Presentation on theme: "Coding with Modifiers Oregon Medical Association October 29, 2009"— Presentation transcript:
1 Coding with Modifiers Oregon Medical Association October 29, 2009 Frann M. Britton, RN, CCS,CCS-P
2 CPT Categories Category I Describe a procedure or service identified with a 5-digit numeric CPT codeGenerally based on the procedure being consistent with contemporary medical practiceBeing performed by many physicians in a clinical practice in multiple locationsBeing HIPAA compliant means applying the correct modifier to the correct CPT/HCPCS code.
3 CPT Categories Category II Performance Measurement Are intended to facilitate data collection by coding certain services and/or tests results that are agreed on as contributing to positive health outcomes and quality patient care.Tracking codes for performance measurementMay be services that are typically part of an Evaluation and management service
4 CPT Categories Category II Performance Measurement May be a component part of a service and are not appropriate for Category I CPT codes.Do not have relative valueNo payment associated with these codesWill decrease need for record abstraction and chart reviewMinimize administrative burden on physicians and health plans
5 CPT Categories Category II Performance Measurement Performance Measures Advisory GroupEvidenced-based measurements with established ties to health outcomesMeasurements that addresses clinical conditions of high prevalence, high risk, or high costWell-established measurements that are currently being used by a large segment of the health care industry nation wide.
6 CPT Categories Category II Performance Measurement The use of these codes is optional and is not required for correct coding.
7 CPT Categories Category III Emerging Technology Temporary set of tracking codes for emerging technologies, services, and procedures.Intended to facilitate data collection and assessment of these services and procedures.Used for data collection purposes to substantiate widespread usage or in the FDA approval process.
8 CPT Categories Category III Emerging Technology Must have relevance for research, either ongoing or planned.Once approved by Editorial Panel are added to Level I CPT codesNo relative valuesPayment subject to payer policiesArchived after 5 years if not added to CPT
9 HCPCS Coding System HCPCS CMS‘s Health Care Common Procedure Coding SystemDeveloped in 1983 to standardize the coding systems to process Medicare claims on a national basis.2 levels CPT and HCPCS
10 HCPCS Coding System Level I CPT Level II National Codes Makes up the majority of the HCPCS systemLevel II National CodesDurable medical equipmentAmbulance servicesMedical and surgical supplies, drugsOrthotics, prosthetics, dental and eye services
11 HCPCS Coding System Level II National Codes 5 character alphanumeric codesFirst character is a letter A-V (except I) followed by 4 numeric digits (A4550)Alphabetic (eg, RT) and alphanumeric (eg, E2) modifiersUpdated annually by CMSRequired for reporting most medical services and supplies provided to Medicare and Medicaid patients.
12 National Correct Coding Initiative Edit of code pairs of CPT or HCPCS that are not separately payable except under certain conditions.Same beneficiary, same physician, same datePromote national correct codingEliminate improper codingCMS developed NCCI edits to promote
13 National Correct Coding Initiative Developed by CMS to prevent inappropriate payment of services that should not be reported together.2 NCCI tables:“Column One/ Column Two Correct Coding Edit Table” and “Mutually Exclusive Edit Table”.
14 National Correct Coding Initiative Each edit table contains edits of pairs of HCPCS/CPT codes in general should not be reported together.If a provider reports the two codes of an edit pair, the column two code is denied.When clinically appropriate to utilize an NCCI-associated modifier, both the column one and column two codes are eligible for payment.
15 National Correct Coding Initiative Column two codes are often a component of a more comprehensive column one code it is not true for many edits.The code pairs simply represents two codes that should not be reported together.Vaginal hysterectomy and total abdominal hysterectomy code together.
16 National Correct Coding Initiative NCCI is used by all practioners, hospitals, providers or suppliers eligible to bill Medicare.
17 National Correct Coding Initiative Coding conventions defined in CPTCurrent standards of medical and surgical careInput from specialty societiesAnalysis of current coding practiceUpdated on quarterly basisDenial based on NCCI edits may not bill patientThe NCCI edits are developed based on the above. Can be downloaded from the CMS website
18 National Correct Coding Initiative 2 columns, 1st lists CPT code2nd (component) code, integral to Column 1Denied without modifierMutually exclusive edit2 codes cannot reasonably be performed together based on code definitions or anatomic considerations.Only column 1 paid s modifier.
19 Procedures and Global Period All procedure on the Medicare Physician Fee Schedule are assigned a Global period of 000,010,090,XXX,YYY or ZZZ.The global concept does not apply to XXX procedures.The global period for YYY procedures is defined by the Carrier.All procedures with a global period of ZZZ are related to another procedure, and the global period for the ZZZ code is determined by the related procedure.
20 Procedures and Global Period NCCI edits are applied to same day services by the same provider to the same beneficiary.An E/M service is separately reportable on the same DOS as a procedure with global days, 000,010,090 under limited conditions.Minor procedures global days are 000 or 10.Major procedures have 90 global days.
21 Procedures and Global Period If an E/M is performed on the same date of service as a major surgical procedure for the purpose of deciding whether to perform this surgical procedure, append modifer -57 to the E/M.The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E/M service.A significant and separately identifiable E/M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier-25.
22 Procedures and Global Period Medicare example:“If a physician determines that a NEW patient with head trauma requires sutures, confirms the allergy and immunization status, obtains informed consent, and performs the repair, an E/M service is not separately reportable.HOWEVER, if the physician also performs a medically reasonable and necessary full neurological examination, an E/M service may be separately reported”.
23 Procedures and Global Period XXX procedures have inherent pre-procedure, intra-procedure and post-procedure work usually performed each time the procedure is completed.(EKG’s. x-rays, ultrasounds)This work should never be reported as a separate E/M.An separate E/M can be reported with -25 if it is significant, separately identifiable.
24 NCCI Modifiers Anatomic modifiers Global surgery modifier E1-E4, FA, F1-F9, TA, T1-T9, LC, LD, RC,LT,RTGlobal surgery modifier-25 Significant E/M same day as Procedure-58 Staged or related Procedure during Postop-78 Unplanned Return to OR during postop-79 Unrelated procedure during postop-59 Distinct Procedure-91 Repeat Clinical Diagnostic Lab-27 Multiple Outpatient E/M on same Date
25 NCCI ModifiersImportant to use NCCI-associated modifiers only when appropriateSeparate patient encounterSeparate anatomic sitesSeparate specimensPaired organs
26 Modifiers Evaluation and Management Only -24 Unrelated E/M Unrelated E/M during thepostoperative period.-25 Separate E/M-57 Decision for Surgery
27 Modifiers Evaluation and Management Only -24 Unrelated E/M Unrelated E/M during the postoperative periodThe same physician and unrelated to the original surgerySeparate note if he/she evaluates the previous surgical site and determines the site requires care, this would not be part of the new encounter.
28 Modifiers Evaluation and Management Only -25 Significant, separately identifiable E/M service performed by the same physician on the day of a procedure.Modifier -25 is critical to appropriate communication about what happened in a patient encounter on a given dateProcedures with 0,10, global days, endoscopies, XXX services.
29 ModifiersModifier was added by CMS in 1992 to help reduce the documentation burden on physicians.Says the provider went “above and beyond” the other service provided.Modifier-25 is not restricted to any level or SOS.The same diagnosis may accurately describe the nature or reason for the encounter and the procedure.The record, however—should document an important,notable, distinct correlation with signs and symptoms tomake a diagnostic classification or demonstrate a distinctproblem.
30 Modifiers Evaluation and Management Only -57 Decision for Surgery is appended to an E/M only when that service represents the initial decision to perform a major surgical procedure.E/M the day prior to or day of a major procedure with a 90 day global period.Be prepared to submit consultation, visit or hospital note to support decision for surgery.
31 Modifiers -22 Unusual Procedure When the service provided is greater than that usually required for the listed procedure.Used in the following sections:AnesthesiaSurgeryRadiologyLaboratory and PathologyMedicine
32 Modifiers -22 Unusual Procedure operative cases Trauma extensive enough to complicate the particular procedure and that cannot be billed with additional proceduresSignificant scarring requiring extra time and workExtra work resulting from morbid obesityIncreased time resulting from extra work by the physicianNeeds a concise statement about how the service differs from the usualAn operative report submitted with the claim
33 Modifier -22Occasionally a provider may perform two procedures that should not be reported together based on an NCCI edit.If the edit allows use of NCCI-associated modifiers to bypass it and the clinical circumstances justify use of one of these modifiers, both services may be reported with the NCCI-associated modifier.If the NCCI edit does not allow use of NCCI-associated modifiers to bypass it and the procedure qualifies as an unusual procedural service, the physician may report the column one column one HCPCS/CPT code of the NCCI edit with modifier 22.
34 Modifier -22The Medicare carrier cannot override an NCCI edit that does not allow use of NCCI-associated modifiers,The carrier has discretion to adjust payment based on modifier 22.
35 Modifiers -26 Professional Component Certain procedures are a combination of a physician component and a technical component. When the physician component is reported separately add -26.If the radiologist owns the equipment, interprets the test, and pays the technologist, modifier TC and 26 do not apply.Physician does not own the equipment -26Facility provided the equipment and technician –TCCPT only has a professional componentmodifier -26 would not be used.
36 Modifiers -26 Professional Component CPT simple cystometrogram (CMG)This code includes all supplies, equipment, and the technician’s work, including interpretation of the results.If the physician only interprets the results and dictates a report, modifer -26 would be appended to the code.The hospital would submit the same code with -TC
37 Modifiers -50 Bilateral Procedure Unless otherwise identified in the listings, bilateral procedures that are performed at the same operative session should be identified with -50.Bilateral procedures are typically performed on both sides of the body (mirror image) during the same operative session.Append to unilateral code as a one-line entry, unit of oneModifier does affect payment 2nd pr at 50%
38 Modifiers -50 Bilateral Procedure If the procedure is performed unilaterally and the descriptor indicates bilateral, append modifier-52.69210 removal cerumen one or both earsDo not use -50 codeProcedure performed unilaterally and descriptor indicates bilateral add -52
39 Modifiers -50 Bilateral Procedure Many payers will not accept -50 for radiology use LT and RTMedicare allows LT and RT instead of -50 when the code does not indicate a bilateral procedure.
40 Modifiers -50 Bilateral Procedure bilateral code sets: 69210 Ear wax removal 1 or both ears55300 Vasotomy, unilateral or bilateral27158 Osteotomy, pelvis, bilateral30801 Cautery and/or ablation, mucosa turbinatesunilateral or bilateral40843 Vestibuloplasty; posterior, bilateral35548 Bypass graft, with vein, unilateral35549 Bypass graft, with vein, bilateral
41 Modifiers -51 Multiple Procedures Used when multiple procedures, other than E/M, are performed at the same session by the same provider, the primary procedure or service is listed first.-51 is add to the additional procedures.List procedures in ranking order highest RVU listed first.-51 not needed for Medicare-52 may be used with E/M physicals its rare. If Medicare does not receive documentation with rationale for coding -52 the modifier will be ignored as if it were not appended to the code.
42 Modifiers -51 Multiple Procedures has 3 applications Multiple, related surgical procedures performed at the same sessionSurgical procedures performed in combination whether through the same or another incision or involving the same or different anatomyA combination of medical and surgical procedures performed at the same session-52 may be used with E/M physicals its rare. If Medicare does not receive documentation with rationale for coding -52 the modifier will be ignored as if it were not appended to the code.
43 Modifiers -51 Multiple Procedures Do not append -51 to E/M service Do not append to “add- on “ codesDo not append to “each additional”(finger fracture's, tendon repair)“List separately in addition to primary procedure.” (lesions, vertebral segments)Modifier 51 exempt symbol ØSee Appendix D in CPT for complete list of add on codes.
44 Modifiers Two or more physicians at same operations -51 Multiple ProceduresTwo or more physicians at same operationsEach surgeon reports his/her own CPT codes without modifer -51Modifier -51 same surgeon, same session, multiple procedures as long as they are not considered incidental or bundledSee Appendix D in CPT for complete list of add on codes.
45 Modifiers -51 Multiple Procedures 100% first procedure 50% 2nd – 5th each additionalafter 5th “by report basis”100, 50, 25 Other payer specific payment policyMedicare payment policy. Remember if modifier-50 is one of the procedures list this code first and double the dollars.
46 Modifiers-52 Reduced Service – part of service or procedure reduced or eliminated at the physician’s discretion.Provides a means of reporting reduced services without disturbing the identification of the basic service.-52 may be used with E/M physicals its rare. If Medicare does not receive documentation with rationale for coding -52 the modifier will be ignored as if it were not appended to the code.
47 Modifiers -52 Reduced Service – May or may not affect reimbursement Chart note or op note should be sent with claimNot all carriers recognizeNot recognized with E/M – CMS-52 may be used with E/M physicals its rare. If Medicare does not receive documentation with rationale for coding -52 the modifier will be ignored as if it were not appended to the code.
48 Modifiers-53 Discontinued ProcedureWhen patients experience unexpected responses (hypotension, arrhythmia) causing a procedure to be terminatedProcedure stopped due to patients life-threatening conditionAfter anesthesia is administered to patientPayers cover only the primary procedureNot for laparoscopic or endoscopic procedure converted to an open procedure-58 endoscopic procedure to open add -58 to open procedure
49 Modifiers -54 Surgical Care Only -55 Postoperative Management Only -56 Preoperative Management Only
50 Global Surgical Package Refers to payment policy of bundling payment for the various services associated with an operation into a single payment covering;OperationPostoperative hospital visitsNormal typical follow-up careMajor procedures only…90 day global
51 Global Surgical Package CMSPreoperative period begins one day prior to surgery in or out of the hospital and continues for 90 days.Carefully monitored by Medicare – may lengthen preoperative period.Major procedures only…90 day global
52 Modifiers -54 Surgical Care Only When one physician performed a surgical procedure and another provided preoperative and/or postoperative management.
53 Modifiers -54 Surgical Care Only Intraoperative care only Fracture reduction in the ED69% of the global feeclosed reduction distal radius
54 Modifiers -55 Postoperative Management Only When one physician performed the postoperative management and anotherperformed the surgical procedure.
55 43770-54 Laparoscopy, gastric band Bariatric surgeryLaparoscopy, gastric band
56 43770 Laparoscopy, gastric band Bariatric surgery Work Expense Mal PracticePre 9% Intra 81% Post 10%
57 Modifiers -55 Postoperative Management Only Date of surgery plus number of daysx5 unitsBill after patient is seen initially in f/uPayment 10-20% of post-op allowableTransfer of care documentedMake sure the number of days the management was provided is listed in the units column on the 1500 and the dates of service equal the global days
58 Modifiers -56 Preoperative Management Only When one physician performed the preoperative care and evaluation and another performed the surgical procedure.
59 ModifiersNeeds to be communication between the surgeon and the physician providing either pre-op or post-op services.Discharge summary of the hospital or ASC
60 ModifiersPaymentModifier -56 based on the preoperative value of the global surgery feeReport date of surgery on 1500CPT Aortic valve repair
61 Modifiers-58 Staged or Related Procedure or Service by the same physician during the postoperative periodPlanned prospectively, more extensive than the original procedure or represents a therapeutic or diagnostic procedure or serviceUsed during the global surgical period for the original procedureNew postoperative period beginsNot used for return to the operating room for treatment of a problemFull reimbursement – new global days
62 ModifiersIf a diagnostic endoscopic procedure results in the decision to perform an open procedure, both procedures may be reported with modifier-58 appended to the CPT code for the open procedure.If the scope is a “scout” procedure to asses anatomic landmarks and or/extent of disease it is not report separately.If snare used to remove 2 polyps one code. Snare and hot biopsy 2 codes. Can’t bill for multiple techniques used on the same site.Medicare (OIG) is looking at Colonoscopies in 2009.
63 A surgeon performed a radical mastectomy (19200) on a 56-yr-old woman A surgeon performed a radical mastectomy (19200) on a 56-yr-old woman. The patient indicated that she preferred a permanent prosthesis after the surgical wound healed. The surgeon took the patient back to the operating room during the post-op period and inserted a permanent prosthesis.CPT code:
64 A diabetic patient with advanced circulatory problems had three gangrenous toes removed from her left foot (28820, , ). During the post-op it became necessary to amputate the patient’s left foot.CPT code:Rationale: because there was a possibility, in light of the patient’s condition, that amputation might be necessary, this is considered a stage procedure.amputation foot, Tran metatarsal
65 Rational:Because there is a possibility, in the light of the patient’s condition, that amputation might be necessary, this is considered a staged procedure.Rationale: because there was a possibility, in light of the patient’s condition, that amputation might be necessary, this is considered a stage procedure.amputation foot, Tran metatarsal
66 35840 Exploration for postoperative hemorrhage thrombosis or infection; abdomen Code:Modifier -78 not -58 not staged, complication of the original (44140)
67 Modifiers -59 Distinct Procedural Service Documentation must support: Different Session or Pt ContactDifferent procedure or surgeryDifferent site or organ systemSeparate incision or excisionSeparate lesionSeparate injurySeparate area of surgery in extensive injuries, not ordinarily encountered or performed on the same day, by the physician
68 Modifiers Modifier -59 For “exceptions” to the normal rules By passes the NCCI editsUsing incorrectly – tells payer every service is an exceptionLeads to further review of a provider’s billing practicesInappropriate or indiscriminate use of the NCCI modifiers could be considered fraudulent or abusiveDo not confuse modifier 59 with -25.Use only if other modifiers can not be used to appropriately describe the reason for the exception.
69 ModifiersModifier -59Use of modifier -59 to indicate different procedures/surgeries does not require a different diagnosis for each CPT/HCPCS code.Different diagnoses are not adequate criteria for use of modifier The codes remain bundled unless the procedure are performed at different anatomic sites or separate encounters.Do not confuse modifier 59 with -25.Use only if other modifiers can not be used to appropriately describe the reason for the exception.
70 ModifiersModifier -59Different anatomic sites includes different organs or different lesions in the same organ.Does not include treatment of contiguous structures of the same organ.E.g. nail, nail bed, and adjacent soft tissue constitutes treatment of a single anatomic site.Do not confuse modifier 59 with -25.Use only if other modifiers can not be used to appropriately describe the reason for the exception.
71 ModifiersModifier -59Treatment of posterior segment structures in the ipsilateral eye constitutes treatment of a single anatomic site.Arthroscopic treatment of a shoulder injury in adjoining areas of the ipsilateral shoulder constitutes treatment of a single anatomic site.Do not confuse modifier 59 with -25.Use only if other modifiers can not be used to appropriately describe the reason for the exception.
72 Modifiers Modifier -59 CPT 38221 bone marrow, biopsy CPT bone marrow, aspiration onlyCode both if different anatomic sites same incision do not code and do not use -59Medicare CPT and G0364 (bone marrow aspiration performed with bone marrow biopsy through same incision on the same DOS).Do not confuse modifier 59 with -25.Use only if other modifiers can not be used to appropriately describe the reason for the exception.
73 ModifiersModifier -59Should not be used when another, more descriptive modifier is availableDocumentation needs to be specific to the distinct procedure or service and be clearly identified in the medical recordBy passed NCCI edits
74 Modifiers Modifier -59 CPT 87070 Culture bacterial, blood Different site (both arms)CPT Culture bacterial; quantitative,aerobic of two sitesWound infection, lower leg with cultures from proximal wound and distal wound siteLook at CPT descriptions…except urine, blood or stool
75 Modifiers Modifier -59 CPT 97597 Removal devitalized tissue Patient’s right hip and anklelater in the day debrided another 20sq cmfrom the sacral areaLook at CPT descriptions…except urine, blood or stool
76 Surgeon removed a soft tissue 3cm tumor from a patient’s left wrist in the outpatient surgery department. During the same operative session, a 0.8-cm lesion was excised from the patient’s right leg.CPT code:25077 Rad resect tumor, forearmexcise, benign lesion
77 Patient had a total colonoscopy with random biopsies from the ascending colon, transverse colon and sigmoid colon. A hot biopsy destroyed a 3-mm polyp in the sigmoid colon.CPT code:45383 Colonoscopy, ablation of tumorColonoscopy, biopsy
78 70 yr old woman, with SOB under went chest x-ray single view 70 yr old woman, with SOB under went chest x-ray single view. Later in the day the radiologist asked the patient to return for a more extensive study.CPT code:71010 rad exam, single viewrad exam, two view
79 Modifiers-62 Co-surgeon two surgeons performing distinct part(s) of a procedureComplexity of the procedureThe patient’s condition or bothAdditional surgeon is not acting as assistant but is performing a distinct portion of the procedure-62 can be used in radiology for specific procedures
80 Modifiers-62 Co-surgeon two surgeons performing distinct part(s) of a procedureEach surgeon bills the same CPT/ICDSeparate operative reports to document their level of involvement in the surgerySpine surgery – physicians discuss in advance what portion of the procedure each is expected to perform-62 can be used in radiology for specific procedures
81 Modifiers-62 Co-surgeon two surgeons performing distinct part(s) of a procedureSpine surgery opens and closes only, -62 is appended to the primary procedure only-80 when needed to continue as assistant-62 can be used in radiology for specific procedures
82 Modifiers-62 Co-surgeon two surgeons performing distinct part(s) of a procedureFor surgical proceduresEndovascular repair (34800, 34802, 34804, 34812, 34813,34820, 34825)Radiological proceduresCPT urologistCPT radiologist-62 can be used in radiology for specific procedures
83 Modifiers-62 Co-surgeon two surgeons performing distinct part(s) of a procedureReview payer guidelinesDocumentation must support need for 2 surgeons,Each bills with same CPT/ICD codesEach surgeon must dictate his/her own operative reportNot used for surgeon acting as “the assistant surgeon”When two surgeons of the same specialty are billing with -62 documentation may be required to support medical necessity of using surgeons of the same specialty.
84 Modifiers -63 Procedure Performed on Infants Less than 4 kg Increased complexity and physician workUsed only with codes from Surgery section of CPTOnly invasive surgical proceduresNot for surgery that assumes the patient is a neonate or infant (eg. Surgery to correct a congenital abnormality) the relative value already reflects the additional work.Use -22 or -63 not both at same session- Neonates and infants
85 Modifiers Modifier 66 Surgical Team Highly complex procedures requiring theconcomitant services of different specialties,performing different portions of a procedure.Heart transplantLung transplantLiver, pancreas
86 Modifiers Each surgeon bills with -66 appended to the procedures Modifier 66 Surgical TeamEach surgeon bills with -66 appended to the proceduresRequires usually requires prior authorizationSend op report
87 Modifiers -76 Repeat Procedure by Same Physician Intended to describe the same procedure or service repeated rather than the same procedure being performed at multiple sites.Modifier indicates not a duplicateMust be same procedure, same physician-76 Repeat angioplasty same date during global period. -77 same date or during global.
88 Modifiers -76 Repeat Procedure by Same Physician Surgical procedure –same date or during globalMedical – same date93010 EKGEKG’s same dayChest x-raysame day for chest tube placement-76 Repeat angioplasty same date during global period. -77 same date or during global.
89 Modifiers -77 Repeat Procedure by Another Physician Medical necessity must support reason for the repeat procedureSecond physician is not affected by first physician’s service-76 Repeat angioplasty same date during global period. -77 same date or during global.
90 Modifiers-78 Return to the Operating Room for a Related Procedure during the Post-operative PeriodSubsequent procedure is related to the first and requires the use of the operating roomMay be used on the same day or during global periodDo not use the code for the original procedureRepeat surgery is due to a complication of the original procedureAppend modifier to each procedure performed that requires treatment for the complication-78 Known complication, return to OR, treatment room, outpatient surgery, laser -78 to each procedure performed that requires treatment, multiple surgery rules do not apply Bilateral rules do not apply.Any known complicationDoes not start global overDecreased reimbursement (intro-op only)-79 new procedure unrelated to originalStarts new globalNew H&P -24
91 Modifiers-78 Return to the Operating Room for a Related Procedure during the Post-operative PeriodDo not use for procedures that indicate in the descriptor “subsequent, related, or redo”If the complication does not require return to the OR do not append -78Reimbursement intra-operative portion onlyNew global days do not beginUse a complication diagnosis code not the same dx as the original surgery-78 Known complication, return to OR, treatment room, outpatient surgery, laser -78 to each procedure performed that requires treatment, multiple surgery rules do not apply Bilateral rules do not apply.Any known complicationDoes not start global overDecreased reimbursement (intro-op only)-79 new procedure unrelated to originalStarts new globalNew H&P -24
92 Modifiers-78 Return to the Operating Room for a Related Procedure during the Post-operative PeriodComplications of Surgical and Medical Care, Not Classified ElsewhereHemorrhage complicating a procedureDisruption of external surgical woundPost-operative wound infection682.6 knee, back, MRSA-78 Known complication, return to OR, treatment room, outpatient surgery, laser -78 to each procedure performed that requires treatment, multiple surgery rules do not apply Bilateral rules do not apply.Any known complicationDoes not start global overDecreased reimbursement (intro-op only)-79 new procedure unrelated to originalStarts new globalNew H&P -24
93 Modifiers-78 Return to the Operating Room for a Related Procedure during the Post-operative PeriodMechanical Comp Internal Ortho DeviceDislocation of jointV43.64 Total hipUse with CPT only-78 Known complication, return to OR, treatment room, outpatient surgery, laser -78 to each procedure performed that requires treatment, multiple surgery rules do not apply Bilateral rules do not apply.Any known complicationDoes not start global overDecreased reimbursement (intro-op only)-79 new procedure unrelated to originalStarts new globalNew H&P -24
94 Modifiers-78 Return to the Operating Room for a Related Procedure during the Post-operative PeriodComplications of Surgical and Medical Care, Not Classified ElsewherePost-operative wound infection-78 Known complication, return to OR, treatment room, outpatient surgery, laser -78 to each procedure performed that requires treatment, multiple surgery rules do not apply Bilateral rules do not apply.Any known complicationDoes not start global overDecreased reimbursement (intro-op only)-79 new procedure unrelated to originalStarts new globalNew H&P -24
95 Medicare Operating Room Operating room or place equipped specifically for procedures.Hospital operating roomAmbulatory surgery centerCardiac cath suiteLaser suiteEndoscopy suiteICU when patient to sick to move
96 Modifiers-79 Unrelated Procedure or Service by Same Physician During the Postoperative PeriodDifferent diagnosisDoes not require a return to the ORIs not limited to surgical proceduresRestricted to the same physicianAppend -79 to all procedures that apply not just firstBegins new 90 day global period
97 Modifiers 80-82 Assistant Surgeons 80 Assistant Surgeon 81 Minimum Assistant Surgeon82 Assistant Surgeon (when qualifiedresident not available)-AS Physician assistant, nurse practitioner,clinical nurse specialistRepeat angioplasty same date
98 ModifiersCo surgeon (-62) share responsibility for a surgical procedure, each serving as a primary surgeon during some portion of the surgery. Both must be surgeons, and usually of different specialties.CMS, to qualify as assistant the surgeon must actively assist. Must be involved in the actual performance of the procedure.To qualify for CMS definition of an assistant surgeon(-80), the assistant surgeon needs to be able to take over the surgery should the primary surgeon become incapacitated.The surgical note should clearly document what the assistant surgeon did during the operating session.An additional pair of hands for the operating surgeon must be actively involved…Medicare does not pay for stand by service. Payment rates: Medicare 16 % of allowable. Other payers 20%.
99 Modifiers -81 Minimum Assistant Surgeon Assistance for a short period of timeMedicare 13% of allowableWork Comp
100 Modifiers-82 Assistant Surgeon (When Qualified Resident Surgeon Not Available)Prerequisite unavailability of qualified resident (teaching hospitals)
101 Modifiers -90 Reference (Outside) Laboratory Laboratory bills the physician and the physician office bills the insurance company.36415 lab drawLipid panel
102 Modifiers -91 Repeat Clinical Diagnostic Test Necessary to repeat the same lab testNot to:Confirm initial test resultsDue to testing problems encountered with specimens or equipmentFor any other reason, one-time reportable result is all that is required
103 Modifiers -91 Repeat Clinical Diagnostic Test Follow-up potassium level after treatment of hyperkalemiaRepeat ABG’sDrug testing for each drug80100 CocainemethamphetamineTHC
104 Modifiers -91 Repeat Clinical Diagnostic Test Glucose, blood, reagent strip82951 glucose, three specimens
105 Modifiers -91 Repeat Clinical Diagnostic Test vs modifier -59 -59 Same procedure for a different specimenLaboratory test that is performed more than once on the same day for the same patient. To obtain subsequent test results.
106 Modifiers HCPCS Level II 33 Anatomic modifiers 10 Anesthesia modifiers 300 CMSLook at Appendix A for National HCPCS modifiers. CMS for all 300 modifiers
107 Modifiers Anatomical - HCPCS -LT Left side of the body -RT Right side of the body-FA Left hand – thumb-T5 Right foot - Great toe24 anatomical modifiers
108 Modifiers HCPCS Level II -GA ABN signed -QW CLIA waved test -TC Technical component-GY Item or service does not meet thedefinition of a Medicare benefit-GZ Item or service expected to be deniedas not reasonable and necessaryLook at Appendix A for National HCPCS modifiers. CMS for all 300 modifiers
109 Modifiers HCPCS Level II -GY modifier : physicians, practitioners, or suppliers want to indicate that the item or service is statutorily non-covered or is not a Medicare benefit.-GZ modifier: to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an Advance Beneficiary Notification (ABN) signed by the beneficiary.-GA modifier: when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny a service as not reasonable and necessary and they do have on file an ABN signed by the beneficiary.Look at Appendix A for National HCPCS modifiers. CMS for all 300 modifiers
110 Modifiers HCPCS Level II Foot Care Q7 One class A finding Q8 Two class B findingsQ9 One class B and two class C findingsLook at Appendix A for National HCPCS modifiers. CMS for all 300 modifiers
111 “Never Events” Invasive procedures include a range of procedures from minimally invasive dermatological proceduresBiopsy, excision, and deep cryotherapy for malignant lesions.Extensive multi-organ transplantationPercutaneous transluminal angioplasty and cardiac catheterization.Placement of probes or catheters requiring the entry into a body cavity through a needle or trocar.Do not includeuse of instruments such as otoscopes for examinations.very minor procedures such as drawing blood.
112 “Never Events”A surgical or other invasive procedure is considered to be the wrong procedure if it is not consistent with the correctly documented informed consent for that patient.
113 “Never Events”Surgical or other invasive procedure is considered to have been performed on the wrong body part if it is not consistent with the correctly documented informed consent for that patient including surgery on the right body part, but on the wrong location on the body;Left versus right (appendages and/or organs), or at the wrong level (spine).
114 “Never Events”The event is not intended to capture changes in the plan upon surgical entry into the patient due to the discovery of pathology in close proximity to the intended site when the risk of a second surgery outweighs the benefit of patient consultation; or the discovery of an unusual physical configuration (e.g., adhesions, spine level/extra vertebrae).
115 Modifiers HCPCS PC PA: Surgery Wrong Body Part PB: Surgery Wrong PatientPC: Wrong Surgery on Correct PatientMedicare states billers have been us87ing PC as Processional Component really modifier -26Modifier TC is Technical Component
116 Modifiers HCPCS PA: Surgery Wrong Body Part E876.7 Correct operation on wrong body partPB: Surgery Wrong PatientE876.6 Performance of operation on pt not scheduled for surgeryPC: Wrong Surgery on PatientE Wrong operation correct patient (wrong deviceimplanted into correct surgical siteE876.7 wrong side, wrong site append modifiers to all codes that applyE876.6 Not intended for this patient – not scheduled for surgeryE876.5 wrong operation on correct patient
117 ModifiersHCPCS PC82 yr old male had surgery performed on his right knee for a torn meniscus. The left knee had the torn meniscus.Code:The incorrect surgery must be billed to Medicare. How to code? Can be billed with $.01 when systems do not accept $.0 dollars in the system.
119 Resources http://www.cms.hhs.gov/Transmittals/downloads/R102NCD.pdf CPT 2009, Edition, American Medical AssociationInternational Classification of Diseases, 2009 EditionCoding with Modifiers, AMACenter for Medicare and Medicaid Services, Program ManualMedicare Claims Processing Manual