My Coding Connection, LLC Unrelated E/M by the same physician during a postoperative period

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1 MODIFIERS Rachel Coon, CCS-P, CPC, CPC-P, CPMA, CPC-I, CEMC, ICD-10 My Coding Connection, LLC GLOBAL PACKAGE MODIFIERS 24 Unrelated E/M by the same physician during a postoperative period 25 Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service 57 Decision for surgery 2 1

2 GLOBAL PACKAGE MODIFIERS 54 Surgical care only 55 Postoperative management only 56 Preoperative management only GLOB PRE INTRA POST HCPCS DESCRIPTION DAYS OP OP OP Percut vertebroplasty lumb Neck spine fusion GLOBAL PACKAGE MODIFIERS 58 Staged or related procedure or service by the same physician during the postoperative period 78 Unplanned return to the operating/ procedure room by the same physician following initial procedure for a related procedure during the postoperative period 79 Unrelated procedure or service by the same physician during the postoperative period 4 2

3 GLOBAL PACKAGE MODIFIERS 78 Unplanned return to the operating/ procedure room by the same physician following initial procedure for a related procedure during the postoperative period Example: January Gastric bypass (90 day global period) March Incisional hernia on the bypass incision, taken back to the operating room for incisional hernia repair. Add modifier 78 to the hernia repair 5 GLOBAL PACKAGE MODIFIERS 79 Unrelated procedure or service by the same physician during the postoperative period Example: January Amputated DIP joint (finger) March Below the knee amputation Add modifier 79 to the below the knee amputation 6 3

4 SURGICAL MODIFIERS 22 Increased Procedural Service 50 - Bilateral Procedure 51 - Multiple Procedures 52 - Reduced Services 53 - Discontinued Procedure 7 MODIFIER 22 - INCREASED PROCEDURAL SERVICE Services required to perform the procedure are significantly greater than usually reported with the procedure Bill with the operative report 8 4

5 Example: MODIFIER 22 - INCREASED PROCEDURAL SERVICE A patient has a colonoscopy and a polyp is removed. The removal of the polyp causes excessive bleeding and an extra 30 minutes is spent controlling the bleeding. Modifier 22 would be added to the surgical code and the operative report and/or letter would be sent with the claim to the payer. 9 MODIFIER 50 - BILATERAL PROCEDURE Check with payers on how to submit: One line item with modifier 50 Example: Two line items with modifier 50 on the second code Example: Two lines using RT/LT Example: RT LT 10 5

6 MODIFIER 50 - BILATERAL PROCEDURE Pay close attention to code descriptions. Some codes specify unilateral and include a parenthetical statement. Example: Ablation, 1 or more renal tumor(s), percutaneous, unilateral, radiofrequency Some codes say 1 or both. Example: Removal impacted cerumen (separate procedure), 1 or both ears 11 MODIFIER 51 - MULTIPLE PROCEDURES More than one procedure performed at the same session by the same provider Not used on E/M services, Physical Medicine or Rehabilitation Services, the provision of supplies such as vaccines or codes designated as add-on codes. Example: An orthopedic surgeon performs a closed treatment of a femoral shaft fracture on the left leg and a closed treatment of a right knee dislocation during the same operative session. It would be coded as LT and RT. 12 6

7 MODIFIER 52 - REDUCED SERVICES Procedure partially reduced at physician discretion Service not completed in its entirety Example: Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device (For individual component placement, report with modifier 52) 13 MODIFIER 53 - DISCONTINUED SERVICES Procedure terminated due to: Extenuating circumstances Circumstances threatening the well-being of the patient Do not use: Elective cancellation prior to induction of anesthesia Example: A patient who is having a surgical procedure and after the administration of general anesthetic exhibits unstable vital signs. At the recommendation of the anesthesiologist the surgeon decides to terminate the procedure. 14 7

8 MODIFIER 59 - DISTINCT PROCEDURAL SERVICE Procedures not normally reported together Different Session or Patient Encounter Different Procedure or Surgery Different Site or Organ System Separate Incision/Excision Separate Lesion 15 MODIFIER 59 - DISTINCT PROCEDURAL SERVICE Example: A patient had a colonoscopy and a lesion is removed proximal to the splenic flexure. During the same colonoscopy a biopsy is taken of a different lesion. Both codes are reportable using modifier 59 on the second procedure. 16 8

9 MODIFIER 76 - REPEAT PROCEDURE OR SERVICE BY SAME PHYSICIAN Example: A patient who goes to the Emergency Room with a trauma to the chest. A two-view chest x-ray is taken that shows a pneumothorax. After a chest tube is placed a repeat two-view chest x-ray is taken to verify the placement of the chest tube. You would report and MODIFIER 77 - REPEAT PROCEDURE OR SERVICE BY ANOTHER Example: PHYSICIAN A patient who sees the family practitioner for chest pain and the physician does an EKG and then refers the patient to a cardiologist. The patient is able to see the cardiologist on the same day and the cardiologist performs a repeat EKG. The second EKG would be reported with modifier

10 MULTIPLE SURGEON MODIFIERS 62 Two Surgeons Work together as primary surgeons Perform distinct parts of a procedure Dictate op report of their distinct part Each will submit the same code and append modifier Surgical Team Highly complex procedures Require differently specialties Modifier 66 appended to procedures coded by the surgical team 19 ASSISTANT SURGEON MODIFIERS 80 Assistant Surgeon Assistant surgeon present for entire or substantial portion of the operation Reports the same surgical procedure with modifier 80 appended 81 Minimum Assistant Surgeon Circumstances present that require the services of an asst surgeon for a short time. Minimal assistance. Reports the same surgical procedure with modifier 81 appended 82 Assistant Surgeon (when qualified resident surgeon not available) Used in a teaching hospital that employs residents No residents available and another surgeon is used 20 10

11 ANCILLARY MODIFIERS Global a procedure containing both a technical and a professional component Modifier 26 Professional Component Modifier TC Technical Component 21 ANCILLARY MODIFIERS Example: A patient comes to the office with wheezing and congestion. The physician takes a 2-view chest X-ray using his or her own equipment and sends it out to be read by a radiologist. The office would code TC for the use of the equipment (technical) The radiologist would bill for his/her interpretation and report (professional service). If the office took the X-ray and also did the interpretation and report, they would code without any modifiers to indicate they did the global service..both the technical and professional components 22 11

12 LABORATORY MODIFIERS 90 Reference (Outside) Laboratory Used to bill for lab services purchased from an outside lab 91 Repeat Clinical Diagnostic Lab Test Not used to confirm results Not used to repeat a test due to equipment malfunction 92 Alternative Lab Platform Testing Single use HIV testing 23 ANESTHESIA MODIFIERS 23 - Unusual Anesthesia 47 - Anesthesia by Surgeon AA - Anesthesia services personally performed be an anesthesiologist QK Medical Direction of two, three, or four concurrent anesthesia procedures by an anesthesiologist Physical Status Modifiers 24 12

13 WPS There are times when the coding and modifier information issued by the Centers for Medicare & Medicaid Services (CMS) differs from the American Medical Association's (AMA) coding advice regarding the use of modifiers. A clear understanding of Medicare's rules and regulations is necessary in order to assign the modifier correctly. This is particularly true for modifiers 22, 25, 50, 51, 59, 76 and 78. Please take careful note of the Medicare usage guidance provided in this manual. 25 WPS Inappropriate Modifier Usage: The system used by Part B carriers to process claims is called the Multi-Carrier System or MCS. The MCS system will deny claims as "unprocessable" for inappropriate modifier use. If the use of a procedure code/modifier combination is inappropriate, you will need to make the necessary corrections and resubmit the claim 26 13

14 WPS Important Review Facts Adding modifiers 24, 25, 26, 58, 59, 76, 78, or 79 to a denied service continues to be one of the top reasons for requesting a review. Remember that two different ICD-9-CM codes alone does not justify adding modifier 25. Calling to add a modifier just because the service was denied is not appropriate. Having front-end edits in your individual claim processing system can eliminate a delay in payment for you and unnecessary follow-up work for both WPS and your offices. Be prepared before calling in for a review. We have experienced providers calling and asking to add a modifier. Then when that modifier did not get the claim paid, they want to try another one. This is inappropriate. 27 WPS Important Documentation Facts 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. It is necessary to indicate you have documentation with modifier 22, critical care, and co-surgery modifiers for the same specialty. 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

15 WPS Important Miscellaneous Facts It is only appropriate to report modifiers 24, 25 and 57 on evaluation and management procedure codes. Never report modifier 76 on a surgical procedure code. When it is necessary to report the following payment modifiers with another modifier, the payment modifier must be reported in the first modifier field: TC, 26, 52, 53, AA, AD, QK, QW, QY and QZ. Report modifiers 54 and 55 on the surgery code only. 29 We will review the appropriateness of the use of certain claims modifier codes during the global surgery period and determine whether Medicare payments for claims with modifiers used during the global surgery period were in accordance with Medicare requirements. surgery period resulted in inappropriate payments The global surgery payment includes a surgical service and related preoperative and postoperative E/M services provided during the global surgery period. (CMS s Medicare Claims Processing Manual, Pub , ch. 12, 40.1.) Guidance for the use of modifiers for global surgeries is in CMS s Medicare Claims Processing Manual, Pub , ch. 12, 30. (OAS; W ; various reviews; expected issue date: FY 2012; new 30 start) 15

16 We will determine the extent to which Medicare improperly paid clams for m in which providers entered GA, GX, GY, or GZ service code modifiers, indicating that Medicare denial was expected. Providers may us GA or GZ modifiers on claims they expect Medicare to deny as no reasonable and necessary pursuant to CMS s Claims Processing Manual. They may us GX or GY modifies for items or services that are statutorily excluded. A recent OIG review found that Medicare paid for 72% of pressure-reducing support surface claims with GA or GZ modifiers, amounting to $4 million in potentially inappropriate payments. ( FY 2013; work in progress) 31 We will review Medicare Part B claims for personally performed anesthesia services to determine whether they were supported in accordance with Medicare requirements. We will also determine whether Medicare payments for anesthesiologist services reported on a claim with the AA service code modifier met Medicare requirements. Physicians report the appropriate anesthesia modifier to denote whether the service was personally performed or medically directed. (CMS s Medicare Claims Processing Manual, Pub. No , Ch. 12,..50) The service code AA modifier is used for anesthesia services personally performed by an anesthesiologist, and the QK modifier is used for medical direction of two, three, or four concurrent anesthesia procedures by an anesthesiologist. The QK modifier limits payment at 50% of the Medicare-allowed amount for personally performed services claimed with the AA modifier. Payments to any service provider are precluded unless the provider has furnished the information necessary to determine the amounts due. ( Social Security Act, 1833 (e).)(fy 2013) 32 16

17 REFERENCES AAPC OIG CPT Questions Contact: Rachel Coon My Coding Connection, LLC

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