Status Active. Reimbursement Policy Section: General Coding Section Policy Number: RP-General Coding Modifier Effective Date: July, 2016

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1 Status Active Reimbursement Policy Section: General Coding Section Policy Number: RP-General Coding Modifier Effective Date: July, 2016 Modifier Policy Description: This policy addresses reimbursement for services that are submitted with a modifier. Modifiers are two-digit codes that are appended to a service as a means to indicate that the service/procedure is affected or altered by a specific circumstance and to add specificity, but not changed in its definition. Modifiers are found in an appendix in both CPT and HCPCS manuals. CPT codes are not limited to CPT modifiers. HCPCS codes are not limited to HCPCS modifiers. HCPCS modifiers may also be used with CPT codes and/or in combination with CPT modifiers. CPT modifiers may also be used with HCPCS codes and/or in combination with HCPCS modifiers. For example, -TC and 76 can be appended to a radiology procedure to indicate the technical component of the services was repeated. Modifiers may be used to indicate: A service or procedure has both a professional and technical component. 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 reduced. Only part of a service was performed. A bilateral procedure was performed. A service or procedure was provided more than once. Unusual events occurred. A DME item is purchased or rented. It is important to append all appropriate modifiers the first time the claim is submitted. Definitions: The following list is not all-inclusive. All valid modifiers will be accepted; however, the modifiers listed below impact payment. 1 Modifier

2 Mod. Definition -22 Increased Procedural Services -24 Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period. Submission Guidelines See Modifier 22 Policy Blue Cross defines the same physician as the same physician(s) or qualified health care practitioner(s) of the same or similar specialty within the same clinical practice. By appending the - 24 modifier to an unrelated evaluation and management (E/M) service you are indicating that the patient s condition requires a significant, separately identifiable E/M service above and beyond the other service provided, or beyond the usual pre-operative and postoperative care associated with the procedure that was performed. Services appended with a 24 modifier must be sufficiently documented in the patient s medical record that the visit was unrelated to the post-operative care of the procedure. An ICD that clearly indicates that the Impact to Payment See Modifier 22 Policy Separate payment of the E/M may be allowed. 2 Modifier

3 -25 Significant Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service reason for the encounter was different and unrelated to the post-operative care may provide sufficient documentation. Note: Requests to add a modifier -24 to a denied service must follow the replacement claim process. An adjustment request will not be allowed. Use the 25 modifier when an E/M service is rendered on the same d ay as a minor surgical procedure (0 or 10 day global period). The use of 25 is appropriate only when the E/M service provided is above and beyond the usual pre and post-operative service associated with a procedure. No documentation needs to be submitted with the initial claim. However, E/M services submitted with a 25 modifier are subject to review. Furthermore, medical documentation, when requested, Separate payment of the E/M may be allowed. 3 Modifier

4 -26 Professional Component -50 Bilateral Procedure -51 Multiple Procedures needs to support the significant, separately identifiable E/M service. Note: Requests to add a modifier -25 to a denied service must follow the replacement claim process. An adjustment request will not be allowed. See Professional and Technical Component Policy Surgical procedures performed on bilateral pieces of anatomy should be billed on one line. The 50 modifier should be appended to the submitted lines of service. The CPT descriptors for some procedures specify that the procedure is bilateral. In such cases, the bilateral modifier should not be used. When more than one service is performed during the same operative session, the 51 modifier may be appended to all secondary surgical procedures. It is not necessary to append the 51 modifier to add See Professional and Technical Component Policy Payment is made at 150% of the allowed amount for the procedure. Multiple surgery pricing logic also applies to bilateral procedures. If -50 is submitted on a CPT defined bilateral procedure that service will be denied based on submission of an incorrect procedure/modifier combination. The -51 modifier itself does not affect payment. Multiple surgical payment is based on whether the surgical procedure may be subject to a multiple surgery. Then the reduction would be based on the allowed amount. The 4 Modifier

5 -52 Reduced Services -53 Discontinued Procedure -54 Surgical Care Only on or to exempt codes. Applicable code edits will be applied to services submitted. Append the 52 modifier to indicate that a service or procedure is partially reduced or eliminated at the physician s discretion. This provides a means of reporting reduced services without disturbing the identification of the basic service. Append 53 when the physician elects to terminate the procedure. Append 54 when one physician performs the intraoperative portion of a surgical procedure while another practitioner(s) from a different practice provides preoperative and/or lowest valued procedure(s) will have the multiple surgical reduction applied. When covered, payment is made at 50% of the allowed amount for all allowable secondary procedures. Multiple surgery pricing logic also applies to bilateral procedures. The normal full charge billed or a reduced charge for the procedure may be submitted. Blue Cross will pay the lesser of either 90% of the physician fee schedule allowance for the procedure or the charge submitted. The normal full charge or reduced charge should be submitted. Payment is made at 80% of the allowed amount. 5 Modifier

6 -55 Post-operative Management Only -56 Pre-operative Management Only -57 Decision for Surgery post-operative management. Surgery should be billed globally (no modifier) if the pre-, intra-, and postoperative services are rendered by the same provider or other practitioners who are employed by the same clinic (same tax ID number). Append 55 to the surgical procedure code only when post-operative services are provided by a different clinic than performed the surgery. Append the 55 to the surgical procedure code. Append 56 to the surgical procedure code only when preoperative services are provided by a different clinic than performed the surgery. Append the 56 to the surgical procedure code. The 57 modifier is appended to indicate that the E/M service resulted in the initial decision to perform surgery either the day Separate payment may be allowed. Services will be denied if the 55 modifier is billed by a practitioner who is employed by the same clinic (same tax ID number) as the surgeon. Separate payment may be allowed. Services will be denied if the 56 modifier is billed by a practitioner who is employed by the same clinic (same tax ID number) as the surgeon. Modifer-57 may not affect edits or payment. However, if applicable, the modifier should be appended to the E/M. 6 Modifier

7 -59 Distinct Procedural Service before or the day of a major surgical procedure (90-day global period). Do not append this modifier when a minor surgical procedure (0-, 10- day global period) is performed. The 57 should not be used to report an E/M service that was pre-planned or prescheduled the day before or the day of surgery, as the E/M would be included as part of the global surgical package. Patients are normally reevaluated on the date of the actual surgery to assure the service can be performed. That clearance would be included in the global period and should not be reported separately. Note: Requests to add a modifier -57 to a denied service must follow the replacement claim process. An adjustment request will not be allowed. Modifier 59 may be appended to identify non-e/m procedures/services that are not Services denied may be considered on subsequent appeal. Modifer-59 may not affect edits or payment. However, if applicable, the 7 Modifier

8 normally reported together, but are appropriate under the circumstances. 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. Modifier 59 is always appended to the component or lesser procedure code. Documentation supporting the separate and distinct status must be present in the patient s medical record. Note: Requests to add a modifier -59 to a denied service must follow the replacement claim process. An adjustment request will not be allowed. -62 Two Surgeons See Co- Surgeon/Team -66 Surgical Team See Co- Surgeon/Team modifier should be appended to the service. Generally, the 59 modifier is only applicable to those code combinations noted in the Correct Coding Initiative (CCI) code list with a modifier indicator of 1 which specifies the services are distinct and separate and thus allowed. Services denied may be considered on subsequent appeal. See Co- Surgeon/Team See Co- Surgeon/Team 8 Modifier

9 -73 Discontinued Out-patient Hospital/ Ambulatory Surgery Center (ASC) Procedure Prior to the Administration of Anesthesia -76 Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional 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, but prior to the administration of. Under these circumstances, the intended service that is prepared for but cancelled can be reported by its usual procedure number and the addition of the modifier -73. The practitioner may need to indicate that a procedure or service was repeated subsequent to the original procedure or service on the same day. This circumstance may be reported by adding modifier 76 to the repeated procedure/service. Note: In situations warranting the use of both the 26 and 76 modifier (for example., reading multiple chest X- rays of a patient performed on the same day), submit Payment is made at 50% of the allowed amount. Separate payment of the service may be made. 9 Modifier

10 -77 Repeat Procedure by Another Physician or Other Qualified Health Care Professional -78 Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a the 26 modifier in the first position with the initial procedure and the 76 in the first position for the repeat procedure. The practitioner may need to indicate that a procedure or service was repeated subsequent to the original procedure or service on the same day. This circumstance may be reported by adding modifier 77 to the repeated procedure/service. Note: In situations warranting the use of both the 26 and 77 modifier (for example, reading multiple chest Xrays of a patient performed on the same day), submit the 26 modifier in the first position with the initial procedure and the 77 in the first position for the repeat procedure. Append this modifier to procedures/services performed during the post-operative period of another procedure, if the procedure/service is Separate payment of the service may be made. Separate payment of the service may be made if the date of the procedure is different from the original related procedure. The procedure/service will be denied if 10 Modifier

11 Related Procedure During the Postoperative Period -79 Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During Postoperative Period -80 Assistant Surgeon -81 Minimum Assistant Surgeon -82 Assistant Surgeon (When Qualified Resident Surgeon Not Available) -90 Reference (Outside) Laboratory -91 Repeat Clinical Diagnostic Laboratory Test related to the original procedure. Append this modifier to procedures/services performed during the post-operative period of another procedure, if the procedure/service is unrelated to the original procedure. See Assistant See Assistant See Assistant The use of the 90 modifier is appropriate when a lab provider, not the treating physician, performs a laboratory procedure. The 90 modifier should be appended to the procedure code/test that was sent to the lab. Append the modifier to a lab procedure that was repeated during the day. performed on the same date. Services denied may be considered on subsequent appeal. Separate payment of the service may be made. See Assistant See Assistant See Assistant The modifier does not impact payment for the lab test; however, it may be used in determining whether payment will be made for more than one type of specimen collection. Separate payment of the service may be made. 11 Modifier

12 -99 Multiple Modifiers -AA -AD Anesthesia services performed personally by Medical supervision by a physician; more than 4 concurrent procedures Modifier -99 indicates that multiple modifiers may apply to a particular service. Because Blue Cross can accept up to four modifiers, -99 should be used only if there are five or more modifiers applicable to a particular service line. In that circumstance, if -99 is submitted, the additional modifiers must be entered on the narrative record. Append the modifier when the is physically present in the operating room, personally performs the induction and emergence, and directly monitors the patient throughout the entire operative procedure. Append the modifier when the supervises more than four concurrent procedures. The may perform the induction and emergence but may not be present Impact of payment or adjudication may be based on what the additional modifier(s) represents. Payment is made at the full-time conversion rate. Payment is made at the part-time conversion rate. 12 Modifier

13 -AS -GA Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist Services for Assistant at Surgery Waiver of Liability statement issued as required by payer policy, individual case during the entire operative session. See Assistant The GA modifier may be submitted when the patient has signed a waiver specifically for a service that may not be covered. If the service is denied, the payment for that service is the patient s liability in most cases. General rules surrounding GA: 1. GA is an acceptable modifier. Providers may submit this modifier if a waiver is signed by the patient and is on file with the provider. The waiver must be for the specific service and date only blanket waivers are not acceptable. 2. Liability will not be changed under Some circumstances: Denial waiting for additional information, duplicate billing, incidental or See Assistant If the service is denied, liability may be changed to subscriber liability. See general rules under Submission Guidelines. 13 Modifier

14 -QJ -QK Services/items provided to a prisoner or patient in state or local custody, however the state or local government, as applicable, meets the requirements in 42 CFR (B) Medical direction of 2, 3 included in the basic service rendered denials, and denials generated from a coding software decision (such as incidental, mutually exclusive or visit logic). These denials will always remain provider liability regardless if the GA is submitted. 3. If the service denies provider liability, the provider may ask for an adjustment to change to subscriber liability, if appropriate (incidental and coding software denials will remain provider liability). For Public Program subscribers, refer to the Blue Plus Provider Manual The appropriate use of this modifier is required for our Government Program and Public Program subscribers. The QJ may be submitted for other subscribers/products as well, but the modifier will not affect adjudication. Append the modifier when the Services or items will deny for Government Program or Public Program subscribers. Payment is made at the part-time 14 Modifier

15 -QS -QX or 4 concurrent procedures by qualified personnel Monitored care service CRNA service with medical direction by a physician supervises two, three or four concurrent procedures. The may perform the induction and emergence but may not be present during the entire operative session. Append the modifier when the provides specific services to a particular patient undergoing a planned procedure including performing a preanesthetic examination, be physically present in the operating suite, monitors the patient s condition, and is prepared to furnish services as necessary. Append the modifier on the CRNA charges when the supervises the conversion rate. The QS modifier is reported as a secondary modifier, thus the pricing for QS will be based on the primary modifier. If the primary modifier is full-time (AA or QZ), the QS will be priced based on the full-time conversion and likewise if the primary modifier is part-time (AD, QK, QX or QY), the QS will be priced based on the part-time conversion. Only one QS service per day will be allowed. Payment is made a the part-time conversion rate. 15 Modifier

16 -QY -QZ -TC XE Medical direction of one Certified Registered Nurse Anesthetist (CRNA) by an Anesthesiologist CRNA service; without medical direction by a physician Technical Component Separate encounter, a service that Is CRNA who performed the procedure. The may perform the induction and emergence but may not be present during the entire operative session. Append the modifier on the charges when the supervises the CRNA who performed the procedure. The may perform the induction and emergence but may not be present during the entire operative session. Append the modifier when the CRNA is physically present in the operating room, personally performs the induction and emergence, and directly monitors the patient throughout the entire operative procedure. See Professional and Technical Component Policy The modifier may be appended to Payment is made a the part-time conversion rate. Payment is made at the full-time conversion rate. See Professional and Technical Component Policy Modifer-XE may not affect edits or 16 Modifier

17 XP XS XU distinct because it occurred during a separate encounter Separate practitioner, a service that is distinct because it was performed by a different practitioner Separate structure, a service that is distinct because it was performed on a separate organ/structure Unusual nonoverlapping service, the use of a service that is distinct because it does not overlap usual components of the main service identify a separate encounter on the same date of service. Note: Requests to add a modifier XE to a denied service must follow the replacement claim process. An adjustment request will not be allowed. The modifier may be appended to identify a service performed by a different practitioner. Note: Requests to add a modifier -XP to a denied service must follow the replacement claim process. An adjustment request will not be allowed. The modifier may be appended to identify a distinct service performed on a separate organ/structure. Note: Requests to add a modifier -XS to a denied service must follow the replacement claim process. An adjustment request will not be allowed. The modifier may be appended to identify a distinct service that does not overlap the usual components of the main service. Note: Requests to add a modifier -XU payment. However, if applicable, the modifier should be appended to the service. Services denied may be considered on subsequent appeal. Modifer-XP may not affect edits or payment. However, if applicable, the modifier should be appended to the service. Services denied may be considered on subsequent appeal. Modifer-XS may not affect edits or payment. However, if applicable, the modifier should be appended to the service. Services denied may be considered on subsequent appeal. Modifer-XU may not affect edits or payment. However, if applicable, the modifier should be appended to the service. Services denied may be 17 Modifier

18 to a denied service must follow the replacement claim process. An adjustment request will not be allowed. considered on subsequent appeal. Anatomical Modifiers The following modifiers indicate a specific anatomic site. Because these modifiers affect edits and payment we suggest they be submitted in the first modifier position, if applicable. Appropriate use of these modifiers may assure correct claims adjudication. E1 Upper left, eyelid E2 Lower left, eyelid E3 Upper right, eyelid E4 Lower right, eyelid F1 Left hand, second digit F2 Left hand, third digit F3 Left hand, fourth digit F4 Left hand, fifth digit F5 Right hand, thumb F6 Right hand, second digit F7 Right hand, third digit F8 Right hand, fourth digit F9 Right hand, fifth digit FA Left hand, thumb LC Left circumflex coronary artery LD Left anterior descending coronary artery LT Left side (used to identify procedures performed on the left side of the body) RC Right coronary artery RT Right side (used to identify procedures performed on the right side of the body) T1 Left foot, second digit T2 Left foot, third digit T3 Left foot, fourth digit T4 Left foot, fifth digit T5 Right foot, great toe T6 Right foot, second digit T7 Right foot, third digit Modifiers Defined by DHS 18 Modifier

19 The national HCPCS Panel developed several modifiers (U1-U9, UA-UD) that could be defined by the various state Medicaid agencies. The Minnesota Department of Human Services (DHS) has specifically defined these codes for their various programs. Refer to the DHS provider manual for detailed definitions. Each modifier has more than one definition dependent on what service it is appended to or the program affected. The modifiers are generally informational only and, with the exception of U7, applicable primarily to services for our PMAP and MNCare subscribers. The U7 definitions are as follows: Mod. Definitions Usage -U7 Definition 1 = Physician extender (medical services) Definition 2 = IEP assistive technology device (T1018) Definition 3 = NET bus/train, monthly pass (A0110) Definition 4 = Oximeter for intermittent use (E0445) Append this modifier to services by non-credentialed or non-enrolled practitioners when performing incident to services under the direct supervision. The services would be reported under the directing physician s provider number. The modifier does not impact payment. Append the modifier if directed to in guidelines that may be found elsewhere in the Provider Policy and Procedure Manual. Policy: Modifiers are also subject to compatibility edits with the procedure to which they are appended. For example, an Evaluation and Management (E/M) service appended with a -59 modifier will be denied. Note: If your claim is denied due to lack of documentation to support the use of a specific modifier or an invalid modifier/procedure combination, you may submit a claim payment appeal or replacement claim. Your appeal must be in writing and accompanied by the necessary documentation. Replacement claims must include an attachment with supporting documentation. This is a general guideline regarding the use of modifiers. The code list is not all-inclusive. Refer to your CPT and HCPCS for a complete list of modifiers. When a specific service/circumstance requires the use of a modifier, the submission criteria is outlined in the applicable specialty 19 Modifier

20 section of the Coding Chapter of the Blue Cross Provider Policy and Procedure Manual. Documentation Submission: Coverage: Coding On submission and/or appeal, the documentation/operative report submitted should clearly indicate and support the need for the modifier submitted. The following applies to all claim submissions. All coding and reimbursement is subject to all terms of the Provider Service Agreement and subject to changes, updates, or other requirements of coding rules and guidelines. All codes are subject to federal HIPAA rules, and in the case of medical code sets (HCPCS, CPT, ICD), only codes valid for the date of service may be submitted or accepted. Reimbursement for all Health Services is subject to current Blue Cross Medical Policy criteria, policies found in the Provider Policy and Procedure Manual sections, Reimbursement Policies and all other provisions of the Provider Service Agreement (Agreement). In the event that any new codes are developed during the course of Provider's Agreement, such new codes will be paid according to the standard or applicable Blue Cross fee schedule until such time as a new agreement is reached and supersedes the Provider's current Agreement. All payment for codes based on Relative Value Units (RVU) will include a site of service differential and will be calculated using the appropriate facility or non-facility components, based on the site of service identified, as submitted by Provider. The following codes are included below for informational purposes only, and are subject to change without notice. Inclusion or exclusion of a code does not constitute or imply subscriber coverage or provider reimbursement. CPT/HCPCS Modifier: All ICD Diagnosis: ICD Procedure: HCPCS: Deleted Codes: Policy History: Initial Committee Approval Date: June 1, 2015 Most recent history: revised March 1,2016 Cross Reference: RP-Surgery/Interventional Procedure-004 Modifier 22 Policy: Increased Procedural Services 20 Modifier

21 Current Procedural Terminology (CPT ) is copyright 2016 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. Copyright 2016 Blue Cross Blue Shield of Minnesota. 21 Modifier

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