Medicare 101: Basics of Modifier Billing. Part B Provider Outreach and Education February 26, 2014

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1 Medicare 101: Basics of Modifier Billing Part B Provider Outreach and Education February 26, 2014

2 Housekeeping Tips When you called in, did you enter your attendee code? Dial-in number: Attendee (participant) Code: Ensure the address provided during registration is correct and make sure that your SPAM filter is turned off for items coming from The handout for today s educational event is located on our Calendar of Events web page. Click on today s event and scroll down to the instructions/materials section. 2

3 DISCLAIMER This resource is not a legal document. This presentation was prepared as a tool to assist our providers. This presentation was current at the time it was created. Although every reasonable effort has been made to assure accurate information, responsibility for correct claims submission lies with the provider of services. Reproduction of this material for profit is prohibited. CPT Disclaimer American Medical Association (AMA) Notice and Disclaimer Current Procedural Terminology (CPT) only copyright 2013 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association (AMA). Applicable FARS/DFARS Restrictions Apply to Government Use. Fee schedules, relative value units, conversion factors, and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

4 What is a Modifier? Types of Modifiers Agenda Understand the Medicare Physician Fee Schedule Database Resources Back to the Basics 4

5 Modifiers Two digit HCPCS Level I and II codes referred to as CPT modifiers and HCPCS modifiers Indicates that a service or procedure has been altered Should always be appended to a procedure code Can be pricing or informational Alpha Numeric Alpha-Numeric GA 78 E1 5

6 Modifiers Pricing modifiers will Effect payment of service Will determine allowance of service billed Should always be placed in the first modifier field Informational modifiers will Provides additional information May state whether a service is reasonable and necessary Should be used in the second, third or fourth field if pricing modifier being used 6

7 Modifier Categories There are several types of modifiers that are specific to billing categories and specialties The most widespread used for Medicare Part B are Evaluation and Management (E&M) Global Surgery Diagnostic services (i.e., radiology procedures) Clinical laboratory National Correct Coding Initiative (NCCI) Surgical billing You may view a comprehensive list on the Cahaba GBA website at the link shown below 7

8 Medicare Physician Fee Schedule Database (MPFSDB) Referred to as the Physician Fee Schedule (PFS) Relative Value File Payment indicator list Provides information about specific codes Updated quarterly by the Centers for Medicare and Medicaid Services (CMS) Changes listed in the Medicare B Newsline 8

9 MPFSDB You can access the file by either the Cahaba GBA or CMS websites For Cahaba GBA Go to Click on Fee Schedules under the quick links For CMS Go to Click on Medicare Under Medicare Fee-for-Service Payment select Physician Fee Schedule Look-up Tool 9

10 MPFSDB Cahaba GBA CMS https://apps.cahabagba.com/fees/getfilesbyyea r.do?year=

11 Global Surgery Global surgical package, also called global surgery, includes all necessary services normally furnished by a surgeon before, during, and after a procedure. Medicare payment for the surgical procedure includes the pre-operative, intra-operative and post operative services. Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. 11

12 There are three types of global surgical packages: 0 day: Endoscopies and some minor procedures No pre-operative period and no post-operative days Visit on day of procedure is generally not payable as a separate service 10 day: Other minor procedures No pre-operative period Visit on day of the procedure is generally not payable as a separate service Total global period is 11 days 90 day: Major procedures Global Surgery One day pre-operative included Day of the procedure is generally not payable as a separate service Total global period is 92 days

13 Modifier 24, 25, and 57 Evaluation & Management (E&M) 24 Unrelated E&M service during a postoperative period of a major or minor surgical procedure For codes with 10 or 90 day global period Used with E&M codes only 13

14 Modifier 24, 25, and 57 Modifier 24 Example Date of Service Treatment 02/03/2014 Destruction of premalignant lesion 02/06/2014 E&M for upper respiratory infection (URI) CPT/Modifier

15 Modifier 24, 25, and 57 Evaluation & Management (E&M) 25 Significant, separately identifiable evaluation and management service by same physician on same day of procedure For codes with 0 or 10 day global period Different diagnoses are not required Used with E&M codes only 15

16 Modifier 24, 25, and 57 Claim Submission Errors Modifier 25 Modifier 25 billed on claim line item with no other service submitted Modifier 25 appended to a surgical or radiological procedure code Modifier 25 billed on same claim with service that does not have global days 16

17 Modifier 24, 25, and 57 Modifier 25 Example Date of Service Treatment 01/06/2014 Trigger point injections 01/06/2014 E&M visit Neck pain and elevated blood pressure CPT/Modifier

18 Modifier 24, 25, and 57 Evaluation & Management (E&M) 57 Decision for surgery-e&m service resulting in the initial decision to perform major surgery Use only when surgical code has a 90 day global period E&M day before surgery E&M day of surgery 18

19 Modifier 24, 25, and 57 Modifier 57 Example Date of Service Treatment CPT/Modifier 02/25/2014 Total hip replacement 02/25/2014 History and physical Use modifier 57 if decision for surgery was done at that time 19

20 Modifier 54, 55, 58, 78, and 79 Transfer of Care (aka Split Care) 54 -Surgical care only; Surgeon is performing only the preoperative and intra-operative care 55 - Postoperative management only; Physician, other than surgeon, assumes all or part of postoperative care Modifiers should be placed on the surgical code Used on 10 day and 90 day surgical procedures 20

21 Modifier 54, 55, 58, 78, and 79 Transfer of Care (aka Split Care) Both the surgeon and the physician providing the postoperative care must keep a copy of the written transfer agreement in the beneficiary s medical record. When a transfer of postoperative care occurs, the receiving physician cannot bill for any part of the global services until he has provided at least one service. Once the physician has seen the patient, that physician may bill for the period beginning with the date on which he assumes care of the patient. 21

22 Transfer of Care Doctor A billing pre-operative and major surgery Doctor B billing post-operative portion

23 Modifier 54, 55, 58, 78, and 79 Staged Procedure 58 - Staged or related procedure during the post-op period by the same physician Must be planned at time of original procedure Must be more extensive than original procedure A therapeutic surgical procedure following a diagnostic surgical procedure 23

24 Modifier 54, 55, 58, 78, and 79 Return Trip and Unrelated Procedure 78 Return to the operating room for a related procedure during a post-operative period Bill CPT code describing procedure performed during return trip Payment limited to intra-operative services only 79 unrelated procedure by the same physician during a post-operative period 24

25 Modifier 26, TC Diagnostic Services 26 Professional Component only TC Technical component only Both modifiers affect payment Verify your code before submitting on claim PC/TC indicators located on the MPFS database 25

26 Modifier 26, TC Claim Submission Errors Modifier 26 and TC Modifier 26/TC used on same claim line for global procedure Modifier 26 and TC appended to office visit and injection procedure codes Misuse of modifier 26 on clinical lab codes 26

27 Modifier QW, 91 and 90 Laboratory QW CLIA waived test Submit with clinical lab tests that are waived Food and Drug Administration (FDA) determine which lab tests are waived Certain codes do not require HCPCS modifier QW Use the first modifier field when submitting claim Don t forget to submit the CLIA certificate number 27

28 Modifier QW, 91 and 90 Laboratory List of approved test is posted on a quarterly basis in the Medicare B Newsline Providers should refer to the CLIA brochure at Education/Medicare-Learning-Network- MLN/MLNProducts/Downloads/CLIABroch ure.pdf

29 Modifier QW, 90, Reference lab Specimen referred to another lab for testing Laboratory Reference lab receives the specimen Labs bill contractor in their jurisdiction for tests performed by reference lab 29

30 Modifier QW, 90, 91 Laboratory 91 Repeat clinical diagnostic laboratory test Identifies a medically necessary lab test on the same day of the same previous laboratory test Should not be used for Rerun of a lab test to confirm results Testing problems for the specimen or of the equipment A procedure code that describe a series of test Do not bill modifier 91 on all claim line services You will not append modifier to your initial lab procedure code 30

31 Modifier 59 Correct Coding Initiative 59 - Distinct procedural service (on the same date of service by same physician) Different session or patient encounter Different procedure or surgery Separate incision/excision Separate injury Should only be used if no other modifier is available Use of the modifier should be supported in the medical record 31

32 Modifier 59 Correct Coding Initiative Column 1/Column 2 list Column 1 is the primary code Column 2 is the code that bundles into column 1 code Last column provides the CCI Modifier Indicator 1 = Modifier can be used 0 = No modifier is allowed 9 = Concept not applicable Refer to the NCCI Coding Edits at NCCI-Coding-Edits.html 32

33 Modifier 59 Correct Coding Initiative Date of Service Treatment 02/17/2014 Biopsy of right hand 02/17/2014 Destruction of lesion Procedure

34 Modifier 59 Claim Submission Errors Modifier 59 Improper usage for Modifier 59 appended to the procedure code with no other services billed on claim submitted with an evaluation & management procedure code used with the weekly radiation therapy management code (CPT 77427) 34

35 Modifier 50, 51, 62, 66, 80, AS Bilateral Service 50 Bilateral procedure Surgery performed on both sides of the body at the same operative session or on the same day Fee Schedule indicator 1 Number of service is 1 Bill code once with modifier Modifier 50 allowable is 150% of MPFS Modifier does not apply to Ambulatory Surgery Center claims 35

36 Modifier 50, 51, 62, 66, 80, AS Multiple Procedure 51 Multiple procedures other than Evaluation & Management performed at same session, by same physician on the same patient on the same day Do not use with add-on codes Not required on claims submitted to Medicare contractor Reduction determined by the MPFS approved amount M/S pricing indicators effect surgical procedures, endoscopy rules, technical components, therapy services, cardiovascular and ophthalmology services 36

37 Modifier 50, 51, 62, 66, 80, AS Co-surgery/Surgical Team 62 Two surgeons work together as primary surgeons performing distinct parts of procedure Both surgeons must agree to use modifier 62 Fee Schedule indicator must be 1 or 2 Both reimbursed each at 62.5% of allowance 66 Team surgery, highly complex procedure requiring skills of different specialties Highly complex procedure Often of different specialties Documentation required and subject to medical review 37

38 Modifier 50, 51, 62, 66, 80, AS Assistant-at-Surgery 80 - An assistant surgeon s services for physician Allowed amount equals16% of the amount AS Used by Physician Assistants, Clinical Nurse Specialist and Nurse Practitioners assisting in surgery Payment is 85% of 16% of surgical fee 38

39 Modifier GA, 76, 77, GV, GW Advance Beneficiary Notice of Noncoverage GA Advance Beneficiary Notice (ABN) on file GY Item or service statutorily excluded or does not meet definition of any Medicare Benefit GZ Item or service expected to be denied as not reasonable and necessary; no ABN on file 39

40 Modifier GA, 76, 77, GV, GW Modifier 76 & Repeat procedure by same physician 77 Repeat procedure by another physician Procedure was repeated subsequent to original service Repeat procedures on same day Add modifier to repeated service 40

41 Modifier GA, 76, 77, GV, GW Hospice Modifiers GV Attending physician not employed or paid under agreement by patient s hospice provider Services related to hospice condition Patients can be seen by both the attending physician and hospice employed physician GW Services not related to a hospice patient s terminal condition Use hospice modifiers after each procedure code billed 41

42 Specialty Modifiers Anesthesia AA - Anesthesia Services performed personally by the anesthesiologist AD - Medical Supervision by a physician; more than 4 concurrent anesthesia procedures QK - Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals QX - CRNA service; with medical direction by a physician QY - Medical direction of one certified registered nurse anesthetist by an anesthesiologist QZ - CRNA service: without medical direction by a physician 42

43 Specialty Modifiers Therapy GN - Services delivered under an outpatient speech language pathology plan of care GO - Services delivered under an outpatient occupational therapy plan of care GP - Services delivered under an outpatient physical therapy plan of care KX - Requirements specified in the medical policy have been met. May be used when a therapy exception is appropriate 43

44 Specialty Modifiers Ambulance Two of the following modifiers are required for each base line item to report the origin and the destination D Diagnostic or therapeutic site other than P or H when these are used as origin codes E Residential, domiciliary, custodial facility (other than an 1819 facility) G Hospital based dialysis facility (hospital or hospital related) H Hospital I Site of transfer (e.g., airport or helicopter pad) between modes of ambulance transport J Non-hospital based dialysis facility N Skilled nursing facility (SNF) (1819 facility) P Physician s office (includes HMO non-hospital facility, clinic, etc.) R Residence S Scene of accident or acute event X (Destination code only) Intermediate stop at physician s office in route to the hospital (includes HMO non-hospital facility, clinic, etc.) 44

45 New Modifiers AO JE PM Modifiers Description Alternate payment method declined by provider of service Administered via dialysate Post mortem 45

46 Tips to Remember Always use the appropriate modifier for the procedure List pricing modifiers first and informational modifiers second Denial of payment may result if An invalid modifier is used The modifier is not used and is required Refer to resource tools such as Your CPT or HCPCS manual Modifier chart on the Cahaba GBA website 46

47 Common Pricing Modifiers Modifier Description AA AS QK QX QY QZ TC Anesthesia Services performed personally by the anesthesiologist Assist at Surgery Non physician practitioner (PA,NP,CNS) Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals CRNA service; with medical direction by a physician Medical direction of one certified registered nurse anesthetist by an anesthesiologist CRNA service: without medical direction by a physician Technical component 26 Professional fee 50 Bilateral service 54 Surgical care only 55 Post-operative care 62 Co-surgery 78 Return to the operating room 80 Assist at surgery physician 47

48 Medicare Updates Comprehensive Error Rate Testing Program New name, logo for Educational Task Force Foresee Survey We want your opinion! 48

49 Acronyms Participants can view a list of acronyms used during today s webinar by accessing the glossary section on the Cahaba GBA website, 49

50 Resources Cahaba GBA Centers for Medicare and Medicaid Services Resource Center for New Providers https://www.cahabagba.com/part-b/education/welcome-to-theresource-center-for-new-providers/ Global Surgery Fact Sheet Network-MLN/MLNProducts/downloads/GloballSurgery-ICN pdf 50

51 Questions? Provider Contact Center:

52 Evaluate Today s Webinar Event We value your opinion and appreciate your feedback and comments regarding today s event Take a moment to complete the Online Evaluation upon conclusion of the webinar We appreciate your feedback and thank you for your participation! 52

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