Appropriate Modifier Usage

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1 Anatomical modifiers Anesthesia modifiers EA, EB and EC FB, FC and FD Anatomical modifiers are used to indicate that a procedure or service was performed at a specific anatomic site or to indicate that a procedure was performed at two separate and distinct anatomic sites. Examples of anatomical modifiers are: E1 E4, FA, F1 F9, TA, T1 T9, LT, RT, LC, LD and RC. Use of anatomical modifiers facilitates the identification of separate and distinct services. For example, a provider may report modifier F2 on one line and modifier F3 on another line when procedure code *26455 is reported as performed on each of those fingers, instead of reporting a count of two on one line. Anatomical modifiers should be reported instead of modifier 59, when possible. For example, if a provider performs foot surgery, reporting code *28285 and code *28292 at the same operative session but on different sites, anatomic modifiers should be appended to each line to indicate that the procedures performed were separate and distinct. 59 is to be used only when there are no other modifiers that accurately indicate the nature of the service performed. If an anatomical modifier is used and the modifier is not appropriate to the procedure code, the claim may be denied. Anesthesia claims must be reported with the appropriate modifier for the practitioner administering the anesthesia: AA, AD, QK or QY is reported for a physician who administers the anesthesia or who supervises its administration. QX or QZ is reported for a certified registered nurse anesthetist who administers the anesthesia. Services performed by CRNAs without the medical direction of an anesthesia physician are paid the charge or 85 percent of the maximum payment, whichever is lower. Anesthesia services performed by CRNAs or anesthesia assistants in physician offices are not eligible for payment. Non-end stage renal disease claims for the administration of erythropoiesis-stimulating agents must contain one of the current HCPCS modifiers: EA, EB or EC. Refer to the Claims chapter of the BCN Provider Manual for information on appropriate usage of the FB, FC and FD modifiers. Specifically, see the Reporting of medical device credits by hospital and ambulatory surgery centers subsection, which is in the Other billing and payment guidelines section of that chapter. 1

2 GN, GO and GP HA JA and JB JW A physical medicine and rehabilitation service must be reported with the appropriate therapy modifier indicating the discipline performing the therapy. The modifiers are GN, GO and GP. The codes requiring these modifiers include the following: *92507, *92508, *92521-*92524, *92526, *92597, * , *96125, *97001-*97004, *97010-*97012, *97014, *97016-*97028, *97032-*97039, * *97124, *97139-*97140, *97150, *97530, *97532-*97537, *97542, *97750, *97755, *97760-*97762, *97799, G0129, G0283, G0329, S8948, S8950, S9152 or S9476. If the procedure code is reported without the modifier, the service may be denied because the required modifier is missing. The reporting of these modifiers indicating the type of therapy performed does not supersede the provider s reimbursement arrangement with BCN for these services. Note: This information applies to all BCN products. The CPT codes *97597, *97598, *97602, *97605, *97606, G0281 and G0329 are classified by the CMS as sometimes therapy procedure codes. (Code G0329 is for BCN Advantage members only; it is not covered for BCN commercial members.) When these services are provided for active wound management, they should not be reported with therapy modifiers (GN, GO or GP) and/or revenue codes 0421/0424, 0431/0434 and 0441/0444, as these modifiers/revenue codes indicate therapy services. Reporting wound management procedure codes with revenue codes 0421/0424, 0431/0434 and 0441/0444, will result in the claim line for the procedure being denied. To receive the correct reimbursement, board-certified child and adolescent psychiatrists should bill with the HA modifier rather than the AM modifier. All claims with an HA modifier will be audited to ensure that only boardcertified child and adolescent psychiatrists are billing the HA modifier. When billing HCPCS codes Q4081, J0882 or J0886 for ESRD patients, it is required that the following modifiers be used: JA and JB. Note: Failure to follow these billing guidelines may result in the claim being returned unprocessed. JW may be used to identify drugs that are discarded or not used for a member. When reporting the modifier for drugs administered from a single-use vial or single-use package, providers should follow these guidelines: JW should not be reported when the billing unit is greater than the actual dose provided. For example, if the procedure code nomenclature for the drug is 10 mg but the dosage administered was 5 mg and the vial contains only 10 mg, then the unit reported on the claim would be 1 because the billing unit provides for full reimbursement of the 10-mg dosage. The modifier JW may be reported if the billing unit is less than the actual dose provided. For example, if the procedure code nomenclature for the drug is 1 mg but the dosage administered was 5 mg and the vial contains 10 mg, then two lines would be reported: o Line 1: Report the five units used. o Line 2: Report the five units discarded with the JW modifier. The JW modifier should be noted only on the line for the wasted drug. Note: Multi-dose vials should not be reported with the JW modifier. 2

3 24 24 is used to report a subsequent but unrelated E&M service performed during the global surgery period that should be evaluated separately. 25 When reporting an office/outpatient or inpatient consultation procedure code with a minor surgical procedure (0 or 10 day) performed on the same day, if the E&M service provided was distinct from the surgical procedure, it needs to be reported with modifier 25. If not reported with the modifier, the E&M visit may receive an edit indicating it was considered part of the global surgical package. Note: BCN audits health care practitioners who report modifier 25 at a rate much higher than their medical specialty peers. 25 should be used with E&M codes only and should not be appended to the code for the surgical procedure or other service (for example, therapeutic injections, therapeutic infusions or diagnostic X-rays or scans). Documentation must be maintained in the member s clinical record to substantiate the use of modifier 25. To document the extra work performed, the member s clinical record must clearly indicate the extra or unusual work. The documentation must support that the E&M service being billed is distinct from the other service performed. 50 When reporting services performed bilaterally, identify the procedure code with modifier 50 and a count of 1 on the claim line. For example, using modifier 50 would be an appropriate way to report a procedure done on the right wrist and the left wrist at the same setting, each with a count of 1. This is different than advice from some payers who request that a bilateral procedure be reported with one line with a modifier 50 and a second line with the same procedure code but without a modifier 50. Only if the procedure was performed twice on each wrist would it be appropriate to report the procedure code with a modifier 50 and a count of When modifier 52 is reported with a procedure code, reimbursement will be adjusted to 50 percent of the fee schedule. When modifier 52 is reported with a procedure code, reimbursement will be adjusted to 50 percent of the allowed amount. Note: This applies to BCN Advantage SM and BCN commercial products. 53 BCN reduces payment by 50 percent of the fee schedule for the procedure code billed with modifier , 55 and 56 A follow-up surgical procedure performed by an emergency room physician within 90 days of a surgical procedure done in an emergency room is typically reported with modifier 54, indicating that only preoperative and surgical care were provided. The member s own physician would be expected to assume the care of the member postoperatively. Claims for these followup surgical procedures will be sent back to the provider with instructions to resubmit. If surgical care is split between providers, the claims submitted should identify the care provided by use of the appropriate modifiers. The surgical care modifiers include modifiers 54, 55 and 56. Claim lines reported with these modifiers will be reimbursed according to the percentages from the national (CMS) Physician Fee Schedule Relative Value Files. 54 is reimbursed by CMS at the combined preoperative and intraoperative percentages. Note: This applies to BCN Advantage and BCN commercial products. 3

4 57 It is not appropriate to report modifier 57 for major surgeries that are planned in advance. When modifier 57 is reported with a procedure that falls within one of the categories of planned surgeries, the E&M service will be denied. The categories of planned surgeries include: Spine surgery, excluding fractures and dislocations Arthroplasty: total, partial and revision Congenital/deformity procedures (for example, clubfoot) Transplant procedures Chronic/subacute conditions (for example, tennis elbow or cataract surgery) 57 should not be used with E&M services performed on the same day as minor surgical procedures is used to indicate that a subsequent procedure performed during the global surgery period was anticipated. The global surgery period is defined according to CMS guidelines and incorporates the postoperative time frames of 0, 10 and 90 days. Medical services performed in the postoperative period that are associated with an earlier surgery must be appropriately coded with modifier 58 to avoid unnecessary editing may be appended when procedures not typically reported together needed to be performed on a patient on the same day by the same physician, such as separate incisions or procedures done on different organ systems. 59 should not be used unless other modifiers do not apply. 59 is not required to override the edit between procedure code *11100 and any of the following codes: *11040-*11042, *11055-*11057, *11200, *11300-*11301, *11305, *11307, *11310, *16000, *16020, *17000, *17250 and * Reporting modifier 59 with *11100 and any of these codes could result in an incorrect reduction in reimbursement. Procedure code *11100 and any of the listed codes will process without a modifier. (This applies to all BCN products except BCN Advantage and BCN 65.) Note: Reporting of other codes with any of the noted combinations could affect clinical editing results. When reporting another injection along with an immunization, you must report modifier 59 on the injection procedure. If both services are provided and modifier 59 is not indicated, an edit may occur between the injection administration code and the immunization administration code. For its commercial membership, BCN recognizes modifier 59 as valid but does not allow it to automatically override all edits allowed in the National Correct Coding Initiative Manual. The codes for which modifier 59 will override appropriate edits and increase payment are listed in the Addendum in this document. (The Addendum applies to all BCN products except BCN Advantage and BCN 65. For BCN Advantage, the CMS listing is followed.) Note: The Medicare Learning Network publishes a comprehensive article on the correct use of modifier 59 in MLN Matters Number: SE0715 at cms.gov/mlnmattersarticles. 73 and 74 When a surgical or diagnostic procedure is discontinued, modifier 73 or 74 is required in order to administer payment appropriately. 73 is reported when the surgical or diagnostic procedure was discontinued before the anesthesia was administered. 74 is reported when the surgical or diagnostic procedure was discontinued after the anesthesia was administered. 4

5 76 and 77 s 76 and 77 can be used for codes *70010-*79999, *88104-*88199, *88300-*88399, *93000, *93005, *93010 and *93040-* can also be used for code * These are the only codes with which these modifiers can be used. When reporting repeat radiology, EKG or surgical pathology procedures with modifier 76 or 77, follow these guidelines: Claims with the initial service (those that would not require a modifier) should be reported before the repeat services (those with modifier 76 or 77) are reported. Subsequent services are to be reported with the appropriate modifier. Use modifier 76 if the procedure is repeated by the same physician; use modifier 77 if a different physician does the procedure. Reporting the initial service (without a modifier) after the subsequent service (those with the modifier) could result in a denial of the initial service. When it is not clear which claim will come into the system first, it is acceptable to report modifier 76 or 77 on the initial line as well to facilitate claims processing. Note: This applies to BCN Advantage and BCN commercial products is used to indicate return trips to the operating room during the global surgery period for complications related to an earlier procedure. The global surgery period is defined according to CMS guidelines, incorporating the postoperative time frames of 0, 10 and 90 days. Medical services performed after an earlier surgery that are unintended or unexpected must be appropriately coded using modifier 78 to avoid unnecessary editing. For procedures with a 10- or 90-day global period, the procedure reported with modifier 78 is reimbursed on the value of the intraoperative care, as noted in the Medicare Fee Schedule. Procedures that have a 0-day global period reported with modifier 78 are not subject to this adjustment. Note: This applies to BCN Advantage and BCN commercial products is used to indicate that a subsequent procedure performed during the global surgery period should be evaluated separately. The global surgery period is defined according to CMS guidelines, incorporating the postoperative time frames of 0, 10 and 90 days. Medical services performed during the postoperative period that are not associated with the earlier surgery must be appropriately coded using modifier 79 to avoid unnecessary editing is used for laboratory tests in the pathology and laboratory code range (*80000 series). 5

6 ADDENDUM The following table lists CPT codes for which modifier 59 impacts payment. *10021 *10022 CPT codes for which modifier 59 impacts payment Note: This addendum applies to BCN commercial products only. *11042 *11043 *11044 *11055 *11056 *11057 *11100 *11101 *11200 *11201 *11400 *11401 *11402 *11403 *11404 *11406 *11420 *11421 *11422 *11423 *11440 *11441 *11442 *11443 *11600 *11601 *11602 *11603 *11604 *11606 *11730 *11732 *11900 *11901 *11970 *12001 *12002 *12004 *12005 *12006 *12007 *12011 *12013 *12014 *12015 *12016 *12017 *12018 *12031 *12032 *12034 *12035 *12036 *12041 *12042 *14000 *14001 *14020 *14021 *14040 *14041 *14060 *14061 *14350 *17000 *17003 *17110 *17250 *19000 *19001 *19100 *19101 *19102 (a) *19103 (a) *19120 *20600 *20605 *20610 *20670 *20680 *20937 *23130 *24357 *24358 *24359 *26180 *27438 *27640 *27641 *27685 *27686 *28104 *28106 *28107 *28120 *28122 *28230 *28232 *28234 *28288 *29075 *29405 *29540 *29580 *29819 *29871 *29873 *29874 *29875 *29876 *29877 *29879 *29880 *29881 *29882 *29883 *29894 *29895 *29897 *29898 *29899 *30130 *30140 *30801 *30802 *30930 *31515 *31520 *31525 *31526 *31527 *31528 *31529 *31575 *31576 *31577 *31578 *33530 *34001 *34203 *35226 *35646 (a) Code ended 12/31/13. 6

7 CPT codes for which modifier 59 impacts payment Note: This addendum applies to BCN commercial products only. *36005 *36014 *36215 *36216 *36217 *36218 *36245 *36246 *36247 *36248 *36410 *36415 *38500 *38525 *38745 *43255 *43268 (a) *45379 *45380 *45381 *45382 *45383 *45384 *45385 *45386 *45387 *47100 *49560 *49561 *49565 *49566 *49568 *49570 *49572 *49580 *49582 *49585 *49587 *52281 *53020 *54161 *55700 *55705 *56700 *57061 *57065 *57170 *58120 *58300 *58301 *63020 *63030 *63035 *63042 *63047 *63048 *63075 *63076 *64716 *64718 *64719 *64721 *64722 *64726 *67250 *67255 *69210 *69310 *71010 *72020 *72275 *73100 *73110 *73120 *73130 *73590 *73592 *73620 *73630 *74000 *74010 *74020 *74022 *74150 *74160 *74170 *76380 *76805 *76810 *76816 *76830 *76856 *76857 *78481 *78483 *80053 *81015 (a) Code ended 12/31/13. 7

8 *84443 *85025 *85027 CPT codes for which modifier 59 impacts payment Note: This addendum applies to BCN commercial products only. *90772 *90773 *90774 *90775 *90779 *90862 (b) *93000 *93005 *93010 *93040 *93041 *93312 *93313 *93314 *94002 *94003 *94004 *94005 *95120 *95125 *95130 *95131 *95132 *95133 *95134 *95870 *96372 *96373 *96374 *96375 *96376 *96379 Note: BCN reserves the right to audit claims, including those submitted with modifier 59, to ensure compliance with BCN s utilization management and claim guidelines. Payment for multiple surgeries applies when two surgery codes are billed on the same claim. (b) Code ended 12/31/12. 8

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