Coding with Modifiers Oregon Medical Association October 29, 2009

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

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 Being HIPAA compliant means applying the correct modifier to the correct CPT/HCPCS code.

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

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

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.

The use of these codes is optional and is not required for correct coding.

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.

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

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

HCPCS Coding System Level I CPT Level II National Codes
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

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.

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 CMS developed NCCI edits to promote

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”.

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.

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.

NCCI is used by all practioners, hospitals, providers or suppliers eligible to bill Medicare.

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 The NCCI edits are developed based on the above. Can be downloaded from the CMS website

2 columns, 1st lists CPT code 2nd (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. Only column 1 paid s modifier.

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.

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.

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.

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”.

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.

NCCI Modifiers Anatomic modifiers Global surgery modifier
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

NCCI Modifiers Important to use NCCI-associated modifiers only when appropriate Separate patient encounter Separate anatomic sites Separate specimens Paired organs

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

-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.

-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.

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.

-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.

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

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

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.

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.

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 only has a professional component modifier -26 would not be used.

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

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 2nd pr at 50%

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

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.

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

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.

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 -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.

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 See Appendix D in CPT for complete list of add on codes.

Modifiers Two or more physicians at same operations
-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 See Appendix D in CPT for complete list of add on codes.

Modifiers -51 Multiple Procedures 100% first procedure
50% 2nd – 5th each additional after 5th “by report basis” 100, 50, 25 Other payer specific payment policy Medicare payment policy. Remember if modifier-50 is one of the procedures list this code first and double the dollars.

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.

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 -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.

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 -58 endoscopic procedure to open add -58 to open procedure

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

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 Major procedures only…90 day global

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. Major procedures only…90 day global

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

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

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

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

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

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

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

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

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

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 Full reimbursement – new global days

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. 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.

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:

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

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

35840 Exploration for postoperative hemorrhage thrombosis or infection; abdomen
Code: Modifier -78 not -58 not staged, complication of the original (44140)

Modifiers -59 Distinct Procedural Service Documentation must support:
Different Session or Pt Contact Different procedure or surgery Different 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

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 Do not confuse modifier 59 with -25. Use only if other modifiers can not be used to appropriately describe the reason for the exception.

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 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.

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. Do not confuse modifier 59 with -25. Use only if other modifiers can not be used to appropriately describe the reason for the exception.

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. Do not confuse modifier 59 with -25. Use only if other modifiers can not be used to appropriately describe the reason for the exception.

Modifiers Modifier -59 CPT 38221 bone marrow, biopsy
CPT bone marrow, aspiration only Code both if different anatomic sites same incision do not code and do not use -59 Medicare 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.

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

Modifiers Modifier -59 CPT 87070 Culture bacterial, blood
Different site (both arms) CPT Culture bacterial; quantitative, aerobic of two sites Wound infection, lower leg with cultures from proximal wound and distal wound site Look at CPT descriptions…except urine, blood or stool

Modifiers Modifier -59 CPT 97597 Removal devitalized tissue
Patient’s right hip and ankle later in the day debrided another 20sq cm from the sacral area Look at CPT descriptions…except urine, blood or stool

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, forearm excise, benign lesion

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 tumor Colonoscopy, biopsy

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 view rad exam, two view

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 -62 can be used in radiology for specific procedures

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 -62 can be used in radiology for specific procedures

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 -62 can be used in radiology for specific procedures

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 urologist CPT radiologist -62 can be used in radiology for specific procedures

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” 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.

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 - Neonates and infants

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

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

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 -76 Repeat angioplasty same date during global period. -77 same date or during global.

Modifiers -76 Repeat Procedure by Same Physician
Surgical procedure –same date or during global Medical – same date 93010 EKG EKG’s same day Chest x-ray same day for chest tube placement -76 Repeat angioplasty same date during global period. -77 same date or during global.

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 -76 Repeat angioplasty same date during global period. -77 same date or during global.

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 -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 complication Does not start global over Decreased reimbursement (intro-op only) -79 new procedure unrelated to original Starts new global New H&P -24

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 -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 complication Does not start global over Decreased reimbursement (intro-op only) -79 new procedure unrelated to original Starts new global New H&P -24

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 Hemorrhage complicating a procedure Disruption of external surgical wound Post-operative wound infection 682.6 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 complication Does not start global over Decreased reimbursement (intro-op only) -79 new procedure unrelated to original Starts new global New H&P -24

Modifiers -78 Return to the Operating Room for a Related Procedure during the Post-operative Period Mechanical Comp Internal Ortho Device Dislocation of joint V43.64 Total hip Use 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 complication Does not start global over Decreased reimbursement (intro-op only) -79 new procedure unrelated to original Starts new global New H&P -24

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 Post-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 complication Does not start global over Decreased reimbursement (intro-op only) -79 new procedure unrelated to original Starts new global New H&P -24

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

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

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 Repeat angioplasty same date

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. 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%.

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

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

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

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

Follow-up potassium level after treatment of hyperkalemia Repeat ABG’s Drug testing for each drug 80100 Cocaine methamphetamine THC

Glucose, blood, reagent strip 82951 glucose, three specimens

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.

Modifiers HCPCS Level II 33 Anatomic modifiers 10 Anesthesia modifiers
300 CMS Look at Appendix A for National HCPCS modifiers. CMS for all 300 modifiers

Modifiers Anatomical - HCPCS -LT Left side of the body
-RT Right side of the body -FA Left hand – thumb -T5 Right foot - Great toe 24 anatomical modifiers

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 Look at Appendix A for National HCPCS modifiers. CMS for all 300 modifiers

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

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 Look at Appendix A for National HCPCS modifiers. CMS for all 300 modifiers

“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.

“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.

“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).

“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).

Modifiers HCPCS PC PA: Surgery Wrong Body Part
PB: Surgery Wrong Patient PC: Wrong Surgery on Correct Patient Medicare states billers have been us87ing PC as Processional Component really modifier -26 Modifier TC is Technical Component

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 E Wrong operation correct patient (wrong device implanted into correct surgical site E876.7 wrong side, wrong site append modifiers to all codes that apply E876.6 Not intended for this patient – not scheduled for surgery E876.5 wrong operation on correct patient

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: 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.

Questions

Resources http://www.cms.hhs.gov/Transmittals/downloads/R102NCD.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

Coding with Modifiers Oregon Medical Association October 29, 2009

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