Seminar 6

Modifiers and Usage  Provide additional information regarding the product or service  Two digit codes  CPT codes are numeric  HCPCS codes are alpha

What do modifiers do?  Clarify procedure performed  Extenuating circumstances  Give reasons why something was done

Modifiers:  The modifier on a claim is very important because:  It will tell the payer what kind of reimbursement you are seeking (i.e. professional or technical)  If there was a problem with the procedure itself (cancelled)  You may get payment on something which otherwise you would have not

Remember:  It may be necessary to use the phrase “additional documentation available upon request” in the narrative field of your claim in order to support the modifier used.  When documentation is requested because of modifier usage, the number one reason for denial is because the documentation is not returned in a timely manner.

 Most commonly used:  25- Separate procedure during same encounter:  Significant, separately identifiable E/M service by the same physician on the same day of the procedure of other service, may be the most important for family physicians

 For example: classic use of this modifier; an annual preventative medicine encounter during which the patient says “oh, by the way…” as a result, you address the “by the way” ailment and the preventative service.  In this case you can submit codes for both a preventative service (99396) and a regular OV (99213) by attaching -25 to the OV code.

 This tells the third party payer that you did perform two significant, separately identifiable E/M services for the same patient on the same date, and it should keep the payer from bundling the services.

 Modifier 50:  Applies to any bilateral procedure performed on both sides at the same session  Do not use modifiers RT/LT when modifier 50 applies. A bilateral procedure is reported on one line using modifier 50. the quantity entry to use when modifier -50 is reported is one.

 Modifiers LT/RT: identical body parts (eyes, arms, legs)  Used when a procedure is performed on both sides of the body  Could be same site, or different site  Also when procedure is done on only one side of the body

 Difference between -50 & LT/RT  Use modifier 50 when a unilateral procedure is performed on both sides  Use modifier 50 for eligible only services (use only for surgical codes (Surgery section codes )  Use LT/RT when using anatomic guidelines  Depends on the insurance company which modifier they prefer  Usually second modifier is “dropped”

 Modifier 59:  “distinct procedural service” is similar to modifier 25, but it is applicable to procedural rather than E/M services  You will attach modifier 59 to a code to indicate that a procedural service is distinct or independent from other services performed the same day, particularly when the services or procedures aren’t normally reported together but are appropriate under the circumstances

 Modifier 51  Used to show that more than one procedure was performed  Multiple procedures require documentation (timely)

 Difference between modifiers 51 and 59:  51: numerous procedures  59: distinct service  Can bill a procedure with both modifiers  Example: (many times last modifier will be dropped)

 Modifier 99  Multiple services: use this modifier to report a procedure or service that has more than one modifier but the third-party payer does not allow the addition of multiple modifiers to the code

 There is a comprehensive list of modifiers that can be found in your CPT book  Review modifiers to become acquainted with the different ones  This affects reimbursement greatly, so you should be knowledgeable

 Which modifier indicates diagnostic mammogram converted from screening mammogram on the same day? a. -59 b. -58 c. -AT d. -GH

 Which modifier indicates diagnostic mammogram converted from screening mammogram on the same day? a. -59 b. -58 c. -AT d. -GH

 When two surgeons work together as primary surgeons performing distinct part(s) of a single reportable procedure, each surgeon should report his/her distinct operative work by adding which of the following modifiers? a. -54 b. -66 c. -59 d. -62

 When two surgeons work together as primary surgeons performing distinct part(s) of a single reportable procedure, each surgeon should report his/her distinct operative work by adding which of the following modifiers? a. -54 b. -66 c. -59 d. -62

 When a patient is in a postoperative period and returns to the operating room for an unrelated procedure by the same physician, which of the following modifiers would you attach to the procedure being performed? a. -59 b. -24 c. -78 d. -79

 When a patient is in a postoperative period and returns to the operating room for an unrelated procedure by the same physician, which of the following modifiers would you attach to the procedure being performed? a. -59 b. -24 c. -78 d. -79

 Anesthesia complicated by emergency conditions would require the use of what modifier or CPT code? a. -23 b c d. P5

 Anesthesia complicated by emergency conditions would require the use of what modifier or CPT code? a. -23 b c d. P5

 Evaluation and management services were performed on an established patient in which the decision to perform a major surgery scheduled for the following morning was made. The patient was counseled for 15 minutes regarding treatment options, risks, and projected outcome. Which of the following modifiers would be appended to the service performed? a. -56 b. -52 c. -50 d. -57

 Evaluation and management services were performed on an established patient in which the decision to perform a major surgery scheduled for the following morning was made. The patient was counseled for 15 minutes regarding treatment options, risks, and projected outcome. Which of the following modifiers would be appended to the service performed? a. -56 b. -52 c. -50 d. -57

 An x-ray of the radius and ulna was performed by the radiology technician. The radiologist reads or interprets the two x- rays and forwards the reports to the patient’s physician for follow up. What modifier is used to reimburse the radiologist? a. -56 b. -26 c. -50 d. -TC

 An x-ray of the radius and ulna was performed by the radiology technician. The radiologist reads or interprets the two x- rays and forwards the reports to the patient’s physician for follow up. What modifier is used to reimburse the radiologist? a. -56 b. -26 c. -50 d. -TC

 Which modifier would be used to describe services by a Registered Dietician? a. AF b. AH c. AJ d. AE

 Which modifier would be used to describe services by a Registered Dietician? a. AF b. AH c. AJ d. AE

 Which modifier is used to describe the following services?:  A procedure which required minimum surgical assistant to complete?

 Which modifier is used to describe the following services?:  A procedure which required minimum surgical assistant to complete?  Modifier 81

 Which modifier is used to describe the following services?:  A procedure which required an anesthesia physical status modifier describing: a patient with mild systemic disease?

 Which modifier is used to describe the following services?:  A procedure which required an anesthesia physical status modifier describing: a patient with mild systemic disease?  Anesthesia modifier P2

 Which modifier is used to describe the following services?:  A procedure which was explained to the patient and the decision to perform surgery was made after the E/M service was provided?

 Which modifier is used to describe the following services?:  A procedure which was explained to the patient and the decision to perform surgery was made after the E/M service was provided?  Modifier 57

 Which modifier is used to describe the following services?:  Patient developed complications after surgery and the procedure needed to be repeated. The same physician returned to the operating room to perform the procedure.

 Which modifier is used to describe the following services?:  Patient developed complications after surgery and the procedure needed to be repeated. The same physician returned to the operating room to perform the procedure.  Modifier 76

 Which modifier is used to describe the following services?:  A situation which required a second lab test to be done because another test result was required for drug levels on the same day

 Which modifier is used to describe the following services?:  A situation which required a second lab test to be done because another test result was required for drug levels on the same day  Modifier 91

 Which HCPCS modifier describes:  Right hand, second digit

 Which HCPCS modifier describes:  Right hand, second digit  Modifier F6

 Which HCPCS modifier describes:  Left foot, great toe

 Which HCPCS modifier describes:  Left foot, great toe  Modifier TA

 Which HCPCS modifier describes:  Right coronary artery

 Which HCPCS modifier describes:  Right coronary artery  Modifier RC

 Which HCPCS modifier describes:  An item that was replaced due to a defect in the product

 Which HCPCS modifier describes:  An item that was replaced due to a defect in the product  Modifier FB

 Which HCPCS modifier(s) would be used:  Procedure performed: simple drainage of a finger abscess, left-hand thumb and second finger.  The CPT code is  What are the modifiers?

 Which HCPCS modifier(s) would be used:  Procedure performed: simple drainage of a finger abscess, left-hand thumb and second finger.  The CPT code is  What are the modifiers?

 Which HCPCS modifier(s) would be used:  Procedure performed: simple drainage of a finger abscess, left-hand thumb and second finger.  The CPT code is  What are the modifiers?  FA Left hand thumb  F1 Second finger

 Which CPT modifier describes a repeat procedure by another physician? a. 77 b. 76 c. 78 d. 79

 Which CPT modifier describes a repeat procedure by another physician? a. 77 b. 76 c. 78 d. 79

 True or False  Adding modifier -76 or -77 is based on whether the physician performing the procedure is the same or different

 True  Adding modifier -76 or -77 is based on whether the physician performing the procedure is the same or different

 Which modifier is used to describe the following services?:  An outpatient hospital procedure which required discontinuation of surgery/procedure after the patient has been prepped but before anesthesia is administered

 Which modifier is used to describe the following services?:  An outpatient hospital procedure which required discontinuation of surgery/procedure after the patient has been prepped but before anesthesia is administered  Modifier 73

 Which modifier is used to describe the following services?:  A procedure which a physician provided the care after surgery/procedure was performed, but did not perform the surgery/procedure itself

 Which modifier is used to describe the following services?:  A procedure which a physician provided the care after surgery/procedure was performed, but did not perform the surgery/procedure itself  Modifier 55

 Which HCPCS modifier is used to describe the following services?:  A patient sees a clinical psychologist for individual psychotherapy.  The CPT code reported is  What is the modifier?

 Which HCPCS modifier is used to describe the following services?:  A patient sees a clinical psychologist for individual psychotherapy.  The CPT code reported is  What is the modifier?  Modifier AH

 Which HCPCS modifier describes services provided by:  Occupational therapy

 Which HCPCS modifier describes services provided by:  Occupational therapy  Modifier GO

 What does modifier E4 describe?

 Lower right, eyelid

Questions???