Medicare Physician Fee Schedule Modifiers

Basics of MPFS Part 3 Medicare Physician Fee Schedule Modifiers Presented by Part B Provider Outreach and Education July 16, 2013

Disclaimer This information released is the property of Cahaba GBA and the Centers for Medicare and Medicaid Services (CMS). It may be freely distributed in its entirety but may not be modified, sold for profit or used in commercial documents. While all information in this document is believed to be correct at the time of creation, this document is for educational purposes only and does not purport to provide legal advice. American Medical Association (AMA) Current Procedural Terminology (CPT ) Copyright Statement Current Procedural Terminology (CPT ) is copyright 2013 American Medical Association. All Rights Reserved. CPT is a trademark of the American Medical Association. 2

Course Objective 1. Definition of a Modifier 2. How to Identify MPFS modifiers 3. Common MPFS modifier errors 4. Self-Service Tools 5. Medicare Resources 3

Acronyms Acronym Term CMS E & M Description Centers for Medicare and Medicaid Services Evaluation and Management MLN Medicare Learning Network MPFS MPFSDB PC TC Medicare Physician Fee Schedule Medicare Physician Fee Schedule Data Base Professional Component Technical Component 4

CMS Manual Reference CMS IOM Publication 100-04 Medicare Claims Processing Manual, Chapter 23 Fee Schedule Administration and Coding Requirements, Section 30 Services Paid Under the Medicare Physician s Fee Schedule found at http://www.cms.gov/regulations-and- Guidance/Guidance/Manuals/Downloads/clm104c23.pdf 5

Definition What is a Modifier? A two-digit code appended to procedure codes Modifiers May affect reimbursement May be informational only Updated annually 6

What is the MPFS database? A list of indicators Provides information about specific codes Edits controlled by CMS Quarterly changes posted in the Medicare B Newsline In addition, MPFS database index file list modifiers 7

MPFS Modifiers The Medicare Physician Fee Schedule (MPFS) modifiers may be used to indicate that: A service or procedure has both a professional and technical component A service or procedure was performed by more than one physician An assistant-at-surgery service was performed A bilateral procedure was performed Unusual events occurred 8

MPFS Database Index and Relative Value 9

Let s Review the MPFS Modifiers Modifier 54 Surgical Care Modifier 55 Postoperative Care Modifier 26 Professional Component Modifier TC Technical Component Modifier 51 Multiple Procedure Modifier 50 Bilateral Procedure Modifier 80 Assistant-at-Surgery (Physician) Modifier AS Assistant-at-Surgery (Non-Physician Practitioner) Modifier 62 Co-Surgery Modifier 66 Team Surgery 10

Split care (Transfer of Care) Surgery care only (54) Surgeon is performing only the preoperative and intra-operative care Modifier is only used on surgical codes Commonly used with ophthalmology specialty Postoperative management only (55) Physician, other than surgeon, assumes all or part of postoperative care Copy of written transfer agreement must be kept in beneficiary s medical record 11

MPFS Component of Split Care The MPFS shows the pre, intra and post operative percentage Providers should review the MPFSDB for their specific code and applicable percentage System calculates allowance based on fee schedule amount multiplied by percentage rate 12

Modifier 54 & 55 Category Indicator Indicator Description Pre % Pre-Operative % - Modifier 56 Intra % Intra -Operative % - Modifier 54 Post % Post -Operative % - Modifier 55 Indicates the percentage of the global allowable for the preoperative portion of the global package. Indicates the percentage of the global allowable for the intra operative portion of the global package including postoperative work in the hospital. Indicates the percentage of the global allowable for the postoperative portion that is provided in the office after discharge from the hospital. Note: Surgeon performing the surgery will be reimbursed for the pre and intra 13

A View of the MPFS (Pre, Intra, Post) 14

Diagnostic Test Professional Component (26) Interpretation of a diagnostic procedure Technical Component (TC) The equipment and technician performing the test Modifier 26 and TC Affect payment Both modifiers are notated with a specific allowable on the MPFS Refer to the MPFS to verify modifier usage 15

Diagnostic Test (26 & TC) P Category Indicator Indicator Description Professional/ Technical Component Modifiers 26 and TC 0 Physician Service codes. Indicator identifies codes that describe physician services such as visits and surgical procedures. Mod 26 & TC cannot be used with these codes. 1 Diagnostic tests or radiology services. Codes generally have both a professional and technical component. Modifiers 26 and TC can be used with these codes. 2 Professional component only codes. This indicator identifies stand alone codes that describe the physician work portion of selected diagnostic tests for which there is an associated code that describes the technical component of the diagnostic test only and another associated code that describes the global test. Modifiers 26 and TC cannot be used with this code. 3 Technical component only codes. This indicator identifies stand alone codes that describe the technical component of selected diagnostic tests for which there is an associated code that describes the professional component of the diagnostic test only. It also identifies codes that are covered only as diagnostic tests and therefore do not have a related professional code. Modifiers 26 and TC cannot be used with this code. 4 Global test only codes. This indicator identifies stand alone codes that describe selected diagnostic tests for which there are associated codes that describe a) the professional component only and b) the technical component of the test only. Modifiers 26 and TC cannot be used with these codes. *This is not an all-inclusive list. 16

A View of the MPFS (PC/TC) 17

Billing Example CPT 93000 CPT code 93000 has a PC/TC 4 indicator on MPFS Relative Value file Code described as global test only Modifier 26 or TC should not be appended to this procedure code 07 15 2013 07 15 2013 93000 26 Incorrect 1234567890 07 15 2013 07 15 2013 93000 Correct 1234567890 18

Billing Example CPT 93005 CPT code 93005 has a PC/TC 3 indicator on MPFS Relative Value file Code described as technical component only Modifier 26 or TC should not be appended to this procedure code 07 28 2013 07 28 2013 93005 TC Incorrect 1234567890 07 28 2013 07 15 2013 93005 Correct 1234567890 19

Billing Example CPT 93010 CPT code 93010 has a PC/TC 2 indicator on MPFS Relative Value file Code described as interpretation only Modifier 26 or TC should not be appended to this procedure code 07 28 2013 07 28 2013 93010 26 Incorrect 1234567890 07 28 2013 07 15 2013 93010 Correct 1234567890 20

Common Billing Errors (Mod 26 & TC) Modifier 26/TC used on same claim line for global procedure Modifier 26 and TC appended to office visit and injection procedure codes Modifier 26 billed on codes that have a PC/TC indicator 2 Modifier TC billed on codes that have a PC/TC indicator 3 21

Multiple Procedure (Modifier 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 for billing Reduction determined by the MPFS approved amount M/S pricing indicators effect surgical procedures, endoscopy rules, technical components, therapy services, cardiovascular and ophthalmology services 22

Multiple Procedure (51) M Category Indicator Indicator Description Multiple Surgery Modifier 51 0 No payment adjustment rules for multiple procedures apply. If procedure is reported on same day as another procedure, base payment on lower of a) the actual charge or b) the fee schedule amount for the procedure. 1 Standard payment adjustment rules in effect before January 1, 1996 for multiple procedures apply. In the 1996 MPFSDB, this indicator only applies to codes with procedure status of D. If a procedure is reported on the same day as another procedure with an indicator of 1, 2, or 3, rank the procedures by fee schedule amount and apply the appropriate reduction to this code (100%, 50%, 25%, 25%, 25%, and by report). 2 Standard payment adjustment rules for multiple procedures apply. If procedure is reported on the same day as another procedure with an indicator of 1, 2, or 3, rank the procedures by fee schedule amount and apply the appropriate reduction to this code (100%, 50%, 50%, 50%, 50%, and by report). 3 Special rules for multiple endoscopic procedures apply if procedure is billed with another endoscopy in the same family (i.e., another endoscopy that has the same base procedure). *This is not an all-inclusive list. 23

A View of the MPFS (Multiple Procedure) 24

Bilateral Procedure (Modifier 50) Surgery performed on both sides of the body at the same operative session or on the same day Always verify the B/S indicator for your procedure code based on the MPFS database file Commonly seen with procedures that allow 150% of MPFS B/S indicator = 1 Number of Service is 1 Bill procedure code on one claim line CPT manual will specify if a code is unilateral, bilateral or unilateral or bilateral 25

Bilateral Surgery (50) Category Indicator Indicator Description S Bilateral Surgery 0 150% payment adjustment for bilateral procedures does not apply. Bilateral is inappropriate for codes in this category because of (a) physiology or anatomy, or (b) because the code description specifically states that it is a unilateral procedure and there is an existing code for the bilateral procedure. 1 150% payment adjustment for bilateral procedures applies. Modifier 50 appropriate if procedure is performed bilaterally. If the code is billed with the bilateral modifier or is reported twice on the same day by any other means (e.g. with RT and LT modifiers or with a 2 in the units field), allows 150% of usual amount. 2 150% payment adjustment for bilateral procedure does not apply. RVUs are already based on the procedure being performed as a bilateral procedure. 3 200% payment adjustments for bilateral procedures apply. Modifier 50 appropriate if performed bilaterally. 9 Concept does not apply. 26

A View of the MPFS (Bilateral Procedure) 27

Common Billing Errors (Mod 50) Modifier 50 used when code descriptions state unilateral or bilateral Billed inappropriately on codes that have a B/S indicator of 0 (Bilateral payment adjustment does not apply) 28

Common Billing Error (Mod 50) Incorrect Billing CPT 19125 with Modifier 50 and LT for same line (B/S indicator is 1) 06 10 13 06 10 13 19125 50 LT 1 1234567890 Correct Should bill CPT 19125 with modifier on one line with NOS 1 06 10 13 06 10 13 19125 50 1 1234567890 29

Common Billing Error (Mod 50) Incorrect Billing CPT 27440 with Modifier 50 and 2 units of service (B/S indicator is 1) 06 10 13 06 10 13 27440 50 2 1234567890 Correct Should bill CPT 27440 with modifier on one line with NOS 1 06 10 13 06 10 13 27440 50 1 1234567890 30

Common Billing Error (Mod 50) Incorrect Billing CPT 51820 with Modifier 50 (B/S indicator is 2) 06 10 13 06 10 13 51820 50 1 1234567890 Correct Should bill CPT 51820 without modifier 50. Code describes unilateral or bilateral in description 06 10 13 06 10 13 51820 1 1234567890 31

Assistant-at-Surgery Assists the physician in charge of surgical procedure Modifier 80 used when the assistant at surgery service provided by a medical doctor Allowable based on 16% of MPFS Modifier AS used when the assistant at surgery service provided by a non-physician practitioner Examples include Physician Assistant and Nurse Practitioner Allowable based on 85% of 16% of MPFS MPFS Indicators for services where assistant at surgery allowed: 0 = Payment restrictions for assistants at surgery applies to this procedure unless supporting documentation 2 = Assistant at Surgery may be paid 32

Assistant at-surgery (Mod 80 & AS) A Category Indicator Indicator Description Assistant at Surgery Modifiers 80, AS 0 Payment restrictions for assistants at surgery apply to this procedure unless supporting documentation is submitted to establish medical necessity. 1 Statutory payment restriction for assistants at surgery applies to this procedure. Assistant at surgery may not be paid. 2 Payment restriction for assistants at surgery does not apply to this procedure. Assistant at surgery may be paid. 9 Concept does not apply. 33

A View of the MPFS (Assistant Surgery) 34

Common Billing Error (Mod AS) Incorrect CPT 27447 -AS was billed by an MD for assistant-at-surgery services. (Assistant-at-Surgery indicator is 2) 06 10 13 06 10 13 27447 AS 1 1234567890 Correct CPT 27447-80 should be used to bill for assistant-at-surgery when performed by an MD 06 10 13 06 10 13 27447 80 1 1234567890 35

Common Billing Errors (Mod 80 & AS) Claims for physician billed with modifier AS Claims for non-physician practitioner billed with modifier 80) Billed inappropriately with codes that have an Assistant-at-Surgery indicator of 1 (Assist at surgery may not be paid) 36

Co-Surgery Modifier 62 Two surgeons work together as primary surgeons performing distinct parts of a procedure Both surgeons must agree to use modifier 62 MPFSDB indicator must be 1 or 2 Reimbursement based on 62.5% of allowance for each surgeon 37

Co- Surgery (62) Category Indicator Indicator Description C Co-Surgeon Modifier 62 0 Co-surgeons not permitted for this procedure. 1 Co-surgeons could be paid; supporting documentation required to establish the medical necessity of two surgeons for the procedure 2 Co-surgeons permitted; no documentation required if two specialty requirements are met. 9 Concept does not apply. 38

A View of the MPFS (Co-Surgery) 39

Recovery Auditor Review MLN matters article SE1322 Identified payment errors because of failure to report co-surgeon modifier Individual skills of two or more surgeons are required to perform surgery on the same patient during the same operative session http://www.cms.gov/outreach-and-education/medicare-learning-network- MLN/MLNMattersArticles/Downloads/SE1322.pdf 40

Team Surgery Modifier 66 Highly complex procedure requiring skills of different specialties Single procedure requiring more than two surgeons of different specialties Documentation required 41

Team Surgery (66) Category Indicator Indicator Description T Team Surgeons Modifier 66 0 Team surgeons not permitted for this procedure 1 Team surgeons could be paid; supporting documentation required to establish medical necessity of a team, pay by report. 2 Team surgeons permitted, pay by report 9 Concept does not apply. 42

A View of the MPFS (Team Surgery) 43

Proper Coding is the Key! Providers are responsible for determining correct coding for services furnished to Medicare beneficiaries Cahaba GBA shall not make determinations about proper use of codes We will encourage our providers to refer to the most current billing manual Current Procedural Terminology Manual ICD-9-CM manual (diagnosis coding) Level 2 Healthcare Common Procedure Coding System American Hospital Association Coding Clinic 44

Website Resources Resource Center for New Providers https://www.cahabagba.com/part-b/education/welcome-to-the-resourcecenter-for-new-providers/ Cahaba University http://www.cahabagba.com/part-b/education/cahaba-u-18370/ CMS IOM Publication 100-04 Medicare Claims Processing Manual, Chapter 12 http://www.cms.gov/regulations-and- Guidance/Guidance/Manuals/Downloads/clm104c12.pdf 45

MM8039: Enrollment Denials Effective October 1, 2013 Implementation date: October 7, 2013 Contractor will deny Form CMS-855 application when an existing or delinquent overpayment exists for Current owner of the applying provider or supplier; or, The applying physician or non-physician practitioner that has an existing overpayment that is equal to or exceeds a threshold of $1500 and it has not been repaid in full at the time the application was filed Forms CMS-855A, CMS-855B, CMS-855I and CMS-855S application 46

Electronic Funds Transfer Reminder Missing Medicare Identification Number (aka Provider Transaction Access Number) in Part II Individual PTAN/NPI submitted in lieu of group PTAN/NPI Form CMS-588 not signed by authorized or delegated official Pre-printed voided check or bank letter not attached 47

48 Appeals Decision Tree

Cahaba GBA Website Secondary links Forms Homepage Redesign InSite Web Portal What s New Foresee Survey 49

MLN Products CMS is looking for interested individuals to pilot Volunteers are needed to test web-based training and review MLN publications You should email to CMSCE@cms.hhs.gov Provide your name, occupation, state of residence, and e-mail address. An email confirmation will be sent Details provided in the June 13th edition of the CMS e-news 50

Questions 51 Provider Contact Center: 877-567-7271

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