Empire BlueCross BlueShield Professional Reimbursement Policy

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1 Subject: Modifier Rules NY Policy: 0017 Effective: 02/01/ /30/2014 Coverage is subject to the terms, conditions, and limitations of an individual member s programs or products and policy criteria listed below. DESCRIPTION A modifier is made up of a two character alpha/numeric indicator that is appended to a Current Procedural Terminology (CPT ) or Healthcare Common Procedure Coding System (HCPCS Level II) code. It is used as a means of reporting a specific circumstance that further defines or alters the code; but it does not change the definition of the procedure performed or item procured. POLICY The Health Plan accepts for claims processing, but not always to determine compensation, all HIPAA compliant CPT and HCPCS modifiers. The Health Plan treats some modifiers as informational only ; some modifiers are important to the adjudication of the claim; and some modifiers may affect the of the. Providers must follow proper coding guidelines as set by CPT or The Centers for Medicare & Medicaid Services (CMS) when reporting modifiers. The Health Plan also uses ClaimsXten for modifier to procedure code validation. ClaimsXten identifies if a modifier is inappropriately used with a procedure code. When an invalid modifier to procedure code combination is detected, the line item will be denied, with a request that the correct code and modifier combination be resubmitted. The Health Plan validates that the following modifiers are appropriately used with procedure codes: 22, 23, 24, 25, 26, 27, 50, 52, 53, 54, 55, 56, 57, 59, 62, 63, 73, 74, 76, 77, 78, 79, 80, 81, 82, 91, AA, AD, AS, E1-E4, F1-F9, FA, LC, LD, LM, LT, MS, P3, P4, P5, QK, QX, QY, QZ, RA, RB, RC, RI, RR, RT, T1-T9, TA, TC and UE. In addition to modifier to procedure code validation, the following modifiers are used in the adjudication of a claim and may impact reimbursement. NY 0017 Page 1 of [17]

2 22 Increased Procedural Services 120% (if approved) 24 Unrelated Evaluation and Management Service by the Same Physician During a Post Operative Period* * See also the Health Plan s Global Surgery Reimbursement Policy. 25 Significant, Separately Identifiable * Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service* *For more information, refer to the Health Plan s Global Surgery and Evaluation and Management Services and Related Modifiers -25 & -57 Reimbursement Policies. Procedure codes reported with modifier 22 without operative notes/office notes will be reimbursed based on the for the procedure code, without review for additional reimbursement. Procedure codes reported with modifier 22 with operative notes/office notes will be reviewed to determine if additional reimbursement is warranted. When appended to an E/M procedure code, modifier 24 may override a surgical aftercare edit and the reported E/M code may be eligible for reimbursement. When appended to an E/M procedure code, modifier 25 may override the following edits and the reported E/M code may be eligible for reimbursement for: Same Day medical visit with a procedure Problem focused E/M reported with preventive E/M NY 0017 Page 2 of [17]

3 26 Professional Component Reimbursement is based on the professional component of a procedure that has both a technical and professional 50 Bilateral Procedures* *For more information, refer to the Health Plan s Multiple and Bilateral Surgery Processing and Multiple Diagnostic Imaging Reimbursement Policies. component. 150% Bilateral surgical services are subject to the multiple surgery reimbursement rules. The surgical CPT code is required to be reported on one line with modifier 50 appended. Reimbursement is made at the rate of 100% for the first side and 50% for the second side ( =150%) Diagnostic services, including radiology, are not subject to multiple surgery reimbursement rules. Therefore, bilateral procedures for this type of service are to be reported on two lines with the LT and RT site-specific modifiers.. 52 Reduced Services 50% Procedure codes reported with modifier 52 are processed and reimbursed at 50% of the. 53 Discontinued Procedure 50% Procedure codes reported with modifier 53 are processed and reimbursed at 50% of the. NY 0017 Page 3 of [17]

4 54 Surgical Care Only* * See also the Health Plan s Global Surgery Reimbursement Policy. 70% Surgical procedures reported with modifier 54 are reimbursed at 70% of the. Reimbursement is made for the surgical procedure only. This lower % rate carves out the preop and post op care which is usually included in the global surgical reimbursement for a surgical procedure. This modifier is reported with the surgical code when one provider performs the surgical procedure and another provides the preoperative and/or postoperative care. 55 Post Operative Management Only* * See also the Health Plan s Global Surgery Reimbursement Policy. 20% Surgical procedures reported with modifier 55 are reimbursed at 20% of the. This lower % rate carves out the preoperative visit and the surgery, which are usually included in the global reimbursement for a surgical procedure. This modifier is reported with the surgical code when one provider performed the postoperative care and another performed the surgical procedure. NY 0017 Page 4 of [17]

5 56 Preoperative Management Only* * See also the Health Plan s Global Surgery Reimbursement Policy. 10% Surgical procedures reported with modifier 56 are reimbursed at 10% of the. This lower % rate carves out the surgery and postoperative care, which are usually included in the global reimbursement for a surgical procedure. This modifier is reported with the surgical code when one provider performed the preoperative care and another performed the surgery. 57 Decision For Surgery* * See also the Health Plan s Global Surgery and Evaluation and Management Services and Related Modifiers -25 & -57 Reimbursement Policies. 59 Distinct Procedural Service* * See also the Health Plan s Bundled Services and Supplies, Frequency Editing, and Modifier 59 Reimbursement Policies. When appended to an E/M procedure code, modifier 57 will override the one-day pre-op and Same Day Procedure/ Medical visit edit; and the reported E/M code will be eligible for reimbursement. Modifier 59 will, in many cases, affect the adjudication of the reported code by overriding incidental, mutually exclusive, and rebundle edits, allowing the reported procedure code to be eligible for separate reimbursement. This modifier will not: o override an edit for a NY 0017 Page 5 of [17]

6 62 Two Surgeons (Co-Surgery)* * For more information, refer to the Health Plan s Co- Surgeon/Team Surgeon Services Reimbursement Policy. o code listed as always bundled in the Bundled Services and Supplies Reimbursement Policy override an edit for a code listed in the Exceptions to Modifier 59 Override section of the Modifier 59 Reimbursement Policy o override a duplicate procedure edit o override frequency edit limits 63% per surgeon When two surgeons act as co-surgeons, each surgeon will receive 63% of the for an individual code. This lower reimbursement rate reflects the shared responsibility for global surgical services. 63 Procedure performed on infants 120% Except for those codes described in Appendix F of the CPT Manual, procedures reported with modifier 63 are eligible for additional reimbursement. 66 Surgical Team* * For more information, refer to the Health Plan s Co- Surgeon/Team Surgeon Services Reimbursement Policy. This modifier has no effect on the of the reported surgical code, but is important to establish team surgery status in the performance of the procedure. NY 0017 Page 6 of [17]

7 76 Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional When appended to a procedure code, modifier 76 indicates that the repeated procedure/service is not a duplicate. A claim may be reviewed to determine the eligibility for separate reimbursement for the repeated procedure code. 77 Repeat Procedure or Service by Another Physician or Other Qualified Health Care Professional When appended to a procedure code, modifier 77 indicates that the repeated procedure/service is not a duplicate. A claim may be reviewed to determine the eligibility for separate reimbursement for the repeated procedure code. 78 Unplanned Return to the Operating / Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period* * See also the Health Plan s Global Surgery Reimbursement Policy. 79 Unrelated Procedure or Service by the Same Physician During the Post Operative Period 70% Surgical procedures reported with this modifier are reimbursed at 70% of the. This lower % rate carves out the pre-op and post op- care which is usually included in the global surgical reimbursement for a surgical procedure. When appended to a procedure or service, modifier 79 will override global surgical editing and the reported procedure code will be eligible for NY 0017 Page 7 of [17]

8 reimbursement. 80 Assistant Surgeon* *For more information, refer to the Health Plan s Assistant Surgeon Services Reimbursement Policy. 81 Minimum Assistant Surgeon* *For more information, refer to the Health Plan s Assistant Surgeon Services Reimbursement Policy. 82 Assistant Surgeon (When Qualified Resident Surgeon Not Available)* *For more information, refer to the Health Plan s Assistant Surgeon Services Reimbursement Policy. 16% Surgical procedures reported with modifier 80 are reimbursed at 16% of the total for the reported code. Modifier 80 should not be used to report assistant surgeon services rendered by non-physician providers. 16% Surgical procedures reported with modifier 81 are reimbursed at 16% of the total for the reported code. Modifier 81 should not be used to report minimum assistant surgeon services rendered by non-physician providers. 16% Surgical procedures reported with modifier 82 are reimbursed at 16% of the total for the reported code. Modifier 82 should not be used to report assistant surgeon services rendered by non-physician providers. NY 0017 Page 8 of [17]

9 91 Repeat Clinical Diagnostic Laboratory Test* *For more information, refer to the Health Plan s Frequency Editing Reimbursement Policy When modifier 91 is appended to a reported laboratory procedure code, our claims editing system will override a frequency edit and allow separate reimbursement for the repeat clinical diagnostic laboratory test except as described in our Frequency Editing Reimbursement Policy related to drug screen testing 99 Multiple Modifiers Identifies when multiple modifiers would be applicable. AD AS Medical Supervision by a Physician: More than four concurrent anesthesia procedures Physician Assistant, Registered Nurse First Assistant, Nurse Practitioner or Clinical Nurse Specialist Services for Assistant at Surgery* *For more information, refer to the Health Plan s Assistant Surgeon Services Reimbursement Policy. 14% of MD fee schedule Anesthesia procedures reported with modifier AD will be reimbursed at 50% of the anesthesia. Surgical procedures reported with modifier AS are reimbursed 14% of MD fee schedule if there is no separate fee schedule for nonphysician providers. Modifier AS is to be used for reporting assistant-at-surgery services by non-physician providers. CC Procedure Code Change E1-E4 Eyelids See Health Plan s instructions for information regarding corrected claims submission. These site-specific modifiers are NY 0017 Page 9 of [17]

10 F1-F9, FA Hand, Digit These site-specific modifiers are GQ GT KC Via asynchronous telecommunications system* *See the Health Plan s Telemedicine and Telehealth Reimbursement Policy Via Interactive Audio and Video Telecommunication Systems* *See the Health Plan s Telemedicine and Telehealth Reimbursement Policy Replacement of special power wheelchair interface* *See the Health Plan s Durable Medical Equipment Policy Services billed with modifier GQ will be processed according to the Health Plan s reimbursement policy for Telemedicine and Telehealth. Services billed with modifier GT will be processed according to the Health Plan s reimbursement policy for Telemedicine and Telehealth. Modifier KC is required for replacement of special power wheelchair interface to be eligible for reimbursement. LC Left Circumflex Coronary Artery This site-specific modifier is LD Left Anterior Descending Coronary Artery This site-specific modifier is LL Lease/Rental (Used when DME equipment rental is to be applied against the purchase price) Monthly rental is equivalent to 1/10 th of the for a DME purchase. NY 0017 Page 10 of [17]

11 LM Left Main Coronary Artery LT Left Side This site-specific modifier is This site-specific modifier is MS NR Six month maintenance and servicing fee for reasonable and necessary parts and labor which are not covered under any manufacturer or supplier warranty* *See the Health Plan s Durable Medical Equipment (DME) Reimbursement Policy New when rented (use the NR modifier when DME which was new at the time of rental is subsequently purchased)* A DME item that is eligible for maintenance reimbursement will be reimbursed no more than two times per year at a frequency of at least 179 days apart. A DME item that is not eligible for maintenance reimbursement will be denied. Modifier NR is required for item to be eligible for reimbursement of purchase. NU *See the Health Plan s Durable Medical Equipment Policy New equipment purchase* *See the Health Plan s Durable Medical Equipment Policy P3, P4, P5 Anesthesia Physical Status Modifiers* *See the Health Plan s Anesthesia Reimbursement Policy Modifier NU is required for item to be eligible for reimbursement of purchase. Anesthesia codes reported with the modifiers P3, P4, or P5 are eligible for additional unit reimbursement as follows: P3= 1 unit P4= 2 units P5 = 3 units NY 0017 Page 11 of [17]

12 PA Surgery or other invasive procedure on wrong body part Procedures reported with this modifier will be denied. PB Surgery or other invasive procedure on wrong patient Procedures reported with this modifier will be denied. PC Wrong surgery or other invasive procedure on patient Procedures reported with this modifier will be denied. QK QX Medical Direction of two, three, or four concurrent anesthesia procedures involving qualified individuals* *See the Health Plan s Anesthesia Reimbursement Policy CRNA Service with medical direction by a physician* *See the Health Plan s Anesthesia Reimbursement Policy 50% The 50% reimbursement rate for medical direction carves out the reimbursement for the qualified professional who actually administered the anesthesia service. Total reimbursement for an anesthesia service is never more than the. 50% The 50% reimbursement rate for medical direction carves out the reimbursement for the qualified professional who actually administered the anesthesia service. Total reimbursement for an anesthesia service is never more than the. NY 0017 Page 12 of [17]

13 QY RA Medical direction of one CRNA by an anesthesiologist* *See the Health Plan s Anesthesia Reimbursement Policy Replacement of a DME, Orthotic, or Prosthetic Item* *See the Health Plan s Durable Medical Equipment Policy 50% The 50% reimbursement rate for medical direction carves out the reimbursement for the qualified professional who actually administered the anesthesia service. Total reimbursement for an anesthesia service is never more than the. Replacement of Health Plandefined frequently serviced DME items will be denied. Health Plan requires frequently serviced DME items to be rented, and repair and/or replacement of these items is included in the rental fee. RB Replacement of a Part of a DME, Orthotic, or Prosthetic Item Furnished as Part of a Repair* *See the Health Plan s Durable Medical Equipment Policy Replacement of parts of Health Plan-defined frequently serviced DME items will be denied. Health Plan requires frequently serviced DME items to be rented, and repair and/or replacement of these items is included in the rental fee. RC Right Coronary Artery This site-specific modifier is RI Ramus Intermedius Coronary Artery This site-specific modifier is NY 0017 Page 13 of [17]

14 RR Rental * For more information, refer to the Health Plan s Durable Medical Equipment Reimbursement Policy. RT Right Side Monthly rental is equivalent to 1/10 th of the maximum allowance for a purchase. This site-specific modifier is SL State Supplied Vaccine A vaccine supplied by a state government agency at no cost to the provider is not eligible for reimbursement by the Health Plan. SU Procedure performed in physician s office (to denote use of facility and equipment). T1-T9, TA Left/Right Foot, Digit Procedures reported with modifier SU will not be eligible for separate reimbursement if a provider is not contracted for the modifier s use. Use of an office facility and equipment are included in the practice expense of the Relative Value Unit (RVU) for a rendered service or procedure. These site-specific modifiers are TC Technical Component Reimbursement is based on the technical component of a procedure that has both a technical and professional component. NY 0017 Page 14 of [17]

15 UE Used durable medical equipment purchase* *See the Health Plan s Durable Medical Equipment Policy Modifier UE is required for item to be eligible for reimbursement of purchase. The following table lists some (but not all) commonly reported modifiers that the Health Plan considers Informational only. These modifiers have no effect on the of the reported code. Modifier Description 23 Unusual Anesthesia* * For more information, refer to the Health Plan s Anesthesia Reimbursement Policy. Informational only with no additional compensation. This modifier has no effect on the reimbursement of the reported anesthesia code. The provider should append the appropriate physical status modifier P1-P6 to indicate a specific physical condition. 32 Mandated Services Informational only. This modifier has no effect on the for a covered procedure code. 33 Preventive Service Preventive services reported with this modifier may be covered at the member s applicable preventive health level of benefits. 47 Anesthesia by Surgeon Informational only with no additional compensation. This modifier has no effect on the for the reported procedure code. 51 Multiple Procedures Informational only. This modifier has no effect on the for the reported procedure code. The Health Plan determines the ranking for applying multiple surgery reimbursement rules through its claim processing system NY 0017 Page 15 of [17]

16 Modifier Description not through the use of this modifier. 58 Staged or related procedure or Informational only. service by the same physician during the postoperative period 90 Reference (Outside) Laboratory Informational only. 92 Alternative Laboratory Platform Testing Informational only. AA Anesthesia Services Performed Personally by Anesthesiologist AI Principal physician of record Informational only Informational only. This modifier has no effect on the reimbursement for the reported anesthesia code. G8 G9 GC GE GR Monitored Anesthesia Care (MAC) Monitored Anesthesia Care (MAC) This service has been performed in part by a resident under the direction of a teaching physician This service has been performed by a resident without the presence of a teaching physician under the primary care exception This service was performed in whole or in part by a resident in a Department of Veterans Affairs Medical Center or clinic, supervised in accordance with VA policy. Informational only. This modifier has no effect on the reimbursement of the reported anesthesia code. Informational only. This modifier has no effect on the reimbursement of the reported anesthesia code. Informational only Informational only Informational only NY 0017 Page 16 of [17]

17 Modifier Description P1, P2, P6 Anesthesia Physical Status Modifiers* PT *See the Health Plan s Anesthesia Reimbursement Policy Colorectal cancer screening test converted to a diagnostic test Informational only. Anesthesia codes reported with modifier P1, P2, or P6 are not eligible for additional unit reimbursement. Colorectal cancer screening procedures may be covered at the member s applicable preventive health level of benefits. QL QS QZ Patient Pronounced Dead After Ambulance Called Monitored Anesthesia Care (MAC) CRNA Service without medical direction by a physician* *See the Health Plan s Anesthesia Reimbursement Policy Informational only. This modifier has no effect on the reimbursement of the reported service. Informational only. This modifier has no effect on the reimbursement of the reported anesthesia code. Informational only. This modifier has no effect on the reimbursement of the reported anesthesia code. 1 CPT is a registered trademark of the American Medical Association 4 ClaimsXten is a registered trademark of McKesson Information Solutions LLC Use of Reimbursement Policy: State and federal law, as well as contract language, including definitions and specific inclusions/exclusions, take precedence over Reimbursement Policy and must be considered first in determining eligibility for coverage. The member s contract benefits in effect on the date that services are rendered must be used. Reimbursement Policy is constantly evolving and we reserve the right to review and update these policies periodically Empire BlueCross BlueShield No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, or otherwise, without permission from Empire BlueCross BlueShield. NY 0017 Page 17 of [17]

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