Separate, But Not Distinct: The Appropriate Use Of Modifiers 25 And 59

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1 Separate, But Not Distinct: The Appropriate Use Of Modifiers 25 And 59 Sandy Giangreco, RHIT, CCS, CPC, CPC-H, CPC-I, PCS AHIMA Approved ICD-10-CM/PCS Trainer Jenny Studdard, CPC, RCC, CPCO AHIMA Approved ICD-10-CM Trainer 1 What purpose do they serve What is the Separate & Distinct E/M Service Appropriate Use of Modifier 25 What is National Correct Coding Initiative (NCCI) Separate & Distinct Procedures Appropriate Use of Modifier 59 Agenda 2 What is the Purpose of a Modifier An integral part of the structure of the CPT code set Indicates that a service of procedure that was performed has in some way been altered The code definition has not changed Enable professionals to respond effectively to payment policy requirements established by other entities 3 1

2 Usage of Modifiers Reporting only the professional component Report a service mandated by a 3 rd party payer Proc performed bilaterally Report that multiple proc were performed at same session by same prov Report a portion of the service or proc was reduced or eliminated at physicians discretion Report assistant surgeon services 4 Reimbursement for the surgical procedure includes some related E&M services Specific E&M services included vary depending on whether the procedure is defined as a major surgical procedure, minor surgical procedure or non-surgical 5 All diagnostic/therapeutic procedures include: Obtaining limited pertinent history Confirming reason for the procedure Establishing presence of allergies / comorbidities that may impact procedure Obtaining informed consent Review of medical record Provision of follow-up instructions Pre / post procedure patient care 6 2

3 Non-Surgical Procedures Procedures with no defined global period Have inherent pre-procedure, intra-procedure, and post-procedure work which should not be reported as an E&M service Only when a significant, separately identifiable service is rendered which involves taking a history, performing an exam, and making medical decisions distinct from the procedure may an E&M be reported in addition to the procedure 7 Non-Surgical Procedures Catheter placements Fistulogram with catheter placement Fine needle aspirations Declotting Central Venous Catheter Intracranial angioplasty 8 Minor Surgical Procedures (0 or 10 day global) All include E&M on the same day Some include E&M for 10 days following the procedure Significant and separately identifiable E&M may be billed within the global period The decision to perform a minor surgical is included in the reimbursement for that procedure and should not be reported as a separate E&M 9 3

4 Minor Surgical Procedures (0 or 10 day global) Procedures with 0 day global period include: Needle biopsies Lower extremity revascularization PICC line placement Procedures with a 10 day global period include: Insertion, replacement & removal of tunneled CVC Placement of G-tube & J-tube Incision & drainage of abscess, hematoma, & soft tissue abscess subfacial 10 Breast Biopsy w/guidance = 0 days For Example 11 For Example Neuro Embolization = 0 days 12 4

5 For Example Kyphoplasty = 10 days 13 Minor Surgical Procedure (0 or 10 day global) When ever a pre-procedure E&M is billed, the documentation should clearly indicate why the service was above and beyond routine pre-procedure evaluation E&M services that meet the significant, separately identifiable standard should be billed with modifier 25 on the E&M code E&M services unrelated to the procedure are billable and should include modifier 24 on the E&M code 14 Major Surgical Procedures (90 day global) Includes E&M services on the day before the procedure and for ninety (90) days following the procedure with the following exceptions: Decision to perform surgical procedure is separately billable. E&M should be filed with modifier 57 to indicate that the decision to perform surgery was made at that visit Visits unrelated to the diagnosis for which the procedure was performed are separately billable. E&M should be filed with modifier 24 to indicate unrelated E&M by same physician during post-op period 15 5

6 For Example Internal/External Biliary Drain = 90 Days 16 Major Surgical Procedures (90 day global) Endovascular repair of the aorta or iliac artery Dialysis fistula/graft declotting Carotid stent placement Biliary drainage 17 CAN I BILL A VISIT OR NOT

7 Pre-Procedure Visits When can a pre-procedure visit be coded? In most instances, a pre-procedure visit should be charged only if the patient s condition necessitates a significant pre-procedure evaluation. Third party payors do not typically consider it medically necessary for the radiologist to provide a separately billable E/M service prior to every procedure. This service, if it is medically necessary and appropriately documented, should be billed as an office/outpatient visit (CPT codes ). 19 Follow-up Visits During the global period Routine Follow-Up Visits: Routine follow-up visits within the global period are not separately billable. Payment for these visits is included in the global surgical payment. No charges should be submitted to third party payors for routine postprocedure visits during the global period. 20 Follow-up Visits During the global period Post-Procedure Complications: CPT definition - The Surgery guidelines in the CPT manual state, Complications, exacerbations, recurrence, or the presence of other diseases or injuries requiring additional services should be separately reported. Therefore, visits during the global period for complications of the procedure can be billed to non-medicare payors unless prohibited by payor policy. 21 7

8 Follow-up Visits During the global period Post-Procedure Complications: Medicare definition - E/M services related to postprocedure complications are included in the global payment for the procedure. Therefore, E/M services related to post-procedure complications should not be billed to Medicare. 22 Follow-up Visits During the global period Other Visits: The global surgical package does not include visits for treatment of the patient s underlying condition, or visits for unrelated conditions. (See Medicare Claims Processing Manual, Chapter 12, Section 40.1.B.) These services are separately billable. 23 Follow-up Visits After the global period Follow-up visits after the global period are separately billable. However, the services must be medically necessary and reasonable for the patient s condition. If it is no longer medically necessary for a patient to be seen following the global period, the physician should not bill for any additional follow-up visits. 24 8

9 Bottom Line Can the Provider Report an EM Service? Was the evaluation provided by the physician/npp Was the evaluation above/beyond the level required for the surgical procedure/imaging study Was the evaluation outside of the global package Does the documentation include all three key components Are extensive conversations appropriately documented Is there a mechanism in place to capture the charge Is the organization/practice ready to manage the co-pays and patient inquires 25 Modifier 25 Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service Although the E/M service may be provided for the same diagnosis as the procedure, the E/M service must be above and beyond the usual pre- and post-procedure service. 26 Modifier 25 Examples The physician is asked to see an inpatient in consultation regarding intra-abdominal bleeding following blunt trauma. The physician performs a Level IV initial inpatient consultation (99254) and determines that the bleeding may be amenable to transcatheter embolization (37204). Diagnostic angiography and embolization are performed the same day. Report code in addition to the codes for the angiography and embolization 27 9

10 Modifier 25 Examples The physician is asked to see a patient in consultation in the hospital outpatient department regarding an abnormal mammogram and breast ultrasound. The physician performs a Level III office/outpatient consultation (99243), followed by biopsy of the breast lesion (19102). Report code in addition to the codes for the breast biopsy. 28 The Highlighter Test Eliminate all the documentation that relates to the procedure. The documentation that is left must meet the criteria for the E/M service in terms of history, examination, and medical decision making. If it does not, only the procedure should be charged. 29 WHAT ABOUT PROCEDURES? 30 10

11 What is NCCI The CMS developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims. 31 What is NCCI These coding policies were developed based on coding conventions defined in the AMA's CPT manual, national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practices, and a review of current coding practices. 32 Separate & Distinct Procedure NCCI edits define when two procedure HCPCS/CPT codes may not be reported together except under special circumstances. Special circumstances include: Different session or patient encounter Different procedure or surgery Different site or organ system Separate incision/excision Separate lesion (different size or site groups) Separate injury (multiple trauma injuries) 33 11

12 Separate & Distinct Procedure Example of Separate & Distinct Procedures HCPCS/CPT coding manual instruction/guideline state obtaining tissue during another procedure is a routine component of such procedure and not a separately billable biopsy destruction all benign or premalignant lesions other than skin tags or cutaneous vascular proliferative lesions, first lesion biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure) unless otherwise listed; single lesion If the biopsy was performed on a separate anatomic site than the destruction, it would be considered a separate & distinct procedure. 34 Separate & Distinct Procedure Documentation is integral to supporting accurate reimbursement for separate & distinct procedures. The medical record must demonstrate that the service is separate and distinct from other services performed that day. 35 Separate & Distinct Procedure Use the following 3 questions to determine whether a service is considered part of the comprehensive procedure. 1. Does the service represent the standard of care in accomplishing the overall procedure? 2. Is the service necessary to successfully accomplish the comprehensive procedure? In other words, if you don t perform the service, will the success of the procedure be compromised? 3. Does the service represent a separately identifiable procedure unrelated to the comprehensive procedure planned? 36 12

13 Modifier 59 Indicates that a procedure is distinct, or independent from, other services performed on the same day Designates that an ordinarily bundled code represents a service performed on a different anatomic site or at a different session Documentation must support the separate nature of the procedures 37 Modifier 59 No other modifier is more appropriate e.g., 58, 78, 79, RT, LT HCPCS anatomical modifiers Regular payment policies apply e.g., multiple procedure reductions Medicare uses the National Correct Coding Initiative Other payers may use other products e.g., ClaimCheck, CodeCorrect 38 Modifier 59 When the procedures performed meet the separate and distinct standard as defined, modifier 59 is attached to the bundled or column 2 code

14 Why is modifier 25 a concern? The OIG published a special report on modifier 25 usage, which is located at: pdf 40 OIG Report According to this report: 35% of claims using modifier 25 that Medicare allowed in 2002 did not meet program requirements, resulting in $538 million in improper payments 41 OIG Report According to this report: Medicare should not have allowed payment for these claims because the E/M services were not significant, separately identifiable, and above and beyond the usual preoperative and postoperative care associated with the procedure 42 14

15 Why is modifier 59 a concern? Incorrect usage of modifier 59 is a huge concern for payors, Medicare and the OIG: Some payors have published guidelines or policies regarding modifier 59, for example: Blue Cross & Blue Shield of Tennessee (http://www.bcbst.com/providers/code_bundling/docs/ ReviewCriteriaforModifier59.pdf ) Cigna (https://my.cigna.com/teamsite/health/provider/medical /edits/pdf/modifier25_59_externalupdate.pdf ) 43 OIG Report In March 2011, the OIG published their list of unimplemented recommendations. In it is a section on the use of modifier 59. This publication is available at: https://oig.hhs.gov/publications/docs/compendiu m/2011/cmp-01_medicare_a+b.pdf 44 OIG Report According to this report: The OIG found providers had a 40% or more error rate for services billed with a 59 modifier. The OIG recommended that: CMS should (1) encourage carriers to conduct prepayment and postpayment reviews of the use of modifier 59 and (2) ensure that the carriers claims processing systems pay claims with modifier 59 only when the modifier is billed with the correct code

16 OIG Report Also included in this report is a list of actions taken by CMS: In April 2006, CMS published clarifying guidance to chapter 4 of the Medicare Claims Processing Manual, which includes the use of modifier 59 (CR 4388). In April 2008, CMS issued an MLN Matters article (classified as Special Edition 0810) to provide continuing education to physicians on how to bill modifier 59 appropriately. In its December 2009 comments, CMS indicated that it would explore the development of an edit for modifier 59. However, upon further analysis in this area, CMS discovered that the implementation of creating an edit for modifier 59 would likely result in increased appeals volume. In its update for 2011, CMS indicated that it will continue to explore alternative solutions to ensure correct coding. 46 QUESTIONS? 47 Thank You For Your Participation Sandy Giangreco Jenny Studdard 48 16

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