PART B MEDICARE. Modifier Billing Guide June NHIC, Corp. RT B. REF-EDO-0058 Version 4.0

Transcription

1 MEDICARE PART B RT B Modifier Billing Guide June 2011 NHIC, Corp.

2 NHIC, Corp. 2 June 2011

3 Table of Contents Introduction... 6 General information... 7 WHAT ARE MODIFIERS?... 7 AMBULANCE... 8 AMBULATORY SURGical CENTER (ASC) ANESTHESIA ASSISTANT SURGEON Reimbursement BILATERAL SERVICES Bilateral Procedures Billed Correctly CHIROPRACTIC CLINICAL PSYCHOLOGIST & CLINICAL SOCIAL WORKER Clinical Research Studies Coronary Artery Drugs and Biologicals ERYTHROPOIESIS STIMULATING AGENTS (ESA) EVALUATION AND MANAGEMENT (E/M) EYE FOOT CARE Digit Modifiers for the Foot HEALTH PROFESSIONAL SHORTAGE AREA (HPSA) HOSPICE LABORATORY SERVICES Billing Tips NATIONAL CORRECT CODING INITIATIVE (NCCI) OUTPATIENT THERAPY SERVICES PHYSICIAN QUALITY REPORTING System (PQRS) Billing Tips: PORTABLE X-RAY RECIPROCAL AND LOCUM TENENS ARRANGEMENTS SURGERY Global Surgical Split Billing (Transfer of Care between Providers) Staged Procedures Co-Surgery and Surgical Teams Repeat Procedures Unrelated Surgical Service Unusual Circumstances Digit Modifiers for the Hand NHIC, Corp. 3 June 2011

4 Surgical Errors Colorectal Cancer Screening TEACHING PHYSICIAN TECHNICAL & PROFESSIONAL COMPONENTS MISCELLANEOUS Modifiers National Correct Coding Initiative Medically Unlikely Edits Limitation of Liability (Advance Beneficiary Notice) ABN Modifiers Local Coverage Determination (LCD) National Coverage Determination (NCD) Medicare Fraud and Abuse Recovery Audit Contractor Comprehensive Error Rate Testing Provider Interactive Voice Response (IVR) Directory Provider Customer Service Directory PROVIDER ENROLLMENT HELP LINE PROVIDER ENROLLMENT STATUS INQUIRY TOOL Mailing Address Directory PROVIDER SERVICES PORTAL (PSP) Durable Medical Equipment (DME) Reconsideration (Second Level of Appeal) Internet Resources NHIC, Corp Provider Page Menus/Links Medicare Coverage Database Medicare Learning Network Open Door Forums Publications and Forms Revision History: NHIC, Corp. 4 June 2011

5 NHIC, Corp. 5 June 2011

6 INTRODUCTION The Provider Outreach and Education Team at NHIC, Corp. developed this guide to provide you with Medicare Part B Modifier billing information. It is intended to serve as a useful supplement to other manuals published by NHIC, and not as a replacement. The information provided in no way represents a guarantee of payment. Benefits for all claims will be based on the patient s eligibility, provisions of the Law, and regulations and instructions from the Centers for Medicare & Medicaid Services (CMS). It is the responsibility of each provider or practitioner submitting claims to become familiar with Medicare coverage and requirements. All information is subject to change as federal regulations and Medicare Part B policy guidelines, mandated by the CMS, are revised or implemented. This information guide, in conjunction with the NHIC website ( J14 A/B MAC Resource (monthly provider newsletter), and special program mailings, provide qualified reference resources. We advise you to check our website for updates to this guide. To receive program updates, you may join our mailing list by clicking on Join Our Mailing List on our website. Most of the information in this guide is based on Publication , Chapter 12; and Publication 100-4, Chapter 23 of the CMS Internet Only Manual (IOM). The CMS IOM provides detailed regulations and coverage guidelines of the Medicare program. To access the manual, visit the CMS website at If you have questions or comments regarding this material, please call the Customer Service Center at DISCLAIMER: This information release is the property of NHIC, Corp. It may be freely distributed in its entirety but may not be modified, sold for profit or used in commercial documents. The information is provided as is without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice. All models, methodologies and guidelines are undergoing continuous improvement and modification by NHIC, Corp. and the CMS. The most current edition of the information contained in this release can be found on the NHIC, Corp. web site at and the CMS web site at The identification of an organization or product in this information does not imply any form of endorsement. The CPT codes, descriptors, and other data only are copyright 2010 by the American Medical Association. All rights reserved. Applicable FARS/DFARS apply. The ICD-9-CM codes and their descriptors used in this publication are copyright 2010 under the Uniform Copyright Convention. All rights reserved. Current Dental Terminology (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association American Dental Association. All rights reserved. Applicable FARS/DFARS apply. NHIC, Corp. 6 June 2011

7 GENERAL INFORMATION The use of modifiers is an important part of coding and billing for health care services. Modifier use has increased as various commercial payers, who in the past did not incorporate modifiers into their reimbursement protocol, recognize and accept CPT/ HCPCS codes appended with these specialized billing flags. Correct modifier use is also an important part of avoiding fraud and abuse or noncompliance issues, especially in coding and billing processes involving the federal and state governments. Several of the top billing errors involve the incorrect use of modifiers. WHAT ARE MODIFIERS? A modifier is a two-digit numeric or alpha numeric character reported with a CPT/HCPCS code, when appropriate. Modifiers are designed to give Medicare and commercial payers additional information needed to process a claim. A modifier provides the means by which a physician can report or indicate that a service or procedure that has been performed has been altered by some special circumstances(s), but has not changed in its definition or code. Modifiers also enable health care professionals to effectively respond to payment policy requirements established by other entities. These codes should be entered in item 24D on the Form CMS-1500 or electronic equivalent. Some examples of when a modifier may be appropriate include: A service or procedure has both a professional and technical component, but both components are not applicable A service or procedure was performed by more than one physician and/or in more than one location A service or procedure has been increased or decreased in complexity or performance An adjunctive service was performed A bilateral procedure was performed Unusual events occurred during a procedure or service Placement of a modifier after a CPT or HCPCS code does not insure reimbursement. A special report may be necessary if the service is rarely provided, unusual, variable or new. The special report should contain pertinent information and adequate definition of the procedure or service performed that supports the use of the assigned modifier. If the service is not documented, or the special circumstance is not indicated, it is not considered appropriate to report the modifier. A report should not be submitted unless requested. NHIC, Corp. 7 June 2011

8 Some modifiers are informational only (e.g., -24 and -25) and do not affect reimbursement. They can however, determine if the service will be covered or denied. Other modifiers such as modifier -22 (increased procedural services) will increase the reimbursement and protocol for many third-party payers if documentation supports the use of this modifier. Modifier -52 (reduced services) will usually equate to a reduction in payment. There will be times when the coding and modifier information issued by CMS differs from the AMA s coding advice in the CPT manual regarding the use of modifiers. A clear understanding of Medicare s rules is necessary in order to assign the modifier correctly. It is the responsibility of each provider or practitioner submitting claims to keep abreast of the Medicare program requirements. AMBULANCE Origin and Destination Modifiers Two single digit modifiers must be used with ambulance service codes to identify both the point of origin and the destination. The first single digit modifier indicates the point of origin. The second single digit modifier indicates the destination. These single digit modifiers are defined as follows: Modifier D E G H I J N P R S X Description Diagnostic or therapeutic site other than "P" or "H" (includes free-standing facilities) Residential, domiciliary, custodial facility (includes non-participating facilities) Hospital-based dialysis facility (hospital or hospital-related) Hospital (includes OPD or ER) Site of Transfer (e.g., airport or helicopter pad) between modes of ambulance transfer Non hospital-based dialysis facility (free standing) Skilled Nursing Facility (Medicare participating only) Physician s Office Residence Scene of accident or acute event Immediate stop at physician s office on the way to the hospital (destination only) Note: Modifier E applies to Assisted Living and Nursing Facilities. Not all modifier combinations are allowed by Medicare. **To avoid denial of lines of service please enter origin/destination modifiers on all lines of the claim. This especially helps when round trips or two trips in one day occur. Each trip must be coded on a separate claim, and the modifiers help identify the differences in the two services. The only time that two trips may be reported on the same claim is if the zip code for the point of pick up for both trips is the same. NHIC, Corp. 8 June 2011

9 Additional Modifiers for Use with Ambulance Transports -GM Multiple patients on one ambulance trip When more than one patient is transported in an ambulance, the Medicare allowed charge for each beneficiary is a percentage of the allowed charge for a single beneficiary transport. The applicable percentage is based on the total number of patients transported, including both Medicare beneficiaries and non-medicare patients. Billing Tips Use the GM modifier to identify a multiple transport. Submit documentation to specify the particulars of a multiple transport. The documentation must include the total number of patients transported in the vehicle at the same time and the health insurance claim numbers for each Medicare beneficiary. Submit the charges applicable to the appropriate service rendered to each beneficiary and the total mileage for the trip. Submit all associated Medicare claims for the multiple transports within a reasonable number of days of submitting the first claim. If there is only one Medicare beneficiary in the multiple patient transports, the supplier must document this. -QL Patient pronounced dead after ambulance called Time of Death Pronouncement - Ground or Water Medicare ambulance benefits are a transport benefit. If no transport of a Medicare beneficiary occurs, then there is no Medicare covered service. In general, if the beneficiary dies before being transported, then no Medicare payment may be made. In a situation where the beneficiary dies, whether any payment under the Medicare ambulance benefits may be made depends on the time at which the beneficiary is pronounced dead by an individual authorized by the State to make such pronouncements. The chart below shows the Medicare payment determination for various ground ambulance scenarios in which the beneficiary dies. In each case, the assumption is that the ambulance transport would have otherwise been medically necessary. Time of Death Pronouncement Before dispatch After dispatch, before beneficiary is loaded onboard the ambulance (before or after arrival at the point of pickup). After pickup, prior to or upon arrival at the receiving facility. Medicare Payment Determination No payment The ambulance BLS base rate is paid. No mileage or rural adjustment. Use the QL modifier when submitting the claim. Medically necessary level of service furnished is allowed. NHIC, Corp. 9 June 2011

10 Air Ambulance Medicare allows payment for an air ambulance service when the air ambulance takes off to pick up a Medicare beneficiary, but the beneficiary is pronounced dead before being loaded onto the ambulance for transport (either before or after the ambulance arrives on the scene). This is provided the air ambulance service would otherwise have been medically necessary. The allowed amount is the appropriate air base rate, i.e.; fixed or rotary wing. No amount is allowed for mileage or rural adjustment. No payment is allowed if the dispatcher received pronouncement of death and had a reasonable opportunity to notify the pilot to abort the flight. The supplier must submit documentation with the claim sufficient to show that: The air ambulance was dispatched to pick up a Medicare beneficiary; The aircraft actually took off to make the pickup; The beneficiary to whom the dispatch relates was pronounced dead before being loaded onto the ambulance for transport; The pronouncement of death was made by an individual authorized by State law to make such pronouncements; and The dispatcher did not receive notice of such pronouncement in sufficient time to permit the flight to be aborted before take off. Air Ambulance Scenarios: Beneficiary Death Time of Death Pronouncement Medicare Payment Determination None. Prior to takeoff to point-of pickup with notice to dispatcher and time to abort the flight After takeoff to the point of pickup, but before the beneficiary is loaded Note: This scenario includes situations in which the air ambulance has taxied to the runway, and/or has been cleared for takeoff, but has not actually taken off. Appropriate air base rate with no mileage or rural adjustment; use the QL modifier when submitting the claim After the beneficiary is loaded onboard, but prior to or upon arrival at the receiving facility As if the beneficiary had not died. NHIC, Corp. 10 June 2011

11 AMBULATORY SURGICAL CENTER (ASC) Only facility charges related to a procedure approved by CMS may be reimbursed when performed in an ASC facility. The complete list of procedures can be found on the following website: Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedure Prior to Administration of Anesthesia: Due to extenuating circumstances or those that threaten the well being of the patient, the physician may cancel a surgical or diagnostic procedure subsequent to the patient s surgical preparation (including sedation when provided, and being taken to the room where the procedure is to be performed), but prior to the administration of anesthesia (local, regional block(s) or general). Note: The elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. For physician reporting of a discontinued procedure, see modifier Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedure After Administration of Anesthesia: Due to extenuating circumstances or those that threaten the well being of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia (local, regional block(s) or general) or after the procedure was started (incision made, intubation started, scope inserted, etc.). Note: The elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. For physician reporting of a discontinued procedure, see modifier FB -FC Item provided without cost to provider, supplier or practitioner, or full credit received for replaced device (examples, but not limited to, covered under warranty, replaced due to defect, free samples) Partial credit received for replaced device Note: The modifiers listed above should only be used by ASC facilities. Physicians should never use these modifiers. NHIC, Corp. 11 June 2011

12 ANESTHESIA Use these modifiers with anesthesia procedure codes to indicate whether the procedure was personally furnished, medically directed, or medically supervised. Anesthesia Services Billed by the Anesthesiologist: -AA Anesthesia services performed personally by anesthesiologist -QY Medical direction of one CRNA by an anesthesiologist -QK Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals -AD Medical supervision by a physician: more than four concurrent anesthesia procedures Anesthesia Services Billed by the CRNA: -QX CRNA service: with medical direction by a physician -QZ CRNA service: without medical direction by a physician Monitored Anesthesia Care (MAC) -G8 Monitored Anesthesia Care (MAC) for deep complex, complicated, or markedly invasive surgical procedure -G9 Monitored Anesthesia Care (MAC) Service for patient who has a history of severe cardiopulmonary condition -QS Monitored Anesthesia Care service This involves the intra-operative monitoring by a physician, or a qualified individual under the medical direction of a physician, of the patient s physiological signs, anticipation of the need for administration of general anesthesia or of the development of adverse physiological patient reaction to the surgical procedures. It also includes the performance of a pre-anesthetic examination and evaluation, prescription of the anesthesia care required, administration of any necessary oral or parenteral medications (e.g., atropine, Demerol, valium) and provision of indicated postoperative anesthesia care. Note: Claims for monitored anesthesia must include the identifying procedure code along with the appropriate anesthesia modifier, plus modifier - G8, - G9, or QS. ASSISTANT SURGEON Medicare will make payment for an assistant-at-surgery when the procedure is covered for an assistant and one of the following situations exist: The person reporting the service is a physician or The person bears the designation of physician assistant, nurse practitioner, nurse midwife, or clinical nurse specialist. NHIC, Corp. 12 June 2011

13 No other person can be paid. If the person who assists at surgery is a surgical technician, a first surgical assistant, scrub nurse, or bears any title other than those listed, the service is not payable by Medicare and is not billable to the patient. To determine whether the services of an assistant surgeon may be submitted to Medicare, refer to the Medicare Physician Fee schedule database (MPFSDB) at the following CMS website Assistant surgeon -81 Minimum assistant surgeon -82 Assistant surgeon (when a qualified resident surgeon is not available) For Modifier 82, reimbursement for services of an assistant-at-surgery in a teaching hospital which has a training program related to the specialty required for the surgical procedure and has a qualified resident available, is prohibited with the following exceptions: o The services are required due to exceptional medical circumstances, or o There is no qualified resident available, or o The primary surgeon has an across the board policy of never involving residents in the preoperative, operative, or postoperative care of his/her patients. -AS PA, nurse practitioner, or clinical nurse specialist services for assistant at surgery Coverage of services under AS is limited to those that are allowed in the state under their license. Reimbursement Assistant surgical services are customarily reimbursed at 16 percent of the fee schedule amount of the surgical procedure, and are subject to multiple surgery pricing rules. The allowed amount for assistant-at-surgery services performed by a nurse practitioner, physician assistant or clinical nurse specialist is the lesser of 80 percent of the actual charge, or 85 percent of the 16 percent allowed based on the physician fee schedule. BILATERAL SERVICES -50 Bilateral procedure: Unless otherwise identified in the listings, bilateral procedures that are performed at the same operative session should be identified by adding modifier 50 to the appropriate five digit code. Billing Tips: Medicare guidelines for the use of modifier -50 differ from those in the CPT manual and many third-party payers accepted protocol. Bilateral procedures should only be reported with one procedure code appended with modifier -50. This should appear on the Form CMS-1500 as a single line item with the number of Days/Units 1. NHIC, Corp. 13 June 2011

14 With the exception of certain radiology procedures, bilateral procedures are customarily reimbursed at 150% of the Medicare Fee Schedule Allowance. Refer to the Medicare Physician Fee Schedule database (MPFSDB) to determine if CPT modifier 50 is applicable to a particular procedure code. The procedure code must have a 1 indicator on the MPFSDB for the modifier -50 to apply. If a procedure is not valid for the modifier -50 or the LT/RT modifiers, there will be a 0 indicator under bilateral surgery on the MPFSDB. Do not submit codes with bilateral indicator 2 with HCPCS modifier RT or LT or CPT modifier 50. Units equal 1 Bilateral Procedures Billed Correctly AT Acute treatment CHIROPRACTIC This modifier is submitted with chiropractic treatment codes when the chiropractor furnishes acute treatment. It should not be used when the treatment is maintenance in nature. This modifier may only be submitted with CPT codes 98940, 98941, and (CPT code is not reimbursed by Medicare.) CLINICAL PSYCHOLOGIST & CLINICAL SOCIAL WORKER The following modifiers must be submitted on an assigned claim and when diagnostic psychological tests and therapeutic psychotherapy services are reported to Medicare. Failure to use the appropriate modifier may result in incorrect payment. -AH -AJ Clinical psychologist Indicates that the therapeutic service(s) reported was personally performed by a clinical psychologist Clinical social worker Indicates that the therapeutic service(s) reported was personally performed by a clinical social worker NHIC, Corp. 14 June 2011

15 CLINICAL RESEARCH STUDIES -Q0 Investigational clinical service provided in a clinical research study that is in an approved clinical research study -Q1 Routine clinical service provided in a clinical research study that is in an approved clinical research study The modifiers include studies that are certified under the Medicare Clinical Research Policy, Investigational Device Exemption (IDE) trials, and studies required under a coverage with evidence development (CED) national coverage determination (NCD). CORONARY ARTERY Transluminal coronary intervention are appropriately considered in those patients who manifest either acute or chronic signs and symptoms of coronary insufficiency, who have not responded adequately to optimized medical therapy, for whom a probative alternative is aortocoronary bypass, who have objective evidence of myocardial ischemia and have lesions amenable to transluminal intervention. Medicare recognizes only three coronary arteries when considering first and additional vessel interventions, the left anterior descending, the left circumflex, and the right coronary arteries. Use these modifiers to indicate the specific vessel involved in the procedure; they are only valid for CPT codes 92973, 92974, 92980, 92981, 92982, 92984, and LC -LD -RC Left circumflex coronary artery Left anterior descending coronary artery Right coronary artery -KD DRUGS AND BIOLOGICALS Drug or biological infused through DME An implanted infusion pump for chronic pain is covered by Medicare. Claims for infusion drugs furnished through DME (Durable Medical Equipment) shall be identified using the KD modifier. Since the infusion of medications take place through an implantable pump, you must add the KD modifier to the drug code. When using medications for infusion, use the HCPCS code assigned to that medication (e.g., J2275, morphine sulfate, preservative-free sterile solution, per 10 mg) plus the KD modifier. NHIC, Corp. 15 June 2011

16 -JW Drug amount discarded/not administered to the patient CMS states that Medicare contractors may require the use of modifier JW. Modifier JW is used to identify unused drugs or biologicals from single use vials or single use packages that are appropriately discarded. At this time, NHIC does not require the use of modifier JW for discarded drugs and biologicals. NHIC will consider payment for the appropriately discarded amount of a single-use drug/biological product after administering what is reasonable and necessary for the patient s condition. If a physician, hospital or other provider must discard the remainder of a single-use vial or other single-use package after administering a dose/quantity of the drug/biological to a Medicare patient, the program provides payment for the amount of drug/biological discarded along with the amount administered up to the amount of the drug or biological indicated on the vial or package label. Drug wastage must be documented in the patient s medical record with date, time, and drug/biological product amount wasted. ERYTHROPOIESIS STIMULATING AGENTS (ESA) The Erythropoiesis Stimulating Agents (ESAs) stimulate the bone marrow to make more red blood cells and are United States Food and Drug Administration (FDA) approved for use in reducing the need for blood transfusion in patients with specific clinical indications. All non-esrd claims billing HCPCS J0881 and J0885 must report one of the following modifiers: -EA -EB -EC Erythropoetic stimulating agent (ESA) administered to treat anemia due to anticancer chemotherapy Erythropoetic stimulating agent (ESA) administered to treat anemia due to anticancer radiotherapy Erythropoetic stimulating agent (ESA) administered to treat anemia not due to anticancer radiotherapy or anticancer chemotherapy -EJ Subsequent claim for a defined course of therapy, e.g., EPO, sodium hyaluronate, infliximab Enter this modifier to indicate subsequent EPO injection. This modifier is purely informational for Medicare use. ESAs administered for more than one of the indicated therapies are to be billed as separate line items; i.e., ESAs for chemo-induced anemia, (EA modifier) are reported as separate line items (e.g., J0881EA); ESAs for radio-induced anemia (EB modifier) are reported as separate line items (e.g., J0885EB); ESAs for non-chemo/radio induced anemia (EC modifier) are reported as separate line items (e.g., J0881EC). Only one of the three ESA modifiers may be reported at the line item level. Claims that are billed without the required modifiers will be returned as unprocessable. All claims for the administration of an ESA must have the hematocrit or hemoglobin level in Item 19 of the CMS 1500 claim form or electronic equivalent. NHIC, Corp. 16 June 2011

17 EVALUATION AND MANAGEMENT (E/M) Report the modifiers listed below on E/M codes only. -AI Principal Physician of Record The principal physician of record will append modifier AI (Principal Physician of Record), to the E/M code when billed. This modifier will identify the physician who oversees the patient s care from all other physicians who may be furnishing specialty care. All other physicians who perform an initial evaluation on this patient shall bill only the E/M code for the complexity level performed. However, claims that include the AI modifier on codes other than the initial hospital and nursing home visit codes (i.e., subsequent care codes or outpatient codes) will not be rejected and returned to the physician or provider. -24 Unrelated evaluation and management service by the same physician during the postoperative period Modifier -24 was intended for use with the E/M service codes performed during the postoperative period for a reason(s) unrelated to the original major or minor surgery. It is not to be used for medical management of a patient by the surgeon following surgery. Billing Tips: Use of the -24 modifier is appropriate with CPT codes and Services submitted with modifier -24 must be sufficiently documented in the medical record to establish that the visit was unrelated to the condition for which the surgery was performed. Do not submit the documentation unless requested to do so. Append modifier -24 to the E/M code performed during a pre or postoperative period of a procedure performed by the same physician, but which is unrelated to the major or minor surgical procedure performed. When submitting modifier 24 with codes ( ), documentation (a diagnosis is acceptable) that the critical care was unrelated to the specific anatomic injury or general surgical procedure performed must be submitted. Examples of Supporting Documentation: ICD-9-CM code(s) that are clearly unrelated to the surgery Documentation clearly explaining why the visit is unrelated to the surgery. Documentation indicating immunosuppressive therapy for organ transplants. To determine the global period of a surgery, refer to the Medicare Physician Fee Schedule database (MPFSDB). Access the database directly from the CMS Website at NHIC, Corp. 17 June 2011

18 -25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service: It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient s condition required a significant, separately, identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by the documentation that satisfies the relevant criteria for the respective service to be reported. The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. Documentation in the patient s medical record must support the use of this modifier. Note: This modifier is not used to report an E/M service that resulted in a decision to perform major surgery (i.e., those with a 90-day follow-up period). Example: Billing Tips: No supporting documentation is required with the claim when this modifier is submitted. However, the patient s medical records must contain information to support the use of modifier - 25 and be available upon request. The following are the exceptions: o Use modifier -25 on initial hospital visit ( ), and a hospital discharge service (99238 and 99239), when billed for the same date as an inpatient dialysis service. o Use modifier -25 when preoperative critical care codes ( ) are billed within a global surgical period. Reporting these E/M services with modifier -25 indicates that they are significant and separately identifiable. Documentation that the patient is critically ill and requires the constant attention of the physician, and the critical care is unrelated to the specific anatomic injury or general procedure performed must be submitted. NHIC, Corp. 18 June 2011

19 o o o Use modifier -25 on an E/M service when performed at the same session as a preventive care visit when a significant, separately identifiable and medically necessary E/M service is performed in addition to the preventive care. The E/M must be carried out for a non-preventive clinical reason, and the ICD-9-CM code(s) for the E/M service should clearly indicate the non-preventive nature of the E/M service. Use modifier -25 if the decision for surgery is made on the same day as a minor surgery (i.e., those with a 0 or 10- day follow-up period) if the decision is made during an E/M service the day of surgery. Do not use modifier -25 on a surgical code ( ) since this modifier is used to explain the special circumstance of providing the E/M service on the same day as a procedure. NOTE: The most common cause for claim denial of an unrelated E/M service billed on the same day as another procedure or during the post operative period for a non-surgery related reason is due to the omission of modifier -25. Multiple Modifiers May Apply o When a visit occurs on the same day as a surgery with 0 global days and within the global period of another surgery AND the visit is unrelated to both surgeries, modifiers 24 and 25 must be submitted. For example: A patient comes to the office for an E/M and an endoscopic procedure is performed. The results require immediate performance of major surgery the next day. The E/M would require the use of modifier -24 for the endoscopic procedure, and -25 for the major surgery performed the next day. -57 Decision for Surgery: An evaluation and management service that resulted in the initial decision to perform the surgery may be identified by adding modifier -57 to the appropriate level E/M service NHIC, Corp. 19 June 2011

20 Billing Tips: E/M services on the day before the procedure, the day of the procedure, and within the 90-day postoperative period are generally not payable. Only initial services and services unrelated to the procedure performed may be considered for payment. Do not use Modifier -57 with minor surgeries (zero- to 10 day postoperative period). See Modifier 25. No supporting documentation is required with the claim when submitted but must be included in the patient s medical record and available upon request. There is a Global Surgery Period Calculator available on the NHIC website under Self-Service Tools that will assist in determining the end of the global period for surgeries. To determine the global period of a surgery, refer to the Medicare Physician Fee Schedule database (MPFSDB) on the CMS Website: EYE Use the appropriate modifier for additional information when billing eye procedures. -LS -VP FDA- monitored intraocular lens implant Submit this modifier on physician claims for eye surgery with IOL implants Aphakic patient Submit this modifier with Evaluation and Management (E/M) codes or eye exam codes to indicate that the patient is aphakic. This modifier is informational only. The following modifiers are often used for procedures or diagnostic tests that may be bundled when performed on the same eye(s): -E1 Upper left eyelid -E2 Lower left eyelid -E3 Upper right eyelid -E4 Lower right eyelid NHIC, Corp. 20 June 2011

21 FOOT CARE Routine foot care is not a covered Medicare benefit. Medicare assumes that the beneficiary or caregiver will perform these services by themselves, and therefore, they are excluded from coverage. Medicare allows exceptions to this exclusion when medical conditions exist that place the patient at increased risk of infection and/or injury if a non-professional would provide these services. Medicare may cover routine foot care in the following situations: The routine foot care is a necessary and integral part of otherwise covered services The patient has a systemic condition To fulfill the claim billing requirements for qualified routine foot care in vascularly compromised patients, one of the following modifiers must be attached to each routine foot care procedure code. -Q7 One Class A finding -Q8 Two Class B findings -Q9 One Class B and two Class C findings Digit Modifiers for the Foot With some procedure codes, it is appropriate to report a digit modifier indicating the toe upon which the procedure was performed. A toe is defined as that appendage structure distal to the mid-metatarsal-phalangeal joint. Digit modifiers are: TA Left foot, great toe T5 Right foot, great toe T1 Left foot, second digit T6 Right foot, second digit T2 Left foot, third digit T7 Right foot, third digit T3 Left foot, fourth digit T8 Right foot, fourth digit T4 Left foot, fifth digit T9 Right foot, fifth digit HEALTH PROFESSIONAL SHORTAGE AREA (HPSA) Federal Law permits special payment for professional services provided by physicians in federally designated geographic Health Professional Shortage Areas (HPSAs). Physicians who provide covered Medicare services in rural or urban HPSAs are eligible for a 10-percent incentive payment. The Health Resources and Services Administration, with the Department of Health & Human Services, is responsible for designating shortage areas. Eligibility for the incentive payment is based on provider specialty and the location where the services were rendered, not necessarily where the physician maintains an office. HPSA boundaries are based on census tracts, and in many cases do not coincide with routinely used boundaries such as ZIP codes or streets. NHIC, Corp. 21 June 2011

22 -AQ Physician providing a service in an unlisted Health Professional Shortage Area Submit modifier AQ in the following instances: When you provide services in zip code areas that do not fall entirely within a designated full county HPSA bonus area; When you provide services in a zip code area that falls partially within a full county HPSA but is not considered to be in that county based on the USPS dominance decision; When you provide services in a zip code area that falls partially within a non-full county HPSA; When you provide services in a zip code area that was not included in the automated file of HPSA areas based on the date of the data run used to create the file. Do not submit modifier -AQ in the following instances: Your global code contains a technical component You are submitting a technical-only component code (e.g., CPT 93005). The service was not rendered in a HPSA. The service was performed by someone that does not meet the definition of a physician (psychiatrists are included in the definition of a physician). You have elected to opt out of the HPSA program. HOSPICE The following modifiers should be used in regards to Hospice billing. -GV: Attending physician not employed or paid under arrangement by the patient's hospice provider This modifier must be submitted when a service meets the following conditions: The service was rendered to a patient enrolled in a hospice, and The service was provided by a physician or non-physician practitioner identified as the patient s attending physician at the time of that patient s enrollment in the hospice program. Submit this modifier regardless of whether the services were related to the patient s terminal condition. Do not submit this modifier: If the service was provided by a physician employed by the hospice or If the service was provided by a physician not employed by the hospice and the physician was not identified by the beneficiary as his/her attending physician -GW: Service not related to the hospice patients terminal condition Submit this modifier when a service is rendered to a patient enrolled in a hospice, and the service is unrelated to the patient s terminal condition. All providers must submit this modifier when this condition applies. NHIC, Corp. 22 June 2011

23 -LR -QP LABORATORY SERVICES Laboratory round trip This modifier may only be submitted by independent clinical laboratories for HCPCS code P9604. Documentation is on file showing that the laboratory test(s) was ordered individually or ordered as a CPT-recognized panel other than automated profile codes , G0058, G0059 and G0060 Submit this modifier when the laboratory test was ordered as a single test or when a single code is available for a grouping of tests. This modifier indicates that the test was ordered individually or ordered as a CPT-recognized panel other than automated profile codes and HCPCS codes G0058-G QW CLIA test waived The Centers for Disease Control and Prevention (CDC) has established several tests, and periodically revises the list of tests, which may be performed by entities holding a CLIA Certificate of Waiver or a higher level CLIA certificate. These tests must be billed with the correct CPT code and modifier QW to be considered for payment. Providers can find a list of CLIA waived tests and those tests that require the use of the QW modifier at Billing Tips Submit this modifier with clinical laboratory tests that are waived from the Clinical Laboratory Improvement Amendments of 1988 (CLIA) list. Note: Not all CLIA-waived tests require HCPCS modifier QW. Refer to the published lists to determine which codes require a modifier. Determine if the CPT code is a waived test by accessing the CMS CLIA Web page: The CLIA certificate number is also required on claims for CLIA waived tests. Submit the CLIA certification number in Item 23 of the CMS-1500 claim form or electronic equivalent. -90 Reference (outside) laboratory: When laboratory procedure are performed by a party other than the treating or reporting physician, the procedure may be identified by adding modifier -90 to the basic procedure. This modifier may only be submitted with clinical laboratory tests. Independent clinical laboratories may submit this modifier to indicate that the service was referred to an outside laboratory. For all laboratory work referred to an outside lab, Item 32 or electronic equivalent must reflect the place where the test was performed. The NPI and / or legacy number are not required in 32a or 32b. NHIC, Corp. 23 June 2011

24 -91 Repeat Clinical Diagnostic Laboratory Test: In the course of treatment of the patient, it may be necessary to repeat the same laboratory test on the same day to obtain subsequent (multiple) test results. Under these circumstances, the laboratory test performed can be identified by its usual procedure code and the addition of modifier -91. This modifier may only be used for laboratory test(s) performed more than once on the same day on the same patient. -92 Alternative Laboratory Platform Testing: When testing is being performed using a kit or transportable instrument that wholly of in part consists of a single use, disposable analytical chamber, the service may be identified by adding modifier 92 to the usual laboratory procedure code (HIV testing ). The test does not require permanent dedicated space; hence by its design it may be hand carried or transported to the vicinity of the patient for immediate testing at that site, although location of the testing is not in itself determinative of the use of this modifier. NATIONAL CORRECT CODING INITIATIVE (NCCI) CMS developed the National Correct Coding Initiative (also referred to as CCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims. CCI edits are pairs of CPT or HCPCS Level II codes that are not separately payable under certain circumstances. The edits are applied to services billed by the same provider for the same beneficiary on the same date of service. All claims are processed against CCI tables. -59 Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-e/m services performed on the same day. Modifier -59 is used to identify procedures or services, other than E/M services, that are not normally reported together but are appropriate under the circumstances. Documentation must support: -a different session -different procedure or surgery -different site or organ system -separate incision or excision -separate lesion -separate injury (or area of injury in extensive injuries) However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances should modifier 59 be used. NHIC, Corp. 24 June 2011

25 Billing Tips: o o o o o o o o o o Modifier -59 is an important National Correct Coding Initiative (NCCI) associated modifier that is often used incorrectly. For the NCCI, the primary purpose of Modifier -59 is to indicate that two or more procedures are performed at different anatomic sites or during different patient encounters. Before submitting this modifier, it is important to verify whether the services are bundled through NCCI. NCCI edits are updated quarterly and may be accessed at Modifier -59 should not be used to bypass an NCCI edit, unless the proper criteria for use of the modifier is met and fully documented in the medical records. Modifier -59 is used only on the procedure which is designated as the distinct procedural service. Modifier -59 is used only if another modifier does not describe the situation more accurately or when its use best explains the circumstances. No special documentation need be submitted with the claim when modifier -59 is used. In all cases, documentation must be maintained in the patient s medical records to support the use of modifier -59 and must be made available upon request. Modifier -59 should not be used with an E/M service. To report a separate and distinct E/M service with a non-e/m service performed on the same date, see modifier 25. Procedure codes that are billed to Medicare and denied due to NCCI may not be billed to the patient. Example: Distinct Procedural Service NHIC, Corp. 25 June 2011

26 1 st Column (Shaded area) This is just the number (counting) of that particular edit. 2 nd Column This is a listing of CPT/HCPCS codes. The CPT/HCPCS code listed in COLUMN 1 is the most comprehensive code. 3 rd Column The CPT/HCPCS code in COLUMN 2 will not be paid on the same day as the code in COLUMN 1. 4 TH Column This column lets you know if the edit was in existence prior to th Column This is the effective date of the edit. 6 th Column This is the termination date of the edit(if applicable). 7 th Column This is the modifier column. Code pairs identified with indicator 0 cannot be submitted for reimbursement under any circumstances. The code in column 2 will never be paid on the same day as the column 1 code. Code pairs identified with indicator 1 may be submitted separately if there is documentation in the medical records to support that the services are distinct or independent of one another. Code pairs identified with indicator 9 are not subject to CCI edits. No modifier is required. CPT (CCI- Column I code): Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical currettement), premalignent lesions (e.g., actinic keratoses); first lesion, submitted with CPT (CCI-column II code): Biopsy of skin, subcutaneous tissue and/ or mucous membrane (including simple closure), unless otherwise listed; single lesion Rationale: Correct usage of modifier -59 is based on CPT coding manual instructions and guidelines. Modifier -59 is only appropriate if the procedures are performed on separate lesions or at separate patient encounters. NHIC, Corp. 26 June 2011

27 OUTPATIENT THERAPY SERVICES Providers are required to report one of the following modifiers to distinguish the type of therapist who performed the outpatient service. If the service was not delivered by a therapist, it is used to report the discipline of the Plan of treatment/care under which the service is delivered. -GN -GO -GP Service delivered under an outpatient speech language pathology plan of care Service delivered under an outpatient occupational therapy plan of care Service delivered under an outpatient physical therapy plan of care Additional Modifier for Outpatient Therapy Services -KX Requirements Specified in the medical policy have been met Submit this modifier with speech language pathology, physical therapy or occupational therapy services when the patient has already met the financial cap for PT/SLP or OT and the service qualifies as an exception to be reimbursed over and above the cap. You must include HCPCS modifier KX on the claim identified as a therapy service in addition to HCPCS modifier GN, GO, or GP when a therapy cap exception has been approved, or it meets all the guidelines for an automatic exception. This allows the approved therapy services to be paid, even though they are above the therapy cap financial limits. Do not add modifier KX to any line of service that is not medically necessary. If additional modifiers are required with the service, HCPCS modifiers GN, GO or GP must be submitted in the first or second modifier position. PHYSICIAN QUALITY REPORTING SYSTEM (PQRS) The Physician Quality Reporting System (PQRS) establishes a financial incentive for eligible professionals to participate in a voluntary quality reporting program. Where a patient falls in the denominator population but specifications define circumstances in which a patient may be excluded from the measure s denominator population, CPT Category II code modifiers 1-P, 2-P, or 3-P are available to describe medical, patient, or system reasons, respectively, for such exclusion. 1P Performance Measure Exclusion Modifier due to Medical Reasons (e.g., such as patient allergic to medicine) 2P Performance Measure Exclusion Modifier used due to Patient Reason (e.g., such as patient refused treatment) NHIC, Corp. 27 June 2011