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Using Modifiers Successfully MCMS & MBA Coding Forum May 8, 2014| Deb Kenney, CPC, CPMA 9:30-11:00 am | Senior Healthcare Consultant Medical Business Advisors,

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Presentation on theme: "Using Modifiers Successfully MCMS & MBA Coding Forum May 8, 2014| Deb Kenney, CPC, CPMA 9:30-11:00 am | Senior Healthcare Consultant Medical Business Advisors,"— Presentation transcript:

1 Using Modifiers Successfully MCMS & MBA Coding Forum May 8, 2014| Deb Kenney, CPC, CPMA 9:30-11:00 am | Senior Healthcare Consultant Medical Business Advisors, LLC

2 Disclaimer All Current Procedural Terminology (CPT®) codes and descriptors used in this presentation are copyright© by the American Medical Association. All rights reserved. The information enclosed was current at the time it was presented. Medicare and commercial payer policy changes frequently. This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of service. Medical Business Advisors, LLC employees, agents and staff make no representation, warranty or guarantee that this compilation of information is error- free and will bear no responsibility or liability for the results or consequences of the use of this guide. This presentation is a general summary that explains certain aspects of the Medicare program, but is not a legal document.

3 Objectives Review the definition and purpose of modifiers Identify which modifiers impact reimbursement Learn which modifiers should be used with specific service types – E/M, Surgery, Interpretations, Informational Only Understand how the proper use of modifiers improves documentation quality and coding accuracy, thereby improving the timeliness and accuracy of your reimbursement

4 Definition and Purpose Modifier Definition : “A modifier provides the means to report or indicate that a service or procedure that has been performed has been altered by some specific circumstance in its definition or code but not changed in its definition or code”* * American Medical Association (AMA) Current Procedural Terminology (CPT®) Manual Modifier Purpose: To enable health care professionals to effectively respond to payment policy requirements

5 When To Use Modifiers Identifying only a professional or technical component of a code An increased, reduced or unusual service Repeat services by the same or different provider To designate a separate service To identify a bilateral procedure or a specific part or side of the body Billing for components of a global surgical package  Note: This is not an all inclusive list

6 Evaluation & Management (E/M) Code Modifiers Modifier AI Modifier AI – Principal Physician of Record Only used on initial hospital/nursing facility care E/M codes Depicts the admitting or attending physician who oversees patient’s care in facility Distinction from other specialty physician care such as consultants Informational Only – No reimbursement impact

7 E/M Code Modifiers, cont’d Modifier 25 Significant, separately identifiable E/M service by the same physician or NPP on the day of a procedure or other service Used with MINOR procedures – 0-10 day global Different diagnosis not required Documentation should support the separate service but medical necessity also required! Ask yourself – What was the purpose of the visit? Impacts Reimbursement but highly scrutinized by payers & CMS

8 E/M Modifiers, cont’d Modifier 57 Modifier 57 – Decision for Surgery Appended to the appropriate E/M service to denote the visit where the decision to perform surgery was made Used when the decision for a major surgery (90-day global period) is made the day of or the day before performing the procedure Cannot be used with a minor surgery (0 or 10-day global period) Impacts Reimbursement

9 E/M Modifiers, cont’d Modifier 24 Modifier 24 – Unrelated E/M service by the same physician or NPP during a postoperative period Should be a different diagnosis (than the surgical procedure) Not used for medical management by the surgeon Not typically used for inpatient visits Exceptions – Immunotherapy management Critical care for burn or trauma patient Subsequent hospitalization Impacts Reimbursement

10 Surgical Modifiers Modifier 50 Modifier 50 – Bilateral Procedure Used when procedure performed on both sides (paired organs/body parts) at the same operative session Through the same incision Separate body parts Do not use when code description contains “bilateral” or “unilateral or bilateral” Typically bill claim line with a unit of 1 with fee increased to 150% of base fee – Check payer guidelines Impacts reimbursement

11 Surgical Modifiers, cont’d LT – Left side LT – Left side Used to identify procedures performed on the left side of the body RT – Right side RT – Right side Used to identify procedures performed on the right side of the body Apply to paired organs or extremities Service performed on one side or pair Informational only – does not impact reimbursement

12 Surgical Modifiers, cont’d Modifier 51 Modifier 51 – Multiple procedures Used to identify the secondary procedure or when multiple procedures are performed On the same day or same session By the same provider Procedures may be in the same operative incision or at a different anatomical site List the major primary (highest dollar value) procedure first and append the modifier to the subsequent procedures Should not be used for CPT® described as the following: Add-on codes (listed in Appendix D noted with the + symbol) CPT codes which are Modifier 51 exempt (listed in Appendix E with the Ø symbol) Impacts Reimbursement

13 Surgical Modifiers, cont’d Modifier 52 Modifier 52 – Reduced services Service or procedure partially reduced or eliminated at the physician’s discretion Used to report procedures for which anesthesia is not planned that are discontinued after the patient is prepared and taken to the room where the procedure is to be performed Appended to CPT® code to signify the service is reduced Impacts reimbursement May also be applied to radiology services

14 Surgical Modifiers, cont’d Modifier 53 Discontinued procedure Physician elects to terminate a surgical or diagnostic procedure due to extenuating circumstances that may threaten the well- being of the patient Append modifier to the discontinued procedure’s CPT® code

15 Surgical Modifiers, cont’d Modifier 58 Modifier 58 – Staged or related procedure or service by the same physician or NPP during the postoperative period Documentation should indicate the following: Procedure was planned or anticipated; More extensive than original procedure; or Therapy following a surgical procedure Impacts Reimbursement

16 Surgical Modifiers, cont’d Modifier 76 – Modifier 76 – Repeat procedure or service by same physician or NPP It may be necessary to indicate that a procedure or service was repeated by the same physician Can be used with surgical or other types of services, such as radiology or medicine services Should not be used with E/M codes Modifier 77 – Modifier 77 – Repeat procedure or service by another physician or NPP Same description as 76 except being a different physician

17 Surgical Modifiers, cont’d Modifier 78 Modifier 78 – Unplanned return to the OR/procedure room by the same physician following the initial procedure for a related procedure during the postoperative period Used to indicate another procedure was performed during the postop period of the initial procedure performed earlier on the same day Impacts reimbursement Modifier 79 Modifier 79 – Unrelated procedure or service by the same physician during the postoperative period Used to report unrelated procedure performed during the postop period that is unrelated and not a result of the initial surgery/procedure Impacts reimbursement

18 Assistant Surgeon Modifiers Modifier 80 – Modifier 80 – Assistant Surgeon Modifier 82 – Modifier 82 – Assistant Surgeon (when qualified resident surgeon is not available) Modifier AS – Modifier AS – Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery Impacts reimbursement

19 Modifier 59 – Stands Alone Distinct Procedural Service SAME For the SAME patient SAME On the SAME day SAME By the SAME provider When another already established modifier is appropriate, it should be used rather than modifier 59 Different diagnosis is not necessary Necessary when NCCI (National Correct Coding Initiative) edits indicate two procedures cannot be billed together Impacts reimbursement

20 Modifier 59, cont’d Documentation is key to appropriate & effective use and must support one of the following not ordinarily encountered or performed on the same day by the same individual Different session or patient encounter Different procedure or surgery Different site or organ system Separate incision or excision Separate lesion Not to be used simply to bypass a CCI Claim Edit!

21 National Correct Coding Initiative (NCCI) CMS developed NCCI to:  Promote national correct coding methodologies  To control improper coding Applies to Bill  By the same physician or provider  For the same beneficiary  On the same date of service Reminders  Modifier 59 and other NCCI associated modifiers should NOT be used to bypass an NCCI edit  Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier used

22 NCCI Resources How to use NCCI tools: MLN/MLNProducts/downloads/How-To-Use-NCCI-Tools.pdf MLN/MLNProducts/downloads/How-To-Use-NCCI-Tools.pdf

23 Additional Important Modifiers Modifier 26 - Modifier 26 - Professional Component Includes: The physician’s work in providing the services (e.g. reading films, interpreting diagnostic tests, etc.) Interpretation and written report provided by the physician performing the service This modifier must be reported in the first modifier position and be reported once on the same line of service Radiology, pathology, cardiology – This is where this modifier is used frequently Impacts reimbursement

24 Additional Important Modifiers Modifier TC – Modifier TC – Technical Component Includes: Providing the equipment Supplies Technical personnel Costs related to the performance of the actual procedure other than the professional services Must be reported in the first modifier position and be reported once on the same line of service Impacts reimbursement

25 Other Important Modifiers Advanced Beneficiary Notice of Noncoverage (ABN) Related Modifiers  Modifier GA  Modifier GA – Waiver of Liability Statement Issued, as Required by Payer Policy - Used to report a required ABN was issued for the service  Modifier GX  Modifier GX – Notice of Liability Issued, Voluntary Under Payer Policy – Used to report a voluntary ABN was issued for the service  Modifier GY  Modifier GY – Notice of Liability Not Issued, Not Required Under Payer Policy - Used to report an ABN was not issued because the item or service is statutorily excluded or does not meet the definition of any Medicare benefit  Modifier GZ  Modifier GZ – Item or Service Expected to be Denied as Not Reasonable and Necessary - Used to report an ABN was not issued for a service

26 Summary – Proper Modifier Use Precisely describes the service performed in relation to the published service description (CPT®) Provides additional information and is mandatory on some services Indicates circumstances or conditions of patient care Demonstrates repeat or multiple procedures Establishes cause for higher or lower cost and corresponding reimbursement Conveys a particular component of a procedure, such as the professional component Describes services such as assistant surgeon services, so proper payment can be determined

27 Resources Internet Only Manual (IOM), Publication 100-4, Chapter 4 & 12 - Guidance/Guidance/Manuals/downloads//clm104c12.pdf Guidance/Guidance/Manuals/downloads//clm104c12.pdf National Correct Coding Initiative (NCCI) - NCCI-Coding-Edits.html NCCI-Coding-Edits.html Modifier 59 Article - ownloads//modifier59.pdf ownloads//modifier59.pdf Billing for Services Related to Voluntary Uses of Advance Beneficiary Notices (ABNs) of Noncoverage - Network- MLN/MLNProducts/downloads/abn_booklet_icn006266.pdf Network- MLN/MLNProducts/downloads/abn_booklet_icn006266.pdf

28 Questions & Discussion

29 Contact Information Deb Kenney, CPC, CPMA Senior Healthcare Consultant Medical Business Advisors, LLC (301) 468-2030

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