Oregon CO-OP Modifier Table - December 2013

Transcription

1 Oregon CO-OP Modifier Table - December 2013 Modifier Modifier Description Pricing Functionality 22 Increased Procedural Services Modifier 22 should only be reported with procedure codes that have a global period of 0, 10 or 90 days. This modifier should not be reported with E/M codes. Supporting documentation for the use of modifier 22 is required. Upon approval, an additional 25% will be allowed. 50 Bilateral Procedure 51 Multiple Procedures Modifier 50 is a bilateral modifier that indicates when a procedure normally performed on only one side of the body is performed on both sides by the same physician during the same session. When modifier 50 is billed, 150% of the global amount is allowed. Modifier 51 denotes when multiple medical procedures or a combination of medical and surgical procedures are performed during the same session by the same provider. The highest valued procedure is paid at 100% and the second through fifth procedures are paid at 50%. 52 Reduced Services Modifier 52 indicates a portion of a procedure or service was reduced or eliminated at the physician's election. Supporting documentation and a statement from the provider regarding reduction of service must be submitted or use of this modifier will be ignored. 54 Surgical Care Only 55 Postoperative Management Only Modifier 54 is appended to a surgical code when the surgeon provides the surgical care only and does not provide preoperative or postoperative care. Payment is limited to the preoperative and intra-operative components of the fee schedule amount. Modifier 55 is appended to a surgical code to indicate a physician provides only the postoperative surgical care. Payment is limited to the post-operative component of the fee schedule amount.

2 Modifier 58 is used to report a surgical procedure that is staged or related to the primary surgical procedure and is performed during the global period. It is most commonly applied in the following instances: 58 Staged or Related Procedure or Service by the Same Physician During the Postoperative Period The second procedure is anticipated or planned to manage the underlying condition. A second, more extensive procedure is needed to treat the underlying disease process. A therapeutic procedure following a surgical procedure is planned. The global period restarts with the subsequent procedure, and the surgeon should receive 100 percent of the allowable reimbursement on both the first and the subsequent procedures. Appropriate multiple procedure payment rules apply if multiple procedures are performed at the subsequent session. 62 Two Surgeons Modifier 62 indicates 2 surgeons are working together as primary surgeons to perform distinct parts of a procedure. Reimbursement is only available for eligible codes and includes 62.5% of the global surgery fee schedule amount for each surgeon. 63 Procedure Performed on Infants less than 4 kg Modifier 63 is only valid for codes Supporting documentation for the use of this modifier is required. Upon approval, an additional 25% will be allowed. 66 Surgical Team Modifier 66 denotes when more than 2 surgeons of different specialties are required to perform different portions of a specific procedure. This modifier is only valid with eligible surgical codes and requires documentation that demonstrates how each surgeon performed components of the procedure in a team manner. Reimbursement is determined on an individual basis.

3 73 Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedure Prior to the Administration of Anesthesia Modifier 73 is used when a facility reports that the service was canceled before the induction of anesthesia at the physician's discretion. This modifier is only used with outpatient hospital departments or ASC reporting. Reimbursement results in a reduction of 50% of the facility rate. 78 Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the Postoperative Period Modifier 78 describes services involving a return trip to the operating room to deal with complications related to the initial procedure. The related procedure is performed on the same day or during a global period with more than 0 global days. Reimbursement for services billed with modifier 78 is the value of the intra-operative services of the code. If an unlisted procedure is billed because no code exists to describe the treatment for complications, payment is based on a maximum of 50% of the value of the intra-operative services originally performed. 79 Unrelated Procedure or Service by the Same Physician During the Postoperative Period Modifier 79 reports an unrelated procedure by the same physician on the same patient during a postoperative period. When modifier 79 is billed documentation to support medical necessity must be submitted; in addition, a new global period begins with this modifier. Reimbursement for services appended with modifier 79 is 100% of the allowed amount. 80 Assistant Surgeon Modifier 80 is used when a surgical assistant is used during the entire surgical procedure to assist a primary surgeon. Surgical assistants can include physicians, physician assistants, nurse practitioners, and clinical nurse specialists. Reimbursement for approved surgical procedures is 16% of the global allowed amount. 81 Minimum Assistant Surgeon Modifier 81 indicates when circumstances arise that require the services of an assistant surgeon during a surgical procedure for a relatively short amount of time. The second surgeon provides minimal assistance to the primary operating physician. This modifier may only be billed by physicians and documentation is required to support medical necessity. Reimbursement shall be no more than 13% of the maximum allowable amount.

4 82 Assistant Surgeon (when qualified resident surgeon not available) Modifier 82 has a prerequisite for its' use: unavailability of a qualified resident surgeon. This modifier is specifically used in teaching hospitals if there is no approved training program related to medical specialty required for the surgical procedure or if no qualified resident is available. Assistant surgeons include physicians, physician assistants, nurse practitioners and clinical nurse specialists. Certification for using modifier 82 must be on file for each claim. Reimbursement is the same as modifier 80 or 16% of the global allowed amount. 91 Repeat Clinical Diagnostic Laboratory Test Modifier 91 is used to indicate a repeat diagnostic laboratory test provided on the same day to the same patient. Inappropriate usage of this modifier includes: confirming initial results, when problems exist with tests or equipment, or when alternate codes describe a series of tests. When modifier 91 is properly billed, reimbursement is 100% for repeat clinical diagnostic laboratory tests. AD Medical supervision by an anesthesiologist: more than 4 concurrent anesthesia procedures. Modifier AD may only be submitted with anesthesia procedure codes through Payment for 'medically supervised' services is based on three base units per procedure with an additional unit of time if the physician documents that he or she was present at induction. The units field must always be '1' when this modifier is submitted. Reimbursement formula: (3 base units + time units) x 50% OR (3 Base + time units + 1 time unit for induction) x 50% AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery Modifier AS identifies the services of a physician assistant, nurse practitioner or clinical nurse specialist for assistant at surgery. If modifier AS is billed by a PA, it must also be accompanied by modifiers 80 or 82 - otherwise the claim will be denied. NPs or CNSs may bill only modifier AS. Supporting documentation describing medical necessity for an assistant must be provided. Reimbursement is the same as modifiers 80 and 82 or 16% of the global allowed amount.

5 GM Multiple patients on one ambulance trip Modifier GM identifies when there are multiple patients on one ambulance trip. When more than 1 patient is transported via ambulance, the allowed charge for each beneficiary is a percentage based on the total number of patients transported. The number of patients transported is documented in Item 19 of the HCFA 1500 claim form. Reimbursement is as follows: If 2 patients are transported together, 50% of the mileage and 75% of the base rate is allowed for each patient. If 3 or more patients are transported, 60% of the base rate is allowed for each patient and mileage is divided by the number of patients on board. PT Colorectal cancer screening test; converted to diagnostic test or other procedure Modifier PT indicates when a service that began as a colorectal cancer screening test was moved to a diagnostic test due to findings during the screening. This modifier is valid for codes through 69999, G0104, G0105, G0106 and G0121. When modifier PT is reported the deductible and coinsurance for all surgical services on the same date as the diagnostic test are waived. This waiver applies in all three outpatient settings physician, hospital outpatient department and ambulatory surgery center. Q3 Live kidney donor surgery and related services Modifier Q3 should be reported in the first modifier position to ensure services are reimbursed at 100%. Expenses for physicians' services rendered to a live kidney donor are treated as though the Medicare beneficiary (recipient) had incurred them. These services include the donor's pre-operative surgical care, kidney excision inpatient stay and any subsequent related post-operative period. Payment for these services is made at 100 % of the allowed amount and there is no deductible or coinsurance charged for services furnished to live donors. QE Prescribed amount of oxygen is less than 1 liter per minute (LPM) Modifier QE is an oxygen modifier and should only be appended to codes E1390, E1391, E0424 and E0439. This modifier should always be billed with modifier RR. The use of this modifier signifies that the monthly payment amount for stationary oxygen is reduced by 50 %.

6 QF Prescribed amount of oxygen exceeds 4 liters per minute (LPM) and portable oxygen is prescribed Modifier QF is an oxygen modifier and should only be appended to codes E1390, E1391, E0424 and E0439. This modifier should always be billed with modifier RR. Use of modifier QF increases the monthly payment for stationary oxygen by 50% of the monthly stationary oxygen payment amount, or, the fee schedule amount for the portable oxygen add-on - whichever is higher. (Note: A separate monthly payment is not allowed for the portable equipment.) QG Prescribed amount of oxygen is greater than 4 liters per minute (LPM) Modifier QG is an oxygen modifier and should only be appended to codes E1390, E1391, E0424 and E0439. This modifier should always be billed with modifier RR. The use of this modifier signifies that the monthly payment amount for stationary oxygen is reduced by 50 %. QK Medical direction of 2, 3, or 4 concurrent anesthesia procedures involving qualified individuals Modifier QY reduces payment to 50% of the contracted rate that is reimbursed to the anesthesiologist. QX CRNA service: with medical direction by a physician Modifier QY reduces payment to 50% of the contracted rate that is reimbursed to the CNRA/AA. QY SF Medical direction of one certified registered nurse anesthetist (CRNA) by an anesthesiologist Second opinion ordered by a professional review organization (PRO) per section 9401, p.l Modifier QY reduces payment to 50% of the contracted rate that is reimbursed to the anesthesiologist. Modifier SF denotes when a second opinion is ordered by a professional review organization. Allow 100% reimbursement with no coinsurance or deductible.

7 UN Two patients served the transportation fee is prorated by the number of patients seen. When modifier UN is billed, total payment is divided by 2. UP UQ UR US Three patients served Four patients served Five patients served Six or more patients served the transportation fee is prorated by the number of patients seen. When modifier UP is billed, total payment is divided by 3. the transportation fee is prorated by the number of patients seen. When modifier UQ is billed, total payment is divided by 4. the transportation fee is prorated by the number of patients seen. When modifier UR is billed, total payment is divided by 5. the transportation fee is prorated by the number of patients seen. When modifier US is billed, total payment is divided by 6.