. Agenda • Brief Facts on Modifiers • Evaluation and Management (E/M) Modifiers • Anatomic Modifiers • Discontinued or Reduced Services Modifiers • Separate, Distinct Service Modifiers • Repeat Procedures Modifiers • Return to Surgery Modifiers • Newer Modifiers • Questions
  • 4. © Health Catalyst. Confidential and Proprietary. Level I Modifiers Level II Modifiers • Developed by the American Medical Association (AMA) • Numeric modifiers • Indicates a change in the description of the code without a change in meaning • See Appendix A of CPT book for complete listing • Developed by CMS (HCFA) • Alpha-numeric modifiers • Used to explain various circumstances that apply to provided services • See Appendix B of HCPCS Manual for complete listing Brief Facts on Modifiers
  • 5. © Health Catalyst. Confidential and Proprietary. Brief Facts on Modifiers • Rules for assigning modifiers vary from payer to payer and between the different Medicare Administrative Contractors (MACs). • Modifier usage does not guarantee payment. • Certain modifiers can be used to override National Correct Coding Initiative (NCCI) edits [aka Procedure to Procedure (PTP) edits]. • Use of certain modifiers will impact reimbursement. Use of “informational” modifiers will provide information that will ease claim processing to avoid delays.
  • 6. © Health Catalyst. Confidential and Proprietary. • Anatomic modifiers: E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, LM, RI. • Global surgery modifiers: 24, 25, 57, 58, 78, 79. • Other modifiers: 27, 59, 91, XE, XS, XP, XU. Modifiers that are NCCI Eligible Brief Facts on Modifiers
  • 7. © Health Catalyst. Confidential and Proprietary. Evaluation and Management (E/M) Modifiers
  • 8. © Health Catalyst. Confidential and Proprietary. Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service • Only used when a significant, separately identifiable E/M service is rendered on the same date of service as another procedure performed with a status indicator of “T” or “S”. • E/M service provided must be above and beyond the usual preoperative and postoperative work of the procedure. • The need for a separate E/M service may be prompted by a symptom, complaint, problem or circumstance that may or may not be related to the procedure. • The record must document the presence of a distinct problem that goes “above and beyond” usual work required for the procedure. • Should only be appended to E/M codes 92002-92014, 99201-99499, 99281-99285 (type A ED visits) and HCPCS Level II codes G0175, G0402, and G0380-G0384 (type B ED visits). Modifier 25 Evaluation and Management (E/M) Modifiers
  • 9. © Health Catalyst. Confidential and Proprietary. Modifier 25 is NOT Used For: • An E/M service that resulted in a decision to perform major surgery (See modifier 57). • Significant, separately identifiable non-E/M services (See modifier 59). • Services that do not meet appropriate guidelines for reporting an E/M service. (Ex. To report code 99203 a medically appropriate history and/or exam and a low level of MDM is required or a total time of 30-44 minutes) must be met and supported in the documentation. • Some services being submitted to commercial payers. Some payer policies differ from Medicare and may not allow separate payment for additional services reported with modifier 25. Modifier 25 Evaluation and Management (E/M) Modifiers
  • 10. © Health Catalyst. Confidential and Proprietary. After sustaining a facial laceration in a car accident, a man went to the ED for treatment. The ED physician performed a medically appropriate history and exam and a moderate level of medical decision making. After the evaluation, the physician repaired one wound, an intermediate repair on the forehead measuring 1.5 cm. CPT Codes Reported: 99284-25, Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. 12051, Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less. Modifier 25 Evaluation and Management (E/M) Modifiers
  • 11. © Health Catalyst. Confidential and Proprietary. A man arrives to the ED after sustaining a scalp laceration on the scalp from a fight. The ED physician documents a medically appropriate history and exam and performs a low level of medical decision making. The laceration measured 1.6 cm. A complex repair was performed in the ED. CPT Codes Reported: 99283-25, Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and low level of medical decision making. 13120, Repair, complex, scalp, arms, and/or legs; 1.1 cm to 2.5 cm. Modifier 25 Evaluation and Management (E/M) Modifiers
  • 12. © Health Catalyst. Confidential and Proprietary. An established patient was seen by the orthopedist in the hospital clinic. The patient had a history of joint pain, and at the last visit the physician had stated that if the medication did not help, the physician would inject the joint. The patient reported that the medication did not help. The physician performed and documented a problem-focused history and examination and injected 1 mg of hylan G- F 20 (Synvisc-One®) in the right knee. CPT Codes Reported: 20610, Arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance. J7325, Hyaluronan or derivative, Synvisc or Synvisc-One, for intra-articular injection, 1 mg. Modifier 25 should not be reported because the intent of the visit is the injection of the joint to treat the joint pain and the E/M service is included in the preoperative care for the patient. The physician did not document that additional work above and beyond the procedure was needed. Modifier 25 Evaluation and Management (E/M) Modifiers
  • 13. © Health Catalyst. Confidential and Proprietary. Multiple Outpatient Hospital E/M Encounters on the Same Date • For hospital outpatient reporting purposes, used to report utilization of hospital resources related to separate and distinct E/M encounters performed in multiple outpatient hospital settings (such as hospital emergency dept, clinic, etc.) on the same date. • CPT guidelines state that the service must be reported by a different physician; CMS says it can be the same physician. • Should only be appended to the following E/M codes: • 92002-92014 • 99201-99499 • HCPCS Level II G0175 and G0402 • G0380-G0384 (type B ED visits) Modifier 27 Evaluation and Management (E/M) Modifiers
  • 14. © Health Catalyst. Confidential and Proprietary. • Condition code G0 (G zero) should be used when multiple medical visits occur on the same day in the same revenue centers. This indicates that these visits were distinct and constituted independent visits (Example: Two visits to the ED- one for a broken arm and another for chest pain). Modifier 27 Evaluation and Management (E/M) Modifiers
  • 15. © Health Catalyst. Confidential and Proprietary. Patient went into type A ED after a fall from his porch with complaints of pain in his right hip and foot. ED physician performed a medically appropriate history and exam, ordered X-rays, and performed a moderate level of medical decision making. X-ray showed no broken bones, so the patient’s sprained foot was wrapped, and patient was given instructions and a prescription for pain medications for the sprain. Later in the day, the patient arrived back in the ED with a burn on his right arm. A different ED doctor was on duty. The physician performed a medically appropriate history and exam and a low level of medical decision making. The physician determined that the burn was minor and dressed the area and gave the patient instructions on how to care for the wound. The physician also noticed that the patient’s blood pressure was high and the patient’s blood pressure medication regimen was adjusted. Modifier 27 Evaluation and Management (E/M) Modifiers
  • 16. © Health Catalyst. Confidential and Proprietary. CPT Codes Reported: 99284, Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. 99383- 27, Emergency department visit for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and low level of medical decision making. Report condition code G0 on second claim form to indicate that the visits occurred within the same revenue center at the facility. Modifier 27 Evaluation and Management (E/M) Modifiers
  • 17. © Health Catalyst. Confidential and Proprietary. Anatomic Modifiers
  • 18. © Health Catalyst. Confidential and Proprietary. 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 Finger Modifiers Anatomic Modifiers
  • 19. © Health Catalyst. Confidential and Proprietary. 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 Toe Modifiers Anatomic Modifiers
  • 20. © Health Catalyst. Confidential and Proprietary. E1 – Upper left, eyelid E2 – Lower left, eyelid E3 – Upper right, eyelid E4 – Lower right, eyelid Eyelid Modifiers Anatomic Modifiers
  • 21. © Health Catalyst. Confidential and Proprietary. LC – Left circumflex coronary artery LD – Left anterior descending coronary artery LM – Left main coronary artery RC – Right coronary artery RI – Ramus intermedius coronary artery Identifies the vessel on which a procedure was performed. If more than one modifier applies, the code should be repeated with the modifier on another line of the claim form. Coronary Artery Modifiers Anatomic Modifiers
  • 22. © Health Catalyst. Confidential and Proprietary. • Informational modifiers; some third-party payers require. • If code description includes a paired organ site (ears, eyes, lungs, ovaries), but procedure is performed on only one side, RT, Right Side or LT, Left Side modifiers are appropriate. • The appropriate modifier for an anatomic site is preferred over a general RT or LT modifier. • Example: If a procedure of the upper left eyelid was performed, modifier E1 should be appended rather than LT. • When code description specifies that procedure is performed on an eyelid, digit, or coronary artery, anatomical modifiers are appropriate. Anatomic Modifiers
  • 23. © Health Catalyst. Confidential and Proprietary. • Do not use if the code description of the code indicates that the procedure applies to different body parts. • Example: 12001, Simple repair of superficial wounds of scalp, neck, axillae, external genitalia, trunk and/or extremities (including hands and feet); 2.5 cm or less. • Do not use if the code description indicates multiple extremities • Example: 95861, Needle electromyography; 2 extremities with or without related paraspinal areas. • Do not use for radiological supervision and interpretation codes. Anatomic Modifiers
  • 24. © Health Catalyst. Confidential and Proprietary. A patient was admitted to the ASC for a tenotomy of the left foot, second digit. A small incision was made at the crease of the toes on the bottom of the foot, the skin was reflected back, and the tendon was exposed. The tendon was released from its attachment and the incision was repaired with a layered closure. CPT Codes Reported: 28234-T1, Tenotomy, open, extensor, foot or toe, each tendon. Anatomic Modifiers
  • 25. © Health Catalyst. Confidential and Proprietary. Bilateral • If code descriptor states that the procedure is “unilateral” or “bilateral” then modifier 50 is not necessary unless the description does not match what was performed. • Example: If procedure is performed bilaterally, but code descriptor says “unilateral,” modifier 50 would be appended. • If code descriptor states “unilateral or bilateral,” modifier 50 is not necessary. • Example: 92081, Visual field examination, unilateral or bilateral, with interpretation and report; limited examination. Modifier 50 would NOT be appropriate on this code. Modifier 50 Anatomic Modifiers
  • 26. © Health Catalyst. Confidential and Proprietary. • Do not use with “add-on” codes (Appendix D in CPT book). • Do not use when using modifiers RT and LT. • The unit entry to use when reporting modifier 50 is 1. • Breaking up procedures that state “bilateral” in the code description and coding them individually for each side when they were performed during the same session is against the NCCI guidelines and incorrect coding from a CPT perspective. Modifier 50 Anatomic Modifiers
  • 27. © Health Catalyst. Confidential and Proprietary. • ASC specialty providers don't report modifier 50 for Medicare claims. • When more than one surgical procedure is performed in the same operative session, multiple surgery rules apply. • Medicare will allow 100% of the highest paying surgical procedure on the claim plus 50% for the other ASC-covered surgical procedures furnished in the same session. • Report bilateral procedures by reporting a single unit on two separate lines or a single unit on one line with "2" in the unit field. • Multiple procedure reduction of 50% will apply to all bilateral procedures subject to multiple procedure discounting. Modifier 50 and Ambulatory Surgical Centers (ASCs) Anatomic Modifiers Date of Service Procedure Code Modifier Units 4/4/23 19303 2 Date of Service Procedure Code Modifier Units 4/4/23 19303 LT 1 4/4/23 19303 RT 1
  • 28. © Health Catalyst. Confidential and Proprietary. A recreational skier injured his right and left knees, with peripheral longitudinal tears of both medial and lateral menisci and underwent arthroscopic meniscus repair of both knees by suture technique. CPT Codes Reported: 29883-50, Arthroscopy, knee, surgical; with meniscus repair (medial AND lateral). Since this is a unilateral code, modifier 50 is necessary to inform the payer that the procedure was completed on both knees. In the ASC setting, for Medicare, this would be reported as a single procedure on two lines or reported on a single line with 2 in the unit field. Modifier 50 Anatomic Modifiers
  • 29. © Health Catalyst. Confidential and Proprietary. Discontinued or Reduced Services Modifiers
  • 30. © Health Catalyst. Confidential and Proprietary. Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC) Procedure Prior to the Administration of Anesthesia. • Used to indicate when a surgical or diagnostic procedure is cancelled after the patient’s surgical preparation (including sedation when provided, and being taken to the room where the procedure is to be performed), but prior to the administration of anesthesia (local, regional block(s), or general) due to extenuating circumstances or those that threaten the well-being of the patient. • Not for physician reporting (see modifier 53 for physician reporting of discontinued procedure). • If procedure is canceled prior to the patient being taken into the operating/procedure room for surgical prep, the procedure and modifier should not be reported. • If the procedure is an approved outpatient hospital or ASC service, Medicare payment will be 50% of the facility rate subject to the ASC payment calculation. Modifier 73 Discontinued or Reduced Services Modifiers
  • 31. © Health Catalyst. Confidential and Proprietary. • If multiple procedures are planned, the completed procedures are reported as usual. The others that were planned, but not started are not reported. • When none of the planned procedures are completed, the first planned procedure is reported with modifier 73 as appropriate. Do not report the additional procedure. • Diagnosis code should be included to indicate the reason for cancellation. • Modifier 73 should not be used to indicate discontinued radiology procedures. Modifier 73 Discontinued or Reduced Services Modifiers
  • 32. © Health Catalyst. Confidential and Proprietary. Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC) Procedure After Administration of Anesthesia. • Used to indicate when a surgical or diagnostic procedure is terminated by the physician after the administration of anesthesia (local, regional block(s) or general) or after the procedure was started (incision made, intubation started, scope inserted, etc.) due to extenuating circumstances or those that threaten the well-being of the patient. • Not for physician reporting (see modifier 53 for physician reporting of discontinued procedure). • If procedure is canceled prior to the patient being taken into the operating/procedure room for surgical prep, the procedure and modifier should not be reported. • If patient has been taken to operating room, but anesthesia has not yet been administered, see modifier 73. Modifier 74 Discontinued or Reduced Services Modifiers
  • 33. © Health Catalyst. Confidential and Proprietary. • If the procedure is an approved outpatient hospital or ASC service, Medicare will not reduce payment because the resources of the facility are consumed in essentially the same manner and to the same extent as they would have been if the procedure had been completed. • If multiple procedures are planned, the completed procedures are reported as usual. The others that were planned, but not started are not reported. • When none of the planned procedures are completed, the first procedure that was planned can be coded with modifier 74 only if the patient had already received anesthesia. If patient had only been taken to operating room and had not yet received anesthesia, modifier 73 would be appended. Modifier 74 Discontinued or Reduced Services Modifiers
  • 34. © Health Catalyst. Confidential and Proprietary. Reduced Services • Used when a service that doesn’t require anesthesia is discontinued or partially reduced at the discretion of the physician or QHP. • Used for partial reduction or discontinuation of radiology procedures and other services that do not require anesthesia. • Used when the procedure performed is less than the requirements of the code description and no alternate code exists. Modifier 52 Discontinued or Reduced Services Modifiers
  • 35. © Health Catalyst. Confidential and Proprietary. • Medicare does not recognize for use with E/M services; If key component is missing, use 99499. • Do not use when the patient has the inability to pay the full charge for the procedure (not used to extend discounts). • Do not use for time-based procedure codes (Ex. 97110 represents 15 minutes of therapy time). • Do not use to report a unilateral procedure when a code description states “unilateral or bilateral”. • Do not use to describe a procedure done without contrast. • Do not use to report the elective cancellation of a procedure. • Do not use to report incomplete laboratory panel. Instead, code individual tests. Modifier 52 Discontinued or Reduced Services Modifiers
  • 36. © Health Catalyst. Confidential and Proprietary. Patient hurt his ankle while running. Physician orders and patient receives a one- view x-ray of ankle. CPT Code Reported: 73600-52, Radiologic examination, ankle; 2 views. Because the code description specifies that it was 2 views and there is no other CPT code to describe a one-view x-ray of the ankle, modifier 52 would be assigned to indicate that only one view was obtained. Modifier 52 Discontinued or Reduced Services Modifiers
  • 37. © Health Catalyst. Confidential and Proprietary. Separate, Distinct Service Modifiers
  • 38. © Health Catalyst. Confidential and Proprietary. Distinct Procedural Service. • Used to indicate that a procedure or service was distinct or independent from other non-E/M services performed the same day. • Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not normally encountered or performed on the same day by the same individual. • If another already established, more descriptive modifier is appropriate it should be used rather than modifier 59. • Modifier 59 should only be used with non-E/M services (for E/M services, use modifier 25). Modifier 59 Separate, Distinct Service Modifiers
  • 39. © Health Catalyst. Confidential and Proprietary. Do NOT Use: • In order to clear an NCCI (PTP) edit without clinical justification for the use of the modifier. • If a more specific modifier can be used to differentiate circumstances or anatomic sites. • With E/M services. • With radiation treatment management (77427). Modifier 59 Separate, Distinct Service Modifiers
  • 40. © Health Catalyst. Confidential and Proprietary. XE, Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter. XS, Separate Structure, A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure. XP, Separate Practitioner, A Service That Is Distinct Because It Was Performed By A Different Practitioner. XU, Unusual Non-Overlapping Service, The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service. These modifiers are used in the place of modifier 59. Do not append both modifier 59 and X- modifier on one code. https://www.cms.gov/files/document/mln1783722-proper-use-modifiers-59-xepsu.pdf Modifiers XE, XS, XP, XU Separate, Distinct Service Modifiers
  • 41. © Health Catalyst. Confidential and Proprietary. Use when a surgical procedure, a non-surgical therapeutic procedure, or a diagnostic procedure is performed during the same encounter on a separate structure, such as: • Different organs. • Different anatomical regions. • In limited situations on different, non-contiguous lesions in different anatomic regions of the same organ. Do not use modifier XS if a more specific anatomic modifier can be used appropriately (RT, LT, E1-E4, etc.). Modifier XS- Separate Structure Separate, Distinct Service Modifiers
  • 42. © Health Catalyst. Confidential and Proprietary. Example: Column 1 Code/Column 2 Code - 11102/17000. • CPT Code 11102 - Tangential biopsy of skin (eg, shave, scoop, saucerize, curette); single lesion. • CPT Code 17000 - Destruction (eg, laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); first lesion. You may report modifiers 59 or XS with either the Column 1 or Column 2 code if you did the procedures at different anatomic sites on the same side of the body and a specific anatomic modifier isn’t applicable. If you did the procedures on different sides of the body, use modifiers RT and LT or another pair of anatomic modifiers. Don’t use modifiers 59 or XS. Modifier XS- Separate Structure Separate, Distinct Service Modifiers
  • 43. © Health Catalyst. Confidential and Proprietary. Use when surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures are performed during different encounters on the same date of service and can’t be described by a more specific modifier (such as modifier 25, 27, 58, 91, etc.). Example: • Patient has a treadmill cardiovascular stress test performed at 9:00 am and a 12- lead EKG performed at 11:30 for further testing. • EKG may be separately coded with XE modifer as this was not performed during the same encounter as the stress test. Modifier XE- Separate Encounter Separate, Distinct Service Modifiers
  • 44. © Health Catalyst. Confidential and Proprietary. Use when a procedure or service is distinct because it was performed by a different practitioner. Example: Patient has a treadmill cardiovascular stress test performed and interpreted by one physician and then is referred to a different physician for a 12-lead EKG to be performed and interpreted. Modifier XP can be appended to the EKG to indicate that it was performed by a different provider. Modifier XP- Separate Practitioner Separate, Distinct Service Modifiers
  • 45. © Health Catalyst. Confidential and Proprietary. • Use for a service that is distinct because it does not overlap usual components of the main service. • Use when documentation indicates that the service was not part of the usual components of the main service. • Use only when there is no other modifier to describe the situation. Modifier XU- Unusual Non-Overlapping Service Separate, Distinct Service Modifiers
  • 46. © Health Catalyst. Confidential and Proprietary. Use when a diagnostic procedure is performed prior to a therapeutic procedure and is clearly the basis for proceeding to the therapeutic procedure. • Diagnostic procedure must not have been required during the therapeutic procedure AND must clearly provide information needed to decide whether or not to proceed to therapeutic procedure. Modifier XU- Unusual Non-Overlapping Service Separate, Distinct Service Modifiers
  • 47. © Health Catalyst. Confidential and Proprietary. Example: Column 1 Code/Column 2 Code - 37220/75710. • CPT Code 37220 - Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplasty. • CPT Code 75710 - Angiography, extremity, unilateral, radiological supervision, and interpretation. You may report modifier XU with CPT code 75710 (angiography) since it was performed prior to the revascularization the result is what led to the decision to perform the revascularization. You may report modifier XU for a diagnostic procedure performed before a therapeutic procedure only when the diagnostic procedure is the basis for performing the therapeutic procedure. Modifier XU- Unusual Non-Overlapping Service Separate, Distinct Service Modifiers
  • 48. © Health Catalyst. Confidential and Proprietary. Use when a diagnostic procedure is performed subsequent to a therapeutic procedure only when the diagnostic procedure is not an expected or necessary follow-up. • Diagnostic procedure must not have been required during the therapeutic procedure AND must not be an inherent component of the therapeutic procedure. Example: A patient requires a chest x-ray following chest tube insertion due to development of fever and persistent cough. • Chest x-ray may be separately coded with modifier XU due to clinical indications. Modifier XU- Unusual Non-Overlapping Service Separate, Distinct Service Modifiers
  • 49. © Health Catalyst. Confidential and Proprietary. Repeat Procedure Modifiers
  • 50. © Health Catalyst. Confidential and Proprietary. 76, Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional. 77, Repeat Procedure by Another Physician or Other Qualified Health Care Professional. • Used when the procedure performed is the exact procedure performed previously by the same or a different physician on the same date of service. • Example: Multiple electrocardiograms are performed for the same patient on the same date of service. Modifier 76 or 77 would be appended to the subsequent ECGs. Modifiers 76 and 77 Repeat Procedure Modifiers
  • 51. © Health Catalyst. Confidential and Proprietary. • Do not use with E/M codes. • Do not use when the definition of the code indicates a repeated procedure or redo (57511, Cautery of cervix; cryocautery, initial or repeat). • Do not use when the same procedure is performed multiple times during a single session. • Patient presents for nerve repair with vein graft of two separate nerves which is performed during a single encounter. CPT code 64911 would be assigned once for each nerve graft performed with modifier 59 or XS assigned to the second instance of the code. Modifiers 76 and 77 Repeat Procedure Modifiers
  • 52. © Health Catalyst. Confidential and Proprietary. Repeat Clinical Diagnostic Laboratory Test • Used when it is medically necessary to repeat the same lab procedure on a single date of service to obtain multiple results. • Examples: Repeated arterial blood-gas measurement to monitor patient’s condition or follow up with potassium level after treatment of hyperkalemia. • Do not use when tests are rerun to confirm initial results, due to testing problems with specimens or equipment or for other reasons when a one-time result is all that is necessary. • Do not use when multiple specimens are required to complete a single lab test. • Example: Glucose tolerance test (82951)- Blood specimens are obtained at specific intervals. Because the description of the code includes “three specimens”, modifier 91 would not be reported. Modifier 91 Repeat Procedure Modifiers
  • 53. © Health Catalyst. Confidential and Proprietary. Modifier 91 vs Modifier 59 for Lab Testing When the same laboratory test is performed on more than one specimen type (eg, blood and urine) or different species or strains reported by the same code, an X modifier or modifier 59 is appropriate. When it is necessary to repeat the same laboratory test on the same day to obtain subsequent test results (eg, repeated blood testing), modifier 91 is appropriate. These serial laboratory test results are used to manage the treatment of the patient. So, the patient may be treated then the lab may be rerun, or the lab may be run at regular intervals to make sure it’s trending in the right direction. Modifier 91 vs Modifier 59 Repeat Procedure Modifiers
  • 54. © Health Catalyst. Confidential and Proprietary. A comprehensive metabolic panel (80053) is performed for a patient and results show a low potassium level. The physician orders infusion therapy to correct the condition. After therapy (on the same day) the physician orders a second potassium level study (84132). 84132, Potassium; serum, plasma or whole blood. 84132-91, Potassium; serum, plasma or whole blood. Modifier 59 A patient has two infected wounds that are swabbed for aerobic bacterial cultures (87071). These specimens were collected at the same time from different locations. 87071, Culture, bacterial; quantitative, aerobic with isolation and presumptive identification of isolates, any source except urine, blood or stool. 87071-59 (or X-modifier), Culture, bacterial; quantitative, aerobic with isolation and presumptive identification of isolates, any source except urine, blood or stool. Modifier 91 vs Modifier 59- Examples Modifier 91 Repeat Procedure Modifiers
  • 55. © Health Catalyst. Confidential and Proprietary. Return to Surgery Modifiers
  • 56. © Health Catalyst. Confidential and Proprietary. Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period. • Used when another procedure is performed during the postoperative period of the initial procedure (unplanned) (For planned subsequent procedures, see Modifier 58). • Treatment of a complication or problem that occurred after the first procedure related to that procedure that needs to be treated with another different procedure. • Procedure must be related to the first procedure (if unrelated, see modifier 79). • Should not be used for repeat procedures (see modifier 76 for repeat procedures). Modifier 78 Return to Surgery Modifiers
  • 57. © Health Catalyst. Confidential and Proprietary. Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period. • Used when another procedure is performed during the postoperative period of the initial procedure (unplanned) (For planned subsequent procedures, see Modifier 58). • Procedure must be unrelated to the first procedure (if related, see Modifier 78). • Should not be used for repeat procedures (see Modifier 76 for repeat procedures). Modifier 79 Return to Surgery Modifiers
  • 58. © Health Catalyst. Confidential and Proprietary. Newer Modifiers
  • 59. © Health Catalyst. Confidential and Proprietary. Zero drug amount discarded/not administered to any patient. • Append to the code for a drug or biological in a single-use vial or single-use package when there is no discarded amount after administering the agent to the patient. • Modifier only applies when the agent is in a single-use vial or single-use package. • Most of the time, if drug or biological code does not require modifier JW, Drug amount discarded/not administered to any patient, it will require JZ. Modifier JZ- Effective 1/1/2023 ; Required 7/1/2023 Newer Modifiers
  • 60. © Health Catalyst. Confidential and Proprietary. Drug amount discarded/not administered to any patient. • Append to the code for a drug or biological in a single-use vial or single-use package to show that the provider administers the necessary or prescribed amount of a drug and discards the remaining amount of the drug. JW should be appended to the discarded amount on a separate line. • Claim line #1: HCPCS code for drug given, No modifier, # of units given, Calculated submitted price for ONLY the amount of drug given. • Claim line #2: HCPCS code for drug wasted, JW modifier to indicate waste, # of units wasted, Calculated submitted price for ONLY the amount of drug wasted. • Documentation must include the amount of the drug that the provider discards. Effective 1/1/2003 Modifier JW
  • 61. © Health Catalyst. Confidential and Proprietary. Resources 2023 Medicare Part B Final Rule Released. https://www.asha.org/news/2022/2023-medicare-part-b-final-rule- released/ Billing and Coding: JW Modifier Billing Guidelines. https://www.cms.gov/medicare-coverage- database/view/article.aspx?articleId=53024&DocID=A52953 Clear Confusion Between Modifier 91 vs 59. American Medical Coding. https://www.americanmedicalcoding.com/modifier-91-vs-59/ Coding with Modifiers 6th Edition. A Guide to Correct CPT and HCPCS Level II Modifier Usage. Robin I. Linker, American Medical Association. CPT 2023 Professional Edition. American Medical Association. HCPCS Level II Expert. Service/Supply Codes for Caregivers & Suppliers. AAPC. Modifier 50 Fact Sheet. https://www.novitas- solutions.com/webcenter/portal/MedicareJL/pagebyid?contentId=00144531
  • 62. © Health Catalyst. Confidential and Proprietary. Questions? Q&A Document can be found on Healthcatalyst.com under Resources/Webinars

Editor's Notes

  1. NCCI and PTP edits indicate that two codes generally can’t be reported together. Certain modifiers help to bypass these edits which I’ll show in the next slide.
  2. modifiers that may be used under appropriate clinical circumstances to bypass an NCCI PTP edit include… It’s very important that NCCI PTP-associated modifiers only be used when appropriate. In general, these circumstances relate to separate patient encounters, separate anatomic sites, or separate specimens. We’re not going to cover all of these today- a couple of these are only for facility use- we will cover most. I just wanted to give you the full list.
  3. First bullet- “T” and “S” are procedures that are covered under OPPS Second bullet- a different diagnosis as the original diagnosis may not be required to report the E/M service on the same date with the modifier 25. So the procedure and the E/M may have the same diagnosis code associated to it. This was clarified by the AMA because there are cases where you are only reporting modifier 25 because you are going above and beyond the usual work for the procedure, not because you are tending to a different issue, so in that case the diagnosis would be the same. Fourth bullet- “above and beyond”… must be documented in the record Last bullet- Type A Ed is ED care 24/7 7 days a week . Type B ED visits is a visit to a facility providing urgent or emergency care that is not open 24 hours a day and 7 days a week. G0175 is a scheduled interdisciplinary team conference with patient present, and G0402 is initial preventative physical exam during first 12 months of medicare enrollment. What happens if you do not append modifier 25 to an E/M service and you report a procedure/service with the E/M service? It would be likely that it would either be denied (even if you have a different diagnosis for each service), or the insurance would pay for the lesser of the two services and bundle the services.
  4. Services that do not meet appropriate guidelines for reporting an E/M service. To report code 99203 a medically appropriate history and/or exam and a low level of MDM is required or a total time of 30-44 minutes) must be met and supported in the documentation. Be careful when dealing with commercial payers… this is one modifier where we tend to see differences between payers and medicare policies. Many payers believe that modifier 25 is over used and abused. This modifier has been on the Office of Inspector General (OIG) watch list and has triggered many provider audits for high use and mis use. So just use caution when reporting this esp. when reporting minor procedures. The documentation must show that the E/M service goes above and beyond usual care for this type of procedure.
  5. The E/M service performed in the ED included all the appropriate elements of an E/M service and after the evaluation the decision that it was necessary to repair the forehead laceration was made. Modifier 25 is reported to prevent inappropriate bundling of these two, separately identifiable services.
  6. The complex repair procedure was performed after the ED visit evaluation, and it is distinct and separately identifiable. Modifier 25 is appended to the visit code to support the evaluation, which is separate from the complex repair procedure performed.
  7. The multiple E/m Services provided do not need to be the same level of care or type of service. Not to be used for physician reporting. Check with your payer to see what is allowed (same physician or different). Instinct is to follow coding guidelines. Makes things confusing when CMS disagrees
  8. Multiple medical visits on the same day in the same revenue center may be submitted on separate claims. Hospitals should report condition code G0 ON THE SECOND CLAIM. The outpatient code editor contains an edit that will reject multiple medical visits on the same day with the same revenue code without the presence of condition code G0.
  9. Patient was seen in the ED in two separate visits on the same date of service at the same facility. Mod 27 reported on the second ED visit to prevent a duplicate services denial. Second claim form should also include condition code G) to indicate that the visits occurred within the same revenue center at the facility.
  10. we see a difference in coding guidance and payers here. Coding guidance says not to use modifier since it’s stated in the code definition but some payers want the modifier regardless. So check with your payer. You can push back here and say coding guidance does not support modifier usage in these circumstances but ultimately it will be on the payer to decide.
  11. These are informational only but were added to streamline claims processing so that there wouldn’t be a need to request additional documentation to avoid duplicate or other inappropriate billing. Some third party payers require these modifiers.
  12. Most S&I codes are already separated into unilateral and bilateral where appropriate Multiple payers do not use these modifiers as intended – Don’t be afraid to push back on payers that are asking for modifiers that violate correct coding principles
  13. T1 is left foot second digit which identifies the specific foot and digit on which the physician performed the procedure. This should be used rather than LT unless a certain payer requires different/doesn’t recognize T1.
  14. This should not be appended to procedures for midline organs like the bladder, uterus, esophagus, or nasal septum. Breaking up procedures that state bilateral in the code description and coding them as two unilateral procedures is against the NICCI guidelines and incorrect coding from a CPT perspective. Another thing to note about mod 50. If more than one bilateral procedure is performed, make sure to adjust the number of units to reflect the number of procedures and it’s also recommended to add an anatomical modifier with the 50 to show that the additional services are not duplicates. For modifier 50- medicare and most payers will pay at 150%
  15. Check with your MAC. Some MACs are okay with no modifiers and some what “RT” and “LT” if you use the second method.
  16. Used when a procedure is canceled after the patient enters the operating room, but before the administration of anesthesia
  17. No reduction in payment
  18. Provides a way to report the report that the procedure was reduced without disturbing the identification of the actual service performed. Second bullet- as opposed to mod 73 and 74 that are for procedures that require anesthesia and are discontinued or reduced.
  19. If a key component is missing from an E/M service, or if the service cannot be supported with another E/M level or code, the service is reported with the unlisted E/M code 99499 Third bullet- time based procedure codes.. Look into this to explain Unilateral or bilateral- descriptor says it covers either so you do not need to reduce the services. If the code describes a panel of tests such as code 80076 which is the hepatic function panel and one of the tests are not done.. Like the albumin test.. Then code all the tests done separately rather than adding the modifier 52 Some payers are still taking this in a facility setting for procedures that use anesthesia so check with your payer. Medicare does not accept.
  20. First bullet- Used to indicate that the procedure being coded is not considered a component of another procedure. It’s used for services that are not normally reported together, but are appropriate under the circumstances. Second bullet- so for example if a patient has two separate operations on the same day. Or if they have one surgery session but on two different anatomic sites through two different incisions (that is not typically reported together). Example: Patient has destruction of actinic keratosis of the back and a skin biopsy of the cheek. The skin biopsy may be separately coded with modifier 59 since the sites are different.
  21. 2nd bullet- Example: 34833 and 34820 describe different procedures; however the instructions found in the CPT book state these procedures should not be reported together for the same side of the body. If performed on separate sides, modifiers RT and LT may be reported 3rd bullet – example for anatomic sites would be to use the finger modifiers (like F1, F2, etc.) to indicate that the procedure was done on separate digits rather than assigning a 59 to the second procedure code.
  22. These four modifiers were created by CMS in Jan. 2015 due to the widespread misuse and abuse of modifier 59. They give more specificity than modifier 59. No more information was posted about these modifiers for years and then In March 2022 more information regarding the use of these modifiers was released and I’ve included the link here. (long time after they initially came out) Basically these modifiers should be used in place of 59 whenever possible. Should only be used when a more specific anatomic modifier can’t be used such as RT, LT, etc. Use XU if the others don’t fit. 59 doesn’t really need to be used anymore unless payer specifically wants 59 and doesn’t recognize the X modifiers which may be the case for some payers since the guidance for the X modifiers is relatively new (about a year old)
  23. If your payer does not accept modifier XS, you would use 59 here instead. From an NCCI program perspective, the definition of different anatomic sites includes different organs or, in certain instances, different lesions in the same organ. We created NCCI edits to prevent the inappropriate billing of lesions and sites that aren’t considered separate and distinct. Treatment of contiguous structures in the same organ or anatomic region doesn’t generally constitute treatment of different anatomic sites. For example: ● Treatment of the nail, nail bed, and adjacent soft tissue distal to and including the skin overlying the distal interphalangeal joint on the same toe or finger constitutes treatment of a single anatomic site (See example 4 below.) Has to be non contiguous sites to use modifier (so not sharing a common border or touching, not next to each other)
  24. If it doesn’t meet criteria for another modifier . Example… Modifiers 25 and 27 have to be on E/M codes so if it’s not an E/M code you could rule those out… modifier 58 is for a staged procedure.. Didn’t talk about this one in this presentation, but if it’s a planned staged procedure you would use that rather than the XE modifier… 91 is only for lab codes)
  25. Medicare considers two physicians in the same ggroup with the same specialty performing services on the same day as the same physician.
  26. Last resort modifier. Should be your least used modifier.
  27. In the MLN article, CMS describes two very specific examples where you may see modifier XU used.. Not to say these are the only situations where it will be used, but these are two examples
  28. The chest xray is not typically required, not expected.. It had to be done because of the cough so it can be picked up with a modifier.
  29. Must be the EXACT same procedure to use these modifiers First bullet ECG example: So the modifier is only appended to the subsequent services/procedures, not the first one. Medicare will allow multiple ECG interpretations on the same day when necessary but to prevent billing denials the time that each service was performed must be submitted on the claim. Obviously this shouldn’t be used with procedures that would not reasonably be done twice in once day like the removal of a device. If they removed it once then it’s out already so it would be questioned.
  30. Bullet 2- So if different doctors run the same test on the same date of service just to confirm results. It would not be appropriate to use modifier 91 in this case. Or if best practices were not followed when drawing the specimen and the specimen was compromised, it would not be appropriate to run the test twice and use modifier 91 on the second. So when you’re reporting this you will report each service on a separate line with 91 only appended to the repeat procedure.
  31. The word Procedure was added to this description to clarify that this modifier does not only apply to major inpatient surgeries.. This is any procedure. Modifier 58 is Staged or related procedure or service by the same physician or QHP during the post op period. Modifier 79 is an unrelated procedure that is performed by the same physician in the post op period. It is something completely different from the first procedure that has nothing to do with the first procedure.. Example if the patient got in a wreck and needed surgery for an injury due to the wreck. Modifier 76 we covered previously but as a reminder this is when the exact same procedure or service is repeated again. Reasons may include: It was performed for comparative purposes The two services were performed at different times (indicate actual times) It was for follow-up after treatment or intervention It was to repeat a test at different intervals Example- If patient was taken back to operative suite because operative site won’t stop bleeding after surgery.
  32. Example- patient had an ACL repair and later that day has a nasal bleed with clots and they try pressure packing and local vasoconstrictors but that doesn’t work… they need to take patient back to surgery to control the nasal hemorrhage
  33. You may start reporting on Jan. 1, 2023 that’s when modifier was effective, but it’s not mandatory until 7/1 Append this modifier to the supply code for the drug or biological to show that there is no discarded amount to report after administration to the patient. Use of this modifier ties in with modifier JW, which is not a new modifier.. Its been around since 2003. JW is appended to drugs or biologicals codes to show that the provider administered the necessary or prescribed amount of the drug supplied in a single dose vial and discarded the remaining amount of the drug. We have an article on the health catalyst website under “insights” with more detail on the use of this modifier and CMS also has a good FAQ document that I have linked in the references at the end.
  34. This is not a new modifier, just want to talk about this one real quick since I just mentioned it and it’s the counterpart of JZ CMS has no specific requirements regarding the method, format, or where the discarded amount of the drug is documented within the EHR. However, the organization expects providers to maintain accurate medical records regarding drug waste for every beneficiary. Just a note about this modifier- it shouldn’t be assigned to drugs that are oral, inhaled, or implanted.