Modifiers. Hoda Henein, CHBME, CP President & CEO, Active Management A Practice Management Consulting and Billing Company

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1 Modifiers Hoda Henein, CHBME, CP President & CEO, Active Management A Practice Management Consulting and Billing Company Fellow, Speaker, Billing & Coding Advisor American Academy of Podiatric Practice Management (AAPPM) & Langer Biomechanics Member of the Editorial Advisory Board for Podiatry Coding Alert Member of Healthcare Billing Management Association(HBMA) Member of American Academy of Professional Coders(AAPC) Member of American Medical Billing Association(AMBA) Member of American Health Information Management Association(AHIMA) Telephone: Fax:

2 Active Management owns the copyright of the material here presented, including photographs and graphic designs, unless otherwise specifically stated. In the case of some materials, Active Management has licensed rights to third parties. This presentation is designed to be used to educate attendees about medical billing and practice management. The use of Active Management material for any purpose, including in hard copy or compilation for CD-ROM or any other electronic media, is prohibited unless prior written permission is obtained. In addition, the use of Active Management material by unauthorized parties in lectures or seminars is also prohibited.

3 Modifiers provide the means by which the reporting provider can indicate a service or procedure has been altered by some specific circumstance but has not changed in its definition or code. Modifiers may be used to indicate that: A service or procedure: has both a professional and technical component was performed by more than one physician has been increased or reduced Only part of a service was performed An additional service was performed A bilateral procedure was performed Unusual events occurred

4 Prior to using a modifier: Be certain of it s accuracy Ensure the patient s clinical situation requires it Support it in your Notes / Chart Modifiers that are not supported can result in Fraudulent Acts

5 New Modifiers in 2010 JC Skin Substitute used as a graft (ie. Apligraf) Skin Graft: If the skin substitute is implanted into the wound to be incorporated as the wound heals JD Skin Substitute not used as a graft NOT a Skin Graft: If the skin substitute is used to cover a wound to protect it from contamination or fluid loss, then it is not a graft, but a dressing The difference between them is whether the skin substitute is used as a graft or as a skin covering

6 New Modifiers in 2010 (Continued) AI (Letter A Letter I) 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 will 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.

7 Most Commonly Used Modifiers

8 Modifiers: E&M Unrelated Evaluation & Management service by the same physician during a postoperative period Significant, separately identifiable E&M service by the same physician on the same day of the procedure or other therapeutic service which has 0-10 day global period. A separate diagnosis is not needed. This modifier is used on the E &M service 57 Initial Decision for surgery (90-day global period). This modifier is used on E&M service, the day before or the day of surgery to exempt it from the global surgery package

9 22 50 Modifiers: Procedures Unusual procedural service - Surgeries for which services performed are significantly greater than usually required. If NY or NJ, supportive documentation required stating about how the service differs from the usual. E.g., operative reports, pathology reports, etc. Bilateral procedure. Medicare will approve 150 percent of the fee schedule amount for those services. 51 Multiple Procedures Internal use only by Carrier. 52 Reduced Services it indicates a service or procedure is partially reduced or eliminated at the physician s election. If New Jersey or New York, supportive documentation is required. E.g.: office records, test results, operative notes, or hospital records.

10 Modifiers: Procedures Discontinued Procedure - Due to extenuating circumstances, or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. Supportive documentation is required. E.g.: office records, test results, operative notes, or hospital records. ICD-9: V64.1 (discontinued due to contraindication) ICD-9: V64.2 (discontinued due to patient) Surgical care only - When one physician performs a surgical procedure and another physician provides preoperative and/or postoperative management, the surgical service should be identified by adding modifier 54 to the usual procedure code. Postoperative management only. When one physician performs the postoperative management and another physician has performed the surgical procedure.

11 Modifiers: Procedures Staged or related procedure or service by the same physician during the postoperative period. If a less extensive procedure fails, and a more extensive procedure is required, the second procedure is payable separately. Modifier 58 must be reported with the second procedure. Distinct procedural service - The physician may need to indicate that a procedure or service was distinct or separate from other services performed on the same day. This may represent a different session or patient encounter, different procedure or surgery, different site, separate lesion, or separate injury. However, when another already established modifier is appropriate, it should be used rather than modifier 59.

12 73 Discontinued out-patient procedure Prior anesthesia administration 74 Discontinued out-patient procedure After anesthesia administration 76 Modifiers: Procedures Repeat procedure by same physician. Indicate the reason or the different times for the repeat procedure in item 19 of the CMS 1500 Form or the electronic equivalent. Repeat procedure by another physician. Indicate the reason or the 77 different times for the repeat procedure in item 19 of the CMS 1500 Form or the electronic equivalent Return to the operating room for a related procedure during the postoperative period. The physician may need to indicate that another procedure was performed during the postoperative period of the initial procedure. It should be reported by adding modifier 78 to the related procedure. Unrelated procedure or service by the same physician during the postoperative period. It indicates that the performance of a procedure or service during the postoperative period was unrelated to the original procedure.

13 Modifiers: Assistant Surgeons GC GE Assistant surgeon. Add modifier 80 to the usual procedure in a non-teaching setting to identify surgical assistant services Assistant surgeon when qualified resident surgeon not available in a teaching setting Service performed in part by a resident under the direction of teaching physician. Service performed by resident without the presence of a teaching physician under the primary care exception.

14 Modifiers: Locator RT LT Right side Left side TA T1 Left foot, great toe Left foot, second toe T2 Left foot, third toe T3 Left foot, fourth toe T4 Left foot, fifth toe T5 Right foot, great toe T6 Right foot, second toe T7 Right foot, third toe T8 Right foot, fourth toe T9 Right foot, fifth toe

15 Q7 Q8 Q9 Modifiers: Class Findings One class "A" finding Two class "B" findings One class "B" and two class "C" findings Class A Class B Class C Non-traumatic amputation of foot or integral skeletal portion thereof Absent posterior tibial pulse Advanced trophic changes as evidenced by any three of the following: 1. hair growth (decrease or increase) 2. nail changes (thickening) 3. pigmentary changes (discoloring) 4. skin texture (thin, shiny) 5. skin color (rubor or redness) Absent dorsalis pedis pulse Claudication Temperature changes (e.g., cold feet) Edema Paresthesias (abnormal spontaneous sensations in the feet) Burning

16 Modifiers: X-rays 26 TC RT LT Professional Component. All diagnostic testing with a technical and professional component done in an outpatient or inpatient setting must reflect the 26 modifier. The fiscal intermediary (Part A Medicare) will reimburse the facility for the technical component. Technical component of diagnostic test. Right side Left side

17 Modifiers: Physical Therapy GP KX Service delivered under an outpatient physical therapy plan of care Specific required documentation on file

18 Modifiers: Hospice GW Service not related to the Hospice s patients terminal condition.

19 Modifiers: Rural Area AQ Physician services provided in health provider shortage area (HPSA) This modifier replaces QB and QU

20 Modifiers KX EY LT RT A1 A2 A3 Specific required documentation on file No Physician order on file. Left Side Right Side 1 Wound 2 Wound 3 Wound A-- Up to 9 additional Wounds NU New Equipment

21 Modifiers Non-covered services GA Advanced Beneficiary Notification on file GY GZ Item or service statutorily excluded or does not meet the definition of any Medicare benefit Item or service expected to be denied as not reasonable and necessary and ABN has not been signed. GA Not Medical Necessary ABN Needed & Signed No Fee Limit Must file with MCR GY Statutorily not covered ABN Not Needed No Fee Limit Only File if pt Requests GZ Not Medical Necessary (not good for Dr) ABN Needed & Not signed Pt can not be charged Must file with MCR

22

23 Podiatry Billing E & M -POS DME Receivables Management Thank you!!! Hoda Henein, CHBME, CP President & CEO, Active Management Management Consulting & Billing Company All rights reserved. This material may not be reproduced, displayed, modified or distributed without the express prior written permission of the copyright holder. Telephone: Fax:

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