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Coding with Modifiers Oregon Medical Association October 29, 2009 Frann M. Britton, RN, CCS,CCS-P.

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Presentation on theme: "Coding with Modifiers Oregon Medical Association October 29, 2009 Frann M. Britton, RN, CCS,CCS-P."— Presentation transcript:

1 Coding with Modifiers Oregon Medical Association October 29, 2009 Frann M. Britton, RN, CCS,CCS-P

2 2 CPT Categories Category I –Describe a procedure or service identified with a 5-digit numeric CPT code –Generally based on the procedure being consistent with contemporary medical practice –Being performed by many physicians in a clinical practice in multiple locations

3 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 measurement –May be services that are typically part of an Evaluation and management service

4 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 value –No payment associated with these codes –Will decrease need for record abstraction and chart review –Minimize administrative burden on physicians and health plans

5 5 CPT Categories Category II Performance Measurement –Performance Measures Advisory Group Evidenced-based measurements with established ties to health outcomes Measurements that addresses clinical conditions of high prevalence, high risk, or high cost Well-established measurements that are currently being used by a large segment of the health care industry nation wide.

6 6 CPT Categories Category II Performance Measurement –The use of these codes is optional and is not required for correct coding.

7 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 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 codes –No relative values –Payment subject to payer policies –Archived after 5 years if not added to CPT

9 9 HCPCS Coding System HCPCS –CMS‘s Health Care Common Procedure Coding System –Developed in 1983 to standardize the coding systems to process Medicare claims on a national basis. –2 levels CPT and HCPCS

10 10 HCPCS Coding System Level I CPT –Makes up the majority of the HCPCS system Level II National Codes –Durable medical equipment –Ambulance services –Medical and surgical supplies, drugs –Orthotics, prosthetics, dental and eye services

11 11 HCPCS Coding System Level II National Codes –5 character alphanumeric codes –First character is a letter A-V (except I) followed by 4 numeric digits (A4550) –Alphabetic (eg, RT) and alphanumeric (eg, E2) modifiers –Updated annually by CMS –Required for reporting most medical services and supplies provided to Medicare and Medicaid patients.

12 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 date Promote national correct coding Eliminate improper coding

13 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 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 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 16 National Correct Coding Initiative NCCI is used by all practioners, hospitals, providers or suppliers eligible to bill Medicare.

17 17 National Correct Coding Initiative Coding conventions defined in CPT Current standards of medical and surgical care Input from specialty societies Analysis of current coding practice Updated on quarterly basis Denial based on NCCI edits may not bill patient

18 18 National Correct Coding Initiative 2 columns, 1 st lists CPT code 2 nd (component) code, integral to Column 1 Denied without modifier Mutually exclusive edit –2 codes cannot reasonably be performed together based on code definitions or anatomic considerations.

19 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 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 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 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 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 24 NCCI Modifiers Anatomic modifiers E1-E4, FA, F1-F9, TA, T1-T9, LC, LD, RC,LT,RT Global 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 25 NCCI Modifiers Important to use NCCI-associated modifiers only when appropriate –Separate patient encounter –Separate anatomic sites –Separate specimens –Paired organs

26 26 Modifiers Evaluation and Management Only -24 Unrelated E/M Unrelated E/M during the postoperative period. -25 Separate E/M -57 Decision for Surgery

27 27 Modifiers Evaluation and Management Only -24 Unrelated E/M Unrelated E/M during the postoperative period The same physician and unrelated to the original surgery Separate 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 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 date Procedures with 0,10, global days, endoscopies, XXX services.

29 29 Modifiers Modifier 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 to make a diagnostic classification or demonstrate a distinct problem.

30 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 31 Modifiers -22 Unusual Procedure When the service provided is greater than that usually required for the listed procedure. Used in the following sections: –Anesthesia –Surgery –Radiology –Laboratory and Pathology –Medicine

32 32 Modifiers -22 Unusual Procedure operative cases Trauma extensive enough to complicate the particular procedure and that cannot be billed with additional procedures Significant scarring requiring extra time and work Extra work resulting from morbid obesity Increased time resulting from extra work by the physician Needs a concise statement about how the service differs from the usual An operative report submitted with the claim

33 33 Modifier -22 Occasionally 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 34 Modifier -22 The 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 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 -26 –Facility provided the equipment and technician –TC –CPT 76140 only has a professional component modifier -26 would not be used.

36 36 Modifiers -26 Professional Component –CPT 51725 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 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 one Modifier does affect payment 2 nd pr at 50%

38 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 ears Do not use -50 code Procedure performed unilaterally and descriptor indicates bilateral add -52

39 39 Modifiers -50 Bilateral Procedure Many payers will not accept -50 for radiology use LT and RT Medicare allows LT and RT instead of -50 when the code does not indicate a bilateral procedure.

40 40 Modifiers -50 Bilateral Procedure bilateral code sets : 69210 Ear wax removal 1 or both ears 55300 Vasotomy, unilateral or bilateral 27158 Osteotomy, pelvis, bilateral 30801 Cautery and/or ablation, mucosa turbinates unilateral or bilateral 40843 Vestibuloplasty; posterior, bilateral 35548 Bypass graft, with vein, unilateral 35549 Bypass graft, with vein, bilateral

41 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

42 42 Modifiers - 51 Multiple Procedures has 3 applications Multiple, related surgical procedures performed at the same session Surgical procedures performed in combination whether through the same or another incision or involving the same or different anatomy A combination of medical and surgical procedures performed at the same session

43 43 Modifiers - 51 Multiple Procedures Do not append -51 to E/M service Do not append to “add- on “ codes Do not append to “each additional” ( finger fracture's, tendon repair) “List separately in addition to primary procedure.” (lesions, vertebral segments) Modifier 51 exempt symbol Ø

44 44 Modifiers -51 Multiple Procedures Two or more physicians at same operations Each surgeon reports his/her own CPT codes without modifer -51 Modifier -51 same surgeon, same session, multiple procedures as long as they are not considered incidental or bundled

45 45 Modifiers - 51 Multiple Procedures 100% first procedure 50% 2 nd – 5 th each additional after 5 th “by report basis” 100, 50, 25 Other payer specific payment policy

46 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.

47 47 Modifiers - 52 Reduced Service – May or may not affect reimbursement Chart note or op note should be sent with claim Not all carriers recognize Not recognized with E/M – CMS

48 48 Modifiers -53 Discontinued Procedure When patients experience unexpected responses (hypotension, arrhythmia) causing a procedure to be terminated Procedure stopped due to patients life-threatening condition After anesthesia is administered to patient Payers cover only the primary procedure Not for laparoscopic or endoscopic procedure converted to an open procedure

49 49 Modifiers -54 Surgical Care Only -55 Postoperative Management Only -56 Preoperative Management Only

50 50 Global Surgical Package Refers to payment policy of bundling payment for the various services associated with an operation into a single payment covering; –Operation –Postoperative hospital visits –Normal typical follow-up care

51 51 Global Surgical Package CMS –Preoperative 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.

52 52 Modifiers -54 Surgical Care Only When one physician performed a surgical procedure and another provided preoperative and/or postoperative management.

53 53 Modifiers -54 Surgical Care Only –Intraoperative care only –Fracture reduction in the ED 69% of the global fee 25605-54 closed reduction distal radius

54 54 Modifiers -55 Postoperative Management Only When one physician performed the postoperative management and another performed the surgical procedure.

55 55 43770-54 Laparoscopy, gastric band Bariatric surgery 43770-55 Laparoscopy, gastric band Bariatric surgery

56 56 43770 Laparoscopy, gastric band Bariatric surgery Work Expense Mal Practice 17.85 7.72 2.19 Pre 9% Intra 81% Post 10%

57 57 Modifiers -55 Postoperative Management Only Date of surgery plus number of days –35321-55 x5 units Bill after patient is seen initially in f/u Payment 10-20% of post-op allowable Transfer of care documented

58 58 Modifiers -56 Preoperative Management Only When one physician performed the preoperative care and evaluation and another performed the surgical procedure.

59 59 Modifiers -Needs 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 60 Modifiers -Payment -Modifier -56 based on the preoperative value of the global surgery fee -Report date of surgery on 1500 -CPT 33400-56 Aortic valve repair

61 61 Modifiers -58 Staged or Related Procedure or Service by the same physician during the postoperative period Planned prospectively, more extensive than the original procedure or represents a therapeutic or diagnostic procedure or service Used during the global surgical period for the original procedure New postoperative period begins Not used for return to the operating room for treatment of a problem

62 62 Modifiers If 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.

63 63 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 64 A diabetic patient with advanced circulatory problems had three gangrenous toes removed from her left foot (28820, 28820-51, 28820-51). During the post-op it became necessary to amputate the patient’s left foot. CPT code:

65 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.

66 66 35840 Exploration for postoperative hemorrhage thrombosis or infection; abdomen Code:

67 67 Modifiers -59 Distinct Procedural Service Documentation must support: Different Session or Pt Contact Different procedure or surgery D ifferent site or organ system Separate incision or excision Separate lesion Separate injury Separate area of surgery in extensive injuries, not ordinarily encountered or performed on the same day, by the physician

68 68 Modifiers Modifier -59 –For “exceptions” to the normal rules –By passes the NCCI edits –Using incorrectly – tells payer every service is an exception –Leads to further review of a provider’s billing practices –Inappropriate or indiscriminate use of the NCCI modifiers could be considered fraudulent or abusive

69 69 Modifiers Modifier -59 –Use 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 -59. The codes remain bundled unless the procedure are performed at different anatomic sites or separate encounters.

70 70 Modifiers Modifier -59 –Different 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.

71 71 Modifiers Modifier -59 –Treatment 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.

72 72 Modifiers Modifier -59 –CPT 38221 bone marrow, biopsy –CPT 38220 bone marrow, aspiration only –Code both if different anatomic sites same incision do not code and do not use -59 –Medicare CPT 38221 and G0364 (bone marrow aspiration performed with bone marrow biopsy through same incision on the same DOS).

73 73 Modifiers Modifier -59 Should not be used when another, more descriptive modifier is available Documentation needs to be specific to the distinct procedure or service and be clearly identified in the medical record By passed NCCI edits

74 74 Modifiers Modifier -59 – CPT 87070 Culture bacterial, blood Different site (both arms) – CPT 87071 Culture bacterial; quantitative, aerobic of two sites Wound infection, lower leg with cultures from proximal wound and distal wound site

75 75 Modifiers Modifier -59 –CPT 97597 Removal devitalized tissue Patient’s right hip and ankle 97597-59 later in the day debrided another 20sq cm from the sacral area

76 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:

77 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:

78 78 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:

79 79 Modifiers - 62 Co-surgeon two surgeons performing distinct part(s) of a procedure Complexity of the procedure The patient’s condition or both Additional surgeon is not acting as assistant but is performing a distinct portion of the procedure

80 80 Modifiers -62 Co-surgeon two surgeons performing distinct part(s) of a procedure Each surgeon bills the same CPT/ICD Separate operative reports to document their level of involvement in the surgery Spine surgery – physicians discuss in advance what portion of the procedure each is expected to perform

81 81 Modifiers -62 Co-surgeon two surgeons performing distinct part(s) of a procedure Spine surgery opens and closes only, -62 is appended to the primary procedure only -80 when needed to continue as assistant

82 82 Modifiers -62 Co-surgeon two surgeons performing distinct part(s) of a procedure For surgical procedures Endovascular repair (34800, 34802, 34804, 34812, 34813,34820, 34825) Radiological procedures –CPT 77778-26-62 urologist –CPT 77778-26-62 radiologist

83 83 Modifiers -62 Co-surgeon two surgeons performing distinct part(s) of a procedure Review payer guidelines Documentation must support need for 2 surgeons, Each bills with same CPT/ICD codes Each surgeon must dictate his/her own operative report Not used for surgeon acting as “the assistant surgeon”

84 84 Modifiers -63 Procedure Performed on Infants Less than 4 kg Increased complexity and physician work Used only with codes from Surgery section of CPT Only invasive surgical procedures Not 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

85 85 Modifiers Modifier 66 Surgical Team Highly complex procedures requiring the concomitant services of different specialties, performing different portions of a procedure. Heart transplant Lung transplant Liver, pancreas

86 86 Modifiers Modifier 66 Surgical Team Each surgeon bills with -66 appended to the procedures Requires usually requires prior authorization Send op report

87 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 duplicate Must be same procedure, same physician

88 88 Modifiers -76 Repeat Procedure by Same Physician –Surgical procedure –same date or during global –Medical – same date 93010 EKG 93010-76 2 EKG’s same day 71010-26 Chest x-ray 71010-76-26 same day for chest tube placement

89 89 Modifiers -77 Repeat Procedure by Another Physician Medical necessity must support reason for the repeat procedure Second physician is not affected by first physician’s service

90 90 Modifiers -78 Return to the Operating Room for a Related Procedure during the Post-operative Period –Subsequent procedure is related to the first and requires the use of the operating room –May be used on the same day or during global period –Do not use the code for the original procedure –Repeat surgery is due to a complication of the original procedure –Append modifier to each procedure performed that requires treatment for the complication

91 91 Modifiers -78 Return to the Operating Room for a Related Procedure during the Post-operative Period –Do 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 -78 –Reimbursement intra-operative portion only –New global days do not begin –Use a complication diagnosis code not the same dx as the original surgery

92 92 Modifiers -78 Return to the Operating Room for a Related Procedure during the Post-operative Period Complications of Surgical and Medical Care, Not Classified Elsewhere 998.11 Hemorrhage complicating a procedure 998.32 Disruption of external surgical wound 998.59 Post-operative wound infection –682.6 knee, 682.2 back, 041.12 MRSA

93 93 Modifiers -78 Return to the Operating Room for a Related Procedure during the Post- operative Period Mechanical Comp Internal Ortho Device 996.42 Dislocation of joint V43.64 Total hip –Use with CPT 27265 only

94 94 Modifiers -78 Return to the Operating Room for a Related Procedure during the Post- operative Period Complications of Surgical and Medical Care, Not Classified Elsewhere 998.59 Post-operative wound infection

95 95 Medicare Operating Room Operating room or place equipped specifically for procedures. – Hospital operating room – Ambulatory surgery center – Cardiac cath suite – Laser suite – Endoscopy suite – ICU when patient to sick to move

96 96 Modifiers -79 Unrelated Procedure or Service by Same Physician During the Postoperative Period –Different diagnosis –Does not require a return to the OR –Is not limited to surgical procedures –Restricted to the same physician –Append -79 to all procedures that apply not just first –Begins new 90 day global period

97 97 Modifiers 80-82 Assistant Surgeons –80 Assistant Surgeon –81 Minimum Assistant Surgeon –82 Assistant Surgeon (when qualified resident not available) -AS Physician assistant, nurse practitioner, clinical nurse specialist

98 98 Modifiers Co 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.

99 99 Modifiers -81 Minimum Assistant Surgeon Assistance for a short period of time Medicare 13% of allowable Work Comp

100 100 M odifiers -82 Assistant Surgeon (When Qualified Resident Surgeon Not Available) Prerequisite unavailability of qualified resident (teaching hospitals)

101 101 Modifiers -90 Reference (Outside) Laboratory Laboratory bills the physician and the physician office bills the insurance company. 36415 lab draw 80061-90 Lipid panel

102 102 Modifiers -91 Repeat Clinical Diagnostic Test Necessary to repeat the same lab test –Not to: –Confirm initial test results –Due to testing problems encountered with specimens or equipment –For any other reason, one-time reportable result is all that is required

103 103 Modifiers -91 Repeat Clinical Diagnostic Test Follow-up potassium level after treatment of hyperkalemia Repeat ABG’s Drug testing for each drug –80100 Cocaine –80100-91 methamphetamine –80100-91 THC

104 104 Modifiers -91 Repeat Clinical Diagnostic Test 82948 Glucose, blood, reagent strip 82948-91 82951 glucose, three specimens

105 105 Modifiers -91 Repeat Clinical Diagnostic Test vs modifier -59 -59 Same procedure for a different specimen Laboratory test that is performed more than once on the same day for the same patient. To obtain subsequent test results.

106 106 Modifiers HCPCS Level II 33 Anatomic modifiers 10 Anesthesia modifiers 300 CMS

107 107 Modifiers Anatomical - HCPCS -LT Left side of the body -RT Right side of the body -FA Left hand – thumb -T5 Right foot - Great toe

108 108 Modifiers HCPCS Level II -GA ABN signed -QW CLIA waved test -TC Technical component -GY Item or service does not meet the definition of a Medicare benefit -GZ Item or service expected to be denied as not reasonable and necessary

109 109 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.

110 110 Modifiers HCPCS Level II Foot Care Q7 One class A finding Q8 Two class B findings Q9 One class B and two class C findings

111 111 “Never Events” Invasive procedures include a range of procedures from minimally invasive dermatological procedures Biopsy, excision, and deep cryotherapy for malignant lesions. Extensive multi-organ transplantation Percutaneous transluminal angioplasty and cardiac catheterization. Placement of probes or catheters requiring the entry into a body cavity through a needle or trocar. Do not include –use of instruments such as otoscopes for examinations. –very minor procedures such as drawing blood.

112 112 “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.

113 113 “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).

114 114 “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).

115 115 Modifiers HCPCS PC PA: Surgery Wrong Body Part PB: Surgery Wrong Patient PC: Wrong Surgery on Correct Patient

116 116 Modifiers HCPCS PA: Surgery Wrong Body Part E876.7 Correct operation on wrong body part PB: Surgery Wrong Patient E876.6 Performance of operation on pt not scheduled for surgery PC: Wrong Surgery on Patient E876.5 Wrong operation correct patient (wrong device implanted into correct surgical site

117 117 Modifiers HCPCS PC 82 yr old male had surgery performed on his right knee for a torn meniscus. The left knee had the torn meniscus. Code:

118 118 Questions

119 119 Resources http://www.cms.hhs.gov/Transmittals/downloads/R1 02NCD.pdf CPT 2009, Edition, American Medical Association International Classification of Diseases, 2009 Edition Coding with Modifiers, AMA Center for Medicare and Medicaid Services, Program Manual Medicare Claims Processing Manual


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