Physician Services Modifiers Explained and New Distinct Procedure Modifiers Overview February 25, G2N, Inc. Honest & Healthy Bottom Lines

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1 Physician Services Modifiers Explained and New Distinct Procedure Modifiers Overview February 25, 2015

2 Mission of G2N We work to ensure America s healthcare providers have honest & healthy bottom lines in order to continue to fulfill their mission of improving community health. 2

3 Rosie Donovan, RHIA, CCS-P Rosie is a Client Partner for G2N, Inc. Rosie provides coding, documentation & acquisition audits and other revenue cycle consulting services. 3

4 Rosie Donovan, RHIA, CCS-P 25+ years of physician practice experience in both multispecialty, independent and Rural Health Clinic ambulatory medical groups Focus on documentation and coding audits, compliance, acquisition audits and reimbursement B.S. from Saint Louis University RHIA, CCS-P credentialed by AHIMA AHIMA-Approved ICD-10-CM/PCS Trainer Joined G2N in

5 Disclaimer The examples and discussion are not meant to be used as coding advice. This presentation will discuss AMA/CPT and Medicare use of modifiers. Check with your other third party payers for modifier policies. This session is for physician and nonphysician modifiers, therefore Hospital, Facility and/or ASC modifiers will not be discussed. 5

6 Agenda Review typical Modifiers used by Health Care Providers Review definitions & requirements & example cases Review new Distinct Procedure Modifiers Questions NOTE: all data contained herein is valid as of January CMS is continually changing billing and coding rules. Please check with your MAC for the most up to date guidelines.

7 Billing & Documentation Guidelines Coding and documentation are not the top priority of practitioners (nor should they be) Our goal is to help practitioners understand modifier use and documentation requirements so that they can be used appropriately We follow CPT rules, which apply to all carriers & all practitioners We follow Medicare regulations to assure compliance 7

8 Documentation if it is not documented, it did not happen if it is not documented, it is not billable Documentation must reflect the service(s) and the reasons for the service(s) billed. Know and understand the documentation requirements for the types of services you provide. E&M, Diagnostics, Procedures MUST BE LEGIBLE 8

9 Healthcare and Reimbursement Nuances of reimbursement are complex Regulations are constantly changing Physicians don t have time to keep up with the status quo of coding compliance 9

10 Basics of Coding & Documentation Document what was done Document why it was done Code for what you documented 10

11 Modifier Definition What is a modifier? Modifiers are used to add information or change the description of service in order to improve accuracy or specificity. Two (2) digits alpha/ alphanumeric/ numeric. Attaches to CPT and/or HCPCS Level II code. Procedure codes are modified under certain circumstances to more accurately represent the service or item rendered. 11

12 Modifiers Use Modifiers are used by both hospitals and physicians. Modifiers affect and are affected by the surgical global period. The time frame in the global period is not the same for hospitals and physicians. For Hospitals, the global period does not apply. For Physicians, the global period is 0, 10, or 90 days (payer policies may vary) There are different modifiers for the same/similar situation. 12

13 Modifiers & Third Party Payers Providers should follow third party payer guidelines when it comes to modifier assignment. While the definitions of the modifiers themselves will not change, the use of the modifier may. Example: MO Medicaid does not recognize Modifier 57- Decision for Surgery. 13

14 Where to find? How to use? Refer to CPT book Appendix A Refer to your J MAC- Part B Carrier Neither is a comprehensive list of modifiers Per Claim form - 4 modifiers allowed per code Formats are different depending on the modifier and the payer Review Medicare and other third party payer policies for information and reporting requirements. 14

15 Medicare & Modifiers Use MPFS to determine some modifiers use Payment or pricing modifier(s) always in 1 st position on claim form. E.g. 50 modifier or bilateral procedure Hierarchy for payment modifiers on which goes first when multiple modifiers Check your local J MAC list- Ask when in doubt! Informational modifier(s) always placed after pricing modifier. E.g. 50 modifier before 58 modifier 15

16 Modifier Look Up Using MPFS See resource MPFS Look Up You will need 3 links: 1) 2) Network- MLN/MLNProducts/downloads/How_to_MPFS_Booklet_ICN pdf -see page 10- of this document for example Payment Policy Indicators 3) Payment/PhysicianFeeSched/PFS-Relative-Value-Files- Items/RVU15A.html?DLPage=1&DLSort=0&DLSortDir=descending -click on RVU15A and then look for PPRRVU15-excel document 16

17 Example STATUS PCTC GLOB PRE INTRA POST MULT BILAT ASST CO- HCPCS DESCRIPTION CODE IND DAYS OP OP OP PROC SURG SURG SURG Incision of gallbladder A Status code- A means active code PC/TC IND- 0 means this concept does not apply since this procedure cannot be split into technical (TC) and professional (PC) components GLOB DAYS- 090 means this procedure has a 90 day global period MULT PROC- 2 means standard payment adjustment rules for Multiple procedures apply. E.g. if this procedure is 1 st listed Payment is 100%. If listed 2 nd with 51 modifier than payment is 50%. BILAT SURG- 0 means 150% payment adjustment does not apply And so on 17

18 Modifier Meanings Separate sessions 58, 78, 79, 59- Now X modifiers Separately identifiable services 25, 57, 59- Now X modifiers Reduced/Discontinued 52, 53 Multiple 51, 99 Repeat 76, 77 18

19 Modifier Meanings Role in surgery >1surgeon: 62, 66 Assist Surgeon: 80, 81, 82, AS Split care or splitting the global surgical package 54, 55, 56 Decision for surgery 25, 57 Unusual 22, 23, 63-infants < 4kg 19

20 Site Specific Modifiers Coronary artery LC-Left Circumflex LD-Left Anterior Descending RC-Right Coronary Artery -Only valid on certain CPT codes Eyelids E1 -Upper left E2 -Lower left E3 -Upper right E4 -Lower right 20

21 Site Specific Modifiers Separate site Coronary Arteries, Fingers and Toes, 59- Now X modifiers Left/Right LT- Left side RT- Right side Bilateral 50 21

22 Modifiers, when do we use? When should a modifier be used? If the answer is yes to any of the following questions, then it is appropriate to use the applicable modifier. Would the modifier add more information regarding the anatomic site of the procedure? Would the modifier help eliminate the appearance of duplicate billing? Would a modifier help eliminate the appearance of unbundling? 22

23 Modifiers Used on E&M Codes 23

24 Modifier 24 Unrelated E&M service by the same physician during a postoperative period. Inpatient hospital care furnished during the same hospitalization as the surgery is not payable unless the physician is also treating another medical condition unrelated to the surgery. Used to indicate an unrelated E&M service was provided during the post operative period. Unrelated? - Different diagnosis - Same diagnosis, but treating the underlying condition, NOT complications from surgery or normal recovery. - Patient note should reflect the management of a new problem or the underlying condition that prompted the surgery. - Modifier 24 goes on E&M code 24

25 Modifier 24 - Example An excision of a malignant lesion from the right thigh is performed in the office on January 10, The diagnosis code reported is (Malignant neoplasm-soft tissue of thigh). The procedure has a 10 day post-operative period. The patient returns to the office on January 15, 2014 and is treated for contact dermatitis diagnosis code The physician should report the appropriate E&M code followed by modifier

26 Modifier 25 Significant, separately identifiable E&M service by the same physician or other qualified health care professional on the same day of a procedure or other service. Used with MINOR procedures (0 or 10 global days). Different diagnosis code is not needed. Documentation supports E&M above & beyond that which is required for pre/post procedure evaluation. Patient care note should clearly reflect the work and management of physician beyond that of the pre/post procedure evaluation. Modifier 25 goes on E&M code. 26

27 Minor Procedures & Modifier 25 Global period of 000 or 010 days, it is defined as a minor surgical procedure. In general, E&M service on the same date of service as a minor procedure is included in the payment for the procedure. However, a significant and separately identifiable E&M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier 25. Some NCCI edits exist but not for all possible scenarios. 27

28 Modifier 25 - Example 1) Diagnostic procedures- necessary because exam is inadequate- E.g. Otoscope-Exam & Nasal Endoscopy 2) Therapeutic procedure- necessary because exam indicates evaluation of system unrelated to decision to perform procedure- lesion removal-neck, exam of lymphatic and neurologic 28

29 Modifier 25 Use Modifier 25 Questions to ask yourself. What was the purpose of the patient s visit? Is there anything that would prompt a separate E&M service? Does the documentation support an E&M service over and above the usual work for the procedure? In 2003, the OIG reported overpayments in excess of $538 Million due to the inappropriate use of modifier

30 Modifier 25 - Example A physician examines a patient complaining of a headache, vomiting, fever, and stiff neck. The physician performs the services described in code providing a detailed exam of the following Constitutional/GI/Neurological/Neck, as well as a spinal puncture using code Is it appropriate for the physician to report this patient encounter with codes and ? Yes, modifier 25 is appropriate, because evaluation of complaint is greater than evaluation pre/post

31 Polling Question #1 Have you found that some of your Third Party Payers are also requiring the use of Modifier 25 when an E&M and a diagnostic procedure (Chest x- ray, EKG, etc.) is performed on the same day? a. Yes b. No c. I m not sure 31

32 Modifier 57 Decision for Surgery Indicates an E&M service resulted in the initial decision to perform surgery either the day before a major surgery (90 day global) or the day of a major surgery. Cannot be used with a minor surgery (0 or 10 day global). Appended to the E&M service to denote the visit where the decision to perform the surgery was made. 32

33 Modifier 57 - Example A patient with abdominal pain is referred to a Surgeon to determine if surgery is necessary. The requesting physician agrees with the findings of the Surgeon and requests the Surgeon assume care and discuss his findings with the patient. The patient undergoes surgery later that day by the Surgeon. Is it appropriate to report the Surgeon s E&M service with modifier 57 indicating the consultation is not part of the global surgical procedure in addition to reporting the appropriate code for the specific surgical procedure? Yes, Surgeon made the decision to perform the surgery on the patient the same day as the surgery. 33

34 Modifier AI Principal Physician of Record Identifies the admitting or attending physician who oversees patient care while in an inpatient or nursing facility setting. Appended to the initial inpatient hospital visit E&M code or the initial nursing facility E&M code. Should not be used by physicians providing specialty care. If not admitting don t use! Does not affect payment. Informational modifier. Append to initial E&M services of admitting physician. 34

35 Modifiers Used on Surgical & Diagnostic Services 35

36 Global Surgical Package Global Surgical Package Surgical CPT Code Preoperative Period Intraoperative Time Postoperative Global Period Incision and Approach Resection or Repair Closure 36

37 Global Surgical Package Pre-op Period Intra-op Service Post-op Period CPT Says Subsequent to the decision for surgery, one related E&M encounter on the date immediately prior to or on the date of procedure (including history and physical) Local infiltration, metacarpal/ metatarsal/digital block or topical anesthesia. Moderate (conscious) sedation may be reported in CPT Immediate postoperative care, including dictating operative notes, talking with the family and other physicians Writing orders Evaluating the patient in the postanesthesia recovery area Pain management services Intraoperative nerve monitoring by the surgeon Typical follow-up care Medicare Says E&M in which the decision is made is separately billable. Visits to perform history and physicals are not separately reportable. Major procedure has a preoperative global period of day before and day of the procedure Minor procedure has a preoperative global period of the day of the procedure Anesthesia of any kind given by the operating surgeon. Exception: moderate (conscious) sedation may be reported by the surgeon when appropriate. Discussion with patient/family about the nature of the procedure, alternative treatment risks, benefits and other informed consent issues Scheduling surgery Writing preoperative admission notes and orders Dictating the operative record Writing postoperative orders and postoperative prescribed care Postoperative pain management including catheter placement by operating surgeon Intraoperative nerve monitoring by the surgeon Follow-up care including treatment of complications unless they require a return to the operating room for the prescribed follow-up period Major procedure has a postoperative global period of 90 days Minor procedure has a postoperative global period of 0 or 10 days 37

38 E&M and Surgical Global Days Remember: During 0-, 10-, and 90-day global periods, you shouldn t separately bill E&M services that are part of the normal pre-op, surgical, or post-op care. That includes any E&M service provided during the post-operative period that is related to the recovery from the surgery, including pain management. 38

39 CMS CPM, Sec 40, Ch 12 Section 40.1 of the Claims Processing Manual (Pub , Chapter 12 Physician/Nonphysician Practitioners) defines the global surgical package to include the following services when furnished during the global period: Preoperative Visits Preoperative visits after the decision is made to operate beginning with the day before the day of surgery for major procedures and the day of surgery for minor procedures; Intra-operative Services Intra-operative services that are normally a usual and necessary part of a surgical procedure; Complications Following Surgery All additional medical or surgical services required of the surgeon during the postoperative period of the surgery because of complications that do not require additional trips to the operating room; Postoperative Visits Follow-up visits during the postoperative period of the surgery that are related to recovery from the surgery; Postsurgical Pain Management By the surgeon; Supplies Except for those identified as exclusions; and Miscellaneous Services Items such as dressing changes; local incisional care; removal of operative pack; removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes. 39

40 Modifier 22 Increased Procedural Service requiring work substantially greater than typically required. Used on surgeries where services performed are significantly greater than usual Anatomical variants, increased intensity, technical difficulty, severity of patient s condition, extra time, etc. Additional time alone does not justify the usage of this modifier. Do not use when there is an existing code to describe the service. Requires explanation in comment field on claim submission and/or the operative report and a separate statement indicating how the service differs from the usual. Reimbursement: no set amount for fee increase (+25%). Append to appropriate CPT code. 40

41 Modifier 22 - Example Emergent appendectomy took an hour and a half longer due to dense adhesiolysis. Laparoscopic Appendectomy + 1 ½ hours of additional work due to adhesions

42 Modifier 50 Bilateral Procedure Unless otherwise identified in the CPT code description, bilateral procedures performed at the same operative session should be identified by adding modifier 50 to the appropriate CPT code. Must be performed on a paired part of the body, not simply left and right side. Skin does not have a left and right side. Reimbursement usually calculated at 150% of allowable. Append to the appropriate CPT code. 42

43 Modifier 50 Use Check with 3 rd party payers for billing preferences -a single unit of service and modifier 50 -one unit on each line using modifier RT/LT -two units of service on a single line and no modifier Payer policies apply here. Verify policy before coding/billing. 43

44 CMS and Modifier 50 CMS reminds providers to report bilateral surgical procedures on a single claim line with modifier 50 and one (1) unit of service. When modifier -50 is required by manual or coding instructions, claims submitted with two lines or two units and anatomic modifiers will be denied for incorrect coding. Review MPFS to determine if bilateral (modifier 50) is allowed. 44

45 Modifier 51 Multiple Procedures performed on the same day, during the same surgical session. Do not use on: Add on codes. + sign in front of the code. See Appendix D in CPT code book. 51 exempt codes. sign in front of code. See Appendix E in CPT code book. Modifier 51 is to be assigned to the code(s) with lower RVU values when multiple codes are billed. Reimbursement usually indicates fee reduction for multiple procedures. 45

46 Modifier 51- Example Surgeon performs an adenoidectomy and placed a tympanostomy tube at the same operative session. Adenoidectomy (RVU 6.02) Tympanostomy (RVU 4.63) Code with 51 modifier expect 50% payment reduction. 46

47 Modifier 52 Reduced Service - Reports a reduced or partially eliminated service or procedure at the physician s discretion. When the procedure was completed but a portion is not performed. Bilateral procedures performed on one side. Do not use for terminated procedures. Do not use for situations when the patient has the inability to pay the full charge. Do not use on a time based code (i.e. anesthesia, psychotherapy, or critical care). Reimbursement no set fee reduction. 47

48 Modifier 52 - Example A patient with a history of Breast Ca. is seen with complaint of lump on arm. Ultrasound of lump is inconclusive. Surgeon performs incision and dissects down beneath subcutaneous tissue no mass found. Report CPT code A Therapeutic Colonoscopy is performed but the scope cannot be moved beyond the splenic flexure and therefore the scope is reduced due to no visualization of the cecum. Report CPT code

49 Modifier 52 Inappropriate Use Do Not Use! If the planned radiological service is a two-view chest x-ray and only one view of the chest is performed, Do not report CPT code (for x-ray chest, two views-reduced service). Report CPT code (x-ray chest, single view). 49

50 Modifier 53 Discontinued Procedure The procedure was started but was discontinued before completion due to patient s condition or extenuating circumstances. Discontinued procedure after induction of anesthesia. Do not use on time based procedure codes. (i.e. critical care and psychotherapy) Do not report on discontinued surgeries prior to the induction of anesthesia. Reimbursement no set fee reduction. First listed diagnosis reason for termination- V64.1, second listed diagnosis reason for surgery 50

51 Modifier 53 - Example Midway through a thyroidectomy, the patient s blood pressure severely drops. Anesthesiologist advises discontinuing the surgery. Thyroidectomy Diagnoses: 1 st - Procedure not carried out due to contraindication: V nd - Iatrogenic Hypotension: rd - Goiter, unspecified:

52 Modifier 54 & 55 Split Surgical Package - These modifiers indicate the Surgeon is not providing the entire surgical package and is splitting the post operative care with another Provider. Modifier 54 is used by Surgeon. Modifier 55 is used by other Provider who is providing all or part of Post-Operative Care. 52

53 Modifier 54 & 55 Use Both claim forms must match exactly in regards to the surgical CPT code. This would be on the first line of the claim form. Each must have: - same surgical date - same surgical CPT code - different Place Of Service - # of units = 1 Box 19 of claim is where more detail is given. 53

54 Modifier 58 Staged or related procedure or service by the same physician during the postoperative period. Used for a procedure the physician performs during the postoperative period if the procedure is: Planned or anticipated (staged) More extensive than the original procedure For therapy following a diagnostic surgical procedure A new postoperative period begins Reimbursement no fee reduction 54

55 Modifier 58 - Example The physician performed a D & C on May 1 and then performed a hysterectomy on May 9. Report 58120, 10 day global begins on May 1. Report , 90 day global begins on May 8. - You do not need to bill both procedures on the same claim form. However if you do it is acceptable. 55

56 Polling Question #2 When using these procedure modifiers do you change your fee on the claim? a. Yes b. No c. I m not sure 56

57 Modifier 59 Distinct Procedural Service Identifies procedures/services not normally reported together, but appropriately billable under the circumstances. Documentation indicates two separate procedures performed on the same day by the same physician Represented by a different session or patient encounter, different procedure or surgery, different site, or separate injury (or area of injury) Modifier of last resort. Bypasses NCCI (National Correct Coding Initiative) edits. Often used instead of billing units. 57

58 Modifier 59 Most widely used and sometimes abused modifier Can be broadly applied Some Providers incorrectly consider it to be the modifier to use to bypass (NCCI) edits *Abuse and high utilization have created increased audit activity; leading to reviews, appeals and even civil fraud and abuse cases. Primary issue is that it is defined for use in a wide variety of circumstances, such as to identify: Different encounters; Different anatomic sites; and Distinct services. *In 2003, the OIG reported overpayments in excess of $59 Million due to the inappropriate use of modifier 59. *More recently, 2013 CERT Report data projected a one-year error of $770 Million in incorrect modifier 59 payments. 58

59 X {EPSU} Modifiers Effective January 1, CMS debuts 4 new distinct procedure modifiers to substitute for the 59 in specific circumstances, they are: XE Separate Encounter: a service that is distinct because it occurred during a separate encounter XP Separate Practitioner: a service that is distinct because it was performed by a different practitioner XS Separate Structure: a service that is distinct because it was performed on a separate organ/structure XU Unusual Non-Overlapping Service: the use of a service that is distinct because it does not overlap usual components of the main service 59

60 When is modifier 59 used? The National Correct Coding Initiative (NCCI) Created Procedure to Procedure Edits Developed by CMS Promote correct coding methodologies Eliminate improper coding Edits are based on coding conventions, current coding practice and input from societies and analysis of current coding practices Edits are created to help prevent the unbundling of procedures and services in various settings. 60

61 PTP Edits Procedure to Procedure (PTP) edits indicate that the second code in the code pair is considered bundled into the work involved in the first code. Column 1 comprehensive code - payable Column 2 component code not payable The component code can become payable if the edit indicator allows it, and documentation supports it. 61

62 Edit Indicators CCI Edit Indicators: 0 modifier does not apply Never unbundle a code pair that has a 0 indicator 1 modifier does apply Use modifier on component code if supported 9 not applicable- edit was deleted See: Network-MLN/MLNMattersArticles/Downloads/SE1418.pdf 62

63 Edit indicator 1, but which modifier? NCCI instructions: All other modifiers should be evaluated for possible application prior to the use of modifier 59 or the new X-EPSU modifiers. Use modifiers such as RT/LT, finger, toe or eyelid modifiers in addition to sometimes utilizing Modifier 25 prior to the use of these new modifiers. 63

64 XE - Example Patient is seen in the outpatient infusion center at 8:00 a.m. and seen again in the outpatient infusion center for an IM injection at 6:00 p.m. -Separate encounter = XE (column 1/NCCI =1)- antibiotic intravenous infusion XE (column 2/NCCI =1)- antibiotic intramuscular injection- performed at a separate time! 64

65 XP - Example Patient undergoes a hernia repair by Dr. Smith at 7:00 a.m. Later in the day the patient develops acute abdominal pain and returns for another physician to perform a surgical laparoscopic appendectomy by Dr. Jones. Both doctors are part of the same general surgery group. - Separate Practitioner - XP (column 1 /NCCI=1)- Laparoscopic hernia repair XP (column 2 /NCCI=1)-Laparoscopic appendectomy performed by a separate Surgeon! 65

66 XS - Example Physician destroys an actinic keratosis on the hand and removes a melanocytic nevus from the ear. -Separate anatomic sites - XS (column 1 /NCCI=1 )- Destruction premalignant lesion; first lesion (hand) XS (column 2 /NCCI=1 )- Excision, benign lesion including margins, ear: excised diameter 0.5 or less performed on a separate site! 66

67 XU - Example A patient presents to the ED with a fall at home due to dehydration. ED Physician performs an intermediate repair of scalp and orders an infusion due to the dehydration. -Non-overlapping service XU (column 1/NCCI=1)- Repair, intermediate, wounds of scalp; 2.5 cm or less XU (column 2/NCCI=1)- Therapeutic intravenous infusion; initial, up to 1 hour performed as a non-overlapping service. 67

68 Available Guidance? WE NEED MORE GUIDANCE! Contact NCCI and CMS via the address given in SE1503. Submit specific questions and examples about how to use the new modifiers. Hopefully this may facilitate the release of more guidance. Mail to: 68

69 Can we use 59 Modifier? YES - modifier 59 is still available for use! My local carrier (WPS) is not requiring providers to use any specific modifier. Remember: when evaluating a coding pair listed as part of the National Correct Coding Initiative (NCCI), the column 2 procedure code is not payable unless the medical record documentation and specific circumstances show the service is a distinct and separate service as described in the NCCI manuals. Providers should evaluate the use of other modifiers including the new -X {EPSU} prior to using modifier 59. SE1503-MLN Matters Continued Use of modifier 59 after January 1, MLN/MLNMattersArticles/Downloads/SE1503.pdf 69

70 Do Not Use! Code pair does not create an PTP edit. Same procedure/cpt code was performed multiple times. (Not a repeat procedure ) CPT code allows billing in multiples or units. Bill CPT code on one line with multiple units. Example:.5 cm benign lesions were removed from cheek and forehead x 2 units excision benign lesion, including margins, except skin tags, face; excised diameter 0.5 cm or less. 70

71 Polling Question #3 Have you received a rejection when using the new X-EPSU modifiers? a. Yes b. No c. I m not sure 71

72 Modifier 76 Repeat Procedure by the Same Physician Used when it is necessary to report repeat procedures performed on the same day by same Physician. This modifier should not be added to procedures designated as add on codes. These are identified in the CPT book by a plus (+) sign in front of the code. Medicare considers two physicians in the same group with the same specialty performing services on the same day as the same physician. Do not confuse with billing units or multiples. Reimbursement no fee reduction. 72

73 76 - Example Tonsillectomy performed on January 15 th. Patient returned to OR on January 16 th for control of 1 st post-op tonsil bleed. Later in the afternoon patient is returned to OR on same day for 2 nd post-op tonsil bleed Control oropharyngeal hemorrhage (return to OR- related) Control oropharyngeal hemorrhage (repeat procedure on same day) 73

74 Modifier 77 Repeat procedure or service by another physician or other qualified health care professional Append to the professional component of an X-Ray or EKG procedure when a different physician repeated the reading as the physician performing the initial interpretation believes another physician's expertise is needed. Append to the professional component of an X-Ray or EKG procedure when the patient has two or more tests and more than one physician provides the interpretation and report. This modifier is payer specific. 74

75 Modifier 78 Unplanned return to the operating room by the same physician following initial procedure for a related procedure during the postoperative period. To identify a related procedure (that has a 000, 010, 090, YYY, or ZZZ global surgery indicator) requiring a return trip to the operating room (OR) on the same day as or within the postoperative period of a major or minor surgery. To treat the patient for complications resulting from the original surgery. When the procedure code used to describe a service for treatment of complications is the same as the procedure code used in the original procedure, modifier 78 is still the correct modifier to use. 75

76 Modifier 78 Modifier 78 Questions to ask yourself. Does the procedure fall within a global period? Is the procedure related to or complication of the initial surgery? Is there a return to the OR? If yes is the answer to all three questions, it is appropriate to use Modifier 78. A new global period does not begin. Reimbursement reductions apply. 76

77 Modifier 79 Unrelated procedure by the same physician during the post-operative period To describe an unrelated procedure performed during the post-operative period of the original procedure. The two procedures are performed by the same physician. All procedure codes except those with XXX in the GLOB (global) field of the MPFS data base. A new global period will begin. Reimbursement reduction apply. 77

78 Modifier 80 Assistant at Surgery Use Modifier AS if the services are provided by a physician assistant (PA) or nurse practitioner (NP) or clinical nurse specialist (CNS). Use Modifier 80 if the services are provided by a medical doctor (MD/DO). Operative note by Surgeon must support what services assistant provided. Submit Assistant Surgeon service on their own claim form. 78

79 Modifier 62 Co-Surgery, or Two Surgeons Under certain circumstances the skills of two surgeons (must be different subspecialists) may be required in the management of a specific surgical procedure. Under such circumstances the separate services may be identified by adding the modifier 62 to the procedure code. Both surgeons need to report the same surgery code with the modifier 62. Each surgeon should have their own operative note describing what specifically they did. Reimbursement calculated at 62.5% for each Surgeon. 79

80 Anatomic Modifiers LT Left side RT Right side Identifies procedures that can be performed on paired body parts or organs such as lungs and kidneys. DO NOT use when modifier 50 applies or when the code is described as being bilateral. 80

81 Anatomic Modifiers Modifiers are available to indicate procedures performed on fingers and toes. F1 left hand, second digit T1 left foot, second toe F2 left hand, third digit T2 left foot, third toe F3 left hand, fourth digit T3 left foot, fourth toe F4 left hand, fifth digit T4 left foot, fifth toe F5 right hand, thumb T5 right foot, great toe F6 right hand, second digit T6 right foot, second toe F7 right hand, third digit T7 right foot, third toe F8 right hand, fourth digit T8 right foot, fourth toe F9 right hand, fifth digit T9 right foot, fifth toe FA left hand, thumb TA left foot, great toe 81

82 Modifier QW CLIA-waived test Laboratory testing site has CLIA certification to perform certain tests. Submit this modifier with clinical laboratory tests that are waived from the Clinical Laboratory Improvement Amendments of 1988 (CLIA) list. The Food and Drug Administration (FDA) determines which laboratory tests are waived. CLIA certification number is required on claim. Guidance/Legislation/CLIA/downloads/waivetbl.pdf 82

83 Modifier Q6 Services furnished by a Locum Tenens Physician When a physician agrees to see patients of another physician under arrangements of the original physician. The regular physician is not available to see patients. The patient arranges or seeks service of their regular physician. Short term coverage provided, under 60 days. The physician seeing the patient is not in practice for themselves, or employed as part of another practice. 83

84 Modifier TC Diagnostic Services TC Technical Component Identifies the technical component of certain services that combine both the professional and technical portions in one procedure code. To bill for only the technical component of a test. When billing both the professional and technical component of a procedure when the technical component was purchased from an outside entity, the provider would bill the professional on one line of service and the technical on a separate line. 84

85 Modifier 26 Diagnostic Services 26 Professional Component Refers to certain procedures that are a combination of a professional component and a technical component. To bill for only the professional component of a test. To report the physician s interpretation of a test. 85

86 Modifiers Used on Unlisted CPTs Unlisted CPT codes DO NOT append modifiers to unlisted CPT codes. Unlisted CPT codes do not have descriptions, therefore they cannot be modified. A modifier cannot tell why the unlisted CPT code was altered. 86

87 Resources NCCI Policy Manual /NationalCorrectCodInitEd WPS Modifiers CLIA Waved Test List Guidance/Legislation/CLIA/downloads//waivetbl.pdf CMS Claims Processing Manual Ch.12, Sec 40 Guidance/Guidance/Manuals/Downloads/clm104c12.pdf CMS Claims Processing Manual Ch.23, Sec Guidance/Guidance/Manuals/downloads/clm104c23.pdf MLN 87

88 A reality of medicine is that it doesn t matter how smart you are or how brilliant your diagnosis; you don t get paid any more money for these things. In medicine, you get paid for how much [how effectively] you can document. William Sonnenberg, M.D.; Health Management Technology

89 Next G2N Webinar ICD-10-CM Chapter 19: Navigating New Concepts and Guidelines for Injuries, Poisonings and Other Consequences of External Causes March 18, 2015 (Wednesday) 10:00 to 11:00am Central Time 89

90 Questions?

91 For More Information Rosie Donovan, RHIA, CCS-P AHIMA-Approved ICD-10-CM/PCS Trainer G2N, Inc