Modifier Magic April 15, 2015 MMBA Modifiers Modifiers should be reported to bypass a clinical edit ONLY if the criteria for the use for the modifiers is met and supporting documentation is included in the member s medical record. This is a direct quote from BCN Provider Manual. For additional information on modifiers, providers should consult the available resources on procedure codes published by the American Medical Association ( your CPT and HCPCS books) and the Centers for Medicare & Medicaid Services. Anatomical Modifiers Anatomical modifiers are used to indicate that a procedure or service was performed at a specific anatomic site or to indicate that a procedure was performed at two separate and distinct anatomic sites. Examples of anatomical modifiers are: E1 E4, FA, F1 F9, TA, T1 T9, LT, RT, LC, LD and RC. Use of anatomical modifiers facilitates the identification of separate and distinct services. For example, a provider may report modifier F2 on one line and modifier F3 on another line when procedure code *26455 is reported as performed on each of those fingers, instead of reporting a count of two on one line. 1
Anatomical Modifiers Anatomical modifiers should be reported instead of modifier 59, when possible. For example, if a provider performs foot surgery, reporting code 28285 and code 28292 at the same operative session but on different sites, anatomic modifiers should be appended to each line to indicate that the procedures performed were separate and distinct. Modifier 59 is to be used only when there are no other modifiers that accurately indicate the nature of the service performed. Anesthesia Modifiers Anesthesia claims must be reported with the appropriate modifier for the practitioner administering the anesthesia: Modifier AA, AD, QK or QY is reported for a physician who administers the anesthesia or who supervises its administration. Modifier QX or QZ is reported for a certified registered nurse anesthetist who administers the anesthesia. Services performed by CRNAs without the medical direction of an anesthesia physician are paid the charge or 85 percent of the maximum payment, whichever is lower. Anesthesia services performed by CRNAs or anesthesia assistants in physician offices are not eligible for payment. Physical Medicine & Rehab Services Modifiers A physical medicine and rehabilitation service must be reported with the appropriate therapy modifier indicating the discipline performing the therapy. The modifiers are GN, GO and GP. The codes requiring these modifiers include the following: *92507, *92508, *92521 *92524, *92526, *92597, *92605 92609, *96125, *97001 *97004, *97010 *97012, *97014, *97016 *97028, *97032 *97039, *97110 *97124, *97139 *97140, *97150, *97530, *97532 *97537, *97542, *97750, *97755, *97760 *97762, *97799, G0129, G0283, G0329, S8948, S8950, S9152 or S9476. If the procedure code is reported without the modifier, the service may be denied because the required modifier is missing. The reporting of these modifiers indicating the type of therapy performed does not supersede the provider s reimbursement arrangement with third party payers. 2
Physical Medicine & Rehab Services Modifiers The CPT codes *97597, *97598, *97602, *97605, *97606, G0281 and G0329 are classified by the CMS as sometimes therapy procedure codes. (Code G0329 is for BCN Advantage members only; it is not covered for BCN commercial members.) When these services are provided for active wound management, they should not be reported with therapy modifiers (GN, GO or GP). Behavioral Health Modifiers To receive the correct reimbursement, board certified child and adolescent psychiatrists should bill with the HA modifier rather than the AM modifier. All claims with an HA modifier will be audited to ensure that only board certified child and adolescent psychiatrists are billing the HA modifier. Discarded Drug Modifiers Modifier JW may be used to identify drugs that are discarded or not used for a member. When reporting the modifier for drugs administered from a single use vial or single use package, providers should follow these guidelines: Modifier JW should not be reported when the billing unit is greater than the actual dose provided. For example, if the procedure code nomenclature for the drug is 10 mg but the dosage administered was 5 mg and the vial contains only 10 mg, then the unit reported on the claim would be 1 because the billing unit provides for full reimbursement of the 10 mg dosage. 3
Discarded Drug Modifiers The modifier JW may be reported if the billing unit is less than the actual dose provided. For example, if the procedure code nomenclature for the drug is 1 mg but the dosage administered was 5 mg and the vial contains 10 mg, then two lines would be reported: o Line 1: Report the five units used. o Line 2: Report the five units discarded with the JW modifier. The JW modifier should be noted only on the line for the wasted drug. Note: Multi dose vials should not be reported with the JW modifier Evaluation & Management Modifiers Modifier 24 is used to report a subsequent but unrelated E&M service performed during the global surgery period that should be evaluated separately. When reporting an office/outpatient or inpatient consultation procedure code with a minor surgical procedure (0 or 10 day) performed on the same day, if the E&M service provided was distinct from the surgical procedure, it needs to be reported with modifier 25. If not reported with the modifier, the E&M visit may receive an edit indicating it was considered part of the global surgical package. Note: BCN audits health care practitioners who report modifier 25 at a rate much higher than their medical specialty peers. Modifier 25 should be used with E&M codes only and should not be appended to the code for the surgical procedure or other service (for example, therapeutic injections, therapeutic infusions or diagnostic X rays or scans). Evaluation & Management Modifiers Documentation must be maintained in the member s clinical record to substantiate the use of modifier 25. To document the extra work performed, the member s clinical record must clearly indicate the extra or unusual work. The documentation must support that the E&M service being billed is distinct from the other service performed. 4
Evaluation & Management Modifiers Modifier 26: Certain procedures are a combination of a physician's professional component and a technical component. One example is the ultrasound performed during surgery where the hospital owns the equipment but the surgeon uses during a procedure for proper placement of hardware. The Surgeon needs to document the use of the ultrasound and findings in the OP note to support billing for the ultrasound reading(s). Evaluation & Management Modifiers Modifier 32: Services related to mandated services such as consultations and/or related services eg: third party payers, governmental, legislative regulations. Modifier 33 for Preventative Services. When the primary purpose of the service is the delivery of an evidence based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive series identified in the preventive services mandates, the services are identified by applying modifier 33. Evaluation & Management Modifiers It is not appropriate to report modifier 57 for major surgeries that are planned in advance. When modifier 57 is reported with a procedure that falls within one of the categories of planned surgeries, the E&M service will be denied. The categories of planned surgeries include: Spine surgery, excluding fractures and dislocations Arthroplasty: total, partial and revision Congenital/deformity procedures (for example, clubfoot) Transplant procedures Chronic/subacute conditions (for example, tennis elbow or cataract surgery) Modifier 57 should not be used with E&M services performed on the same day as minor surgical procedures 5
Other Modifiers GA Advance notice of non coverage provided: use this modifier to tell us that you provided a notice of Medicare non coverage to the patient. If you bill for non covered services without using the GA modifier indicating you did not give notice of non coverage to the patient, insurance carriers will deny your claim. It will go to provider liability. GY Service is not covered by Medicare by statute 1. Under Original Medicare the GY modifier identifies that a service is not covered by Medicare by statute and does not require that notice of noncoverage be provided. 2. Under Medicare Part C (Medicare Advantage) rules: You MUST give a patient notice that a service will not be covered, even when the service provided or referred is not covered by statute. You should then bill their insurance for the non covered, statutorily excluded service. However, if you do use the GY modifier, this means you have not given the member a notice of non coverage and the claim will go to provider liability. Other Modifiers GZ Service is not covered by Medicare Under Original Medicare the GZ modifier identifies that 1) an item or service is expected to be denied as not reasonable and necessary, and 2) no advance notice of non coverage was supplied to the member. You may bill with this modifier. Payers follow Original Medicare billing rules, which are that claims having the GZ modifier: Should be denied automatically Are not subject to complex medical reviews Will be provider liability Other Modifiers Using modifier 22, unusual procedural services Each procedure code has an expected range of complexity, length, risk, and difficulty. When the service provided exceeds these normal ranges (more complicated, complex, difficult, or requiring significantly more time than usual), add modifier 22 to the procedure code. When use of modifier 22 is valid, an additional payment may be allowed. Additional payment consideration may not apply to every code paid. Additional reimbursement will be considered only when the documentation submitted clearly states the exceptional nature of the service provided. Modifier 22 always requires code review. Do not append modifier 22 to unlisted codes. 6
Modifiers 22 Documentation is key! Documentation within the operative report should reflect the unusual circumstances of the procedure. It is the responsibility of the surgeon to submit all necessary documentation. An explanation of how the service provided differs from the usual service must be included Priority Health has a specific form that they require when using modifier 22 on claims. Modifier 22 When modifier 22 is valid: Validity requires two or more of the following factors, OR one of the following factors in addition to extended anesthesia: Extreme obesity that significantly complicates surgery Co morbidities that cause complications during the surgery Trauma extensive enough to complicate the particular procedure and not billed as additional procedure codes Modifier 22 When modifier 22 is valid: Other pathologies, tumors, malformations (genetic, traumatic, surgical) that directly interfere with the procedure but are not billed separately The services rendered are significantly more complex than described for the CPT code in question Excessive blood loss for the particular procedure Difficult surgical approach Revisions or removals of prior operative work that are unusually complex or difficult 7
Other Modifiers Other valid uses of modifier 22 Modifier 22 may also be given individual consideration in other situations. For example, if access to the primary operative site is difficult and time consuming, additional payment may be warranted for the primary procedure. However: Secondary procedures performed through the same incision may not meet the same criteria. Reductions for multiple procedures will still apply. This process does not exempt claims from clinical code edits relative to bundled services and other code edits More Modifiers When reporting services performed bilaterally, identify the procedure code with modifier 50 and a count of 1 on the claim line. For example, using modifier 50 would be an appropriate way to report a procedure done on the right wrist and the left wrist at the same setting, each with a count of 1. This is different than advice from some payers who request that a bilateral procedure be reported with one line with a modifier 50 and a second line with the same procedure code but without a modifier 50. Only if the procedure was performed twice on each wrist would it be appropriate to report the procedure code with a modifier 50 and a count of 2. 8
When modifier 52 is reported with a procedure code, reimbursement will be adjusted to 50 percent of the fee schedule. When modifier 52 is reported with a procedure code, reimbursement will be adjusted to 50 percent of the allowed amount. Note: This applies to BCN Advantage SM and BCN commercial products as well as many of the other third party payers. Modifier 53 Discontinued services: Under certain circumstances, the physicians may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. Note: The modifier is not used to report the elective cancellation of a procedure PRIOR to the anesthesia induction and/or surgical preparation in the operating suite. (Per CPT 2015). Modifier 54: Surgical care only Modifier 55: Postoperative Management Modifier 56: Preoperative Management 9
A follow up surgical procedure performed by an emergency room physician within 90 days of a surgical procedure done in an emergency room is typically reported with modifier 54, indicating that only preoperative and surgical care were provided. The patient s own physician would be expected to assume the care of the patient postoperatively. Claims for these follow up surgical procedures will be sent back to the provider with instructions to resubmit. If surgical care is split between providers, the claims submitted should identify the care provided by use of the appropriate modifiers. The surgical care modifiers include modifiers 54, 55 and 56. Claim lines reported with these modifiers will be reimbursed according to the percentages from the national (CMS) Physician Fee Schedule Relative Value Files. Modifier 54 is reimbursed by CMS at the combined preoperative and intraoperative percentages. Modifier 58 is used to indicate that a subsequent procedure performed during the global surgery period was anticipated. The global surgery period is defined according to CMS guidelines and incorporates the postoperative time frames of 0, 10 and 90 days. Medical services performed in the postoperative period that are associated with an earlier surgery must be appropriately coded with modifier 58 to avoid unnecessary editing. 10
Modifier 62: Two surgeons work together as primary surgeons perfuming DISTINCT part(s) of a procedure, each surgeon should report his/her own work. Each surgeon should report the co surgery once using the same procedure code. If additional procedure(s) are performed during the same surgical session, separate code(s) may also be reported. DOCUMENATION! DOCUMENTATION! DOCUMENTATION! Modifier 63: Procedures performed on infants less than 4kg that may involve significantly increase complexity on work normally associated with these patients. Modifier 66 Surgical Team: Under certain circumstances, highly complex procedures are carried out under the surgical team concept. These circumstances may be identified by each participating individual with the addition of modifier 66. Documentation has to clearly support the individual surgeon as to their involvement in the OR. Modifier 76 Repeat procedure or service by same physician or other qualified Health Care Professional: It may be necessary to indicate that a procedure or service was repeated by the same physician subsequent to the original procedure or service. Modifier 77 Repeat procedure or service by ANOTHER physician or other qualified Health Care Professional: It may be necessary to indicate that a basic procedure or service was repeated by another physician subsequent to the original procedure or service. These modifiers should never be appended to an E/M service. 11
Modifier 78 is used to indicate return trips to the operating room during the global surgery period for complications related to an earlier procedure. The global surgery period is defined according to CMS guidelines, incorporating the postoperative time frames of 0, 10 and 90 days. Medical services performed after an earlier surgery that are unintended or unexpected must be appropriately coded using modifier 78 to avoid unnecessary editing. For procedures with a 10 or 90 day global period, the procedure reported with modifier 78 is reimbursed on the value of the intraoperative care, as noted in the Medicare Fee Schedule. Procedures that have a 0 day global period reported with modifier 78 are not subject to this adjustment. Modifier 79 is used to indicate that a subsequent procedure performed during the global surgery period should be evaluated separately. The global surgery period is defined according to CMS guidelines, incorporating the postoperative time frames of 0, 10 and 90 days. Medical services performed during the postoperative period that are not associated with the earlier surgery must be appropriately coded using modifier 79 to avoid unnecessary editing. Using modifiers 80, 81, 82: Assistant at surgery: Modifier 80, assistant at surgery. This includes MD, DO, and DPM provider types and is an assistant surgeon providing full assist to the primary surgeon. Modifier 81, minimal assistant at surgery. This includes MD, DO, and DPM provider types and is an assistant surgeon providing minimal assistance to the primary surgeon. This modifier may be used when more than one assistant is involved or if one person assists during a portion of the surgery. This modifier is not intended for use by non physician assistants (e.g., RN, PA). Modifier 82, assistant at surgery when a qualified resident surgeon is not available to assist the primary surgeon. This includes MD, DO, and DPM provider types. HCPCS Level II modifier AS, a non physician assistant at surgery. This would include PA, CNS, CRNFA, RNFA, NP, LPN, DDS, DMD, and surgical technician provider types, subject to contract eligibility. 12
Modifier 59 Modifier 59 may be appended when procedures not typically reported together needed to be performed on a patient on the same day by the same physician, such as separate incisions or procedures done on different organ systems. Modifier 59 should not be used unless other modifiers do not apply. Modifier 59 MLN Matters number MM8863 (included in your handouts): The Medicare National Correct Coding Initiative (NCCI) has Procedure to Procedure (PTP) edits to prevent unbundling of services, and the consequent overpayment to physicians and outpatient facilities. The underlying principle is that the second code defines a subset of the work of the first code. Reporting the codes separately is inappropriate. Separate reporting would trigger a separate payment and would constitute double billing. Modifier 59 CMS has established 4 new HCPCS to define specific subsets of the Modifier 59 which were effective 1 1 2015: XE Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter, XS Separate Structure, A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure, XP Separate Practitioner, A Service That Is Distinct Because It Was Performed By A Different Practitioner, and XU Unusual Non Overlapping Service, The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service. 13
Modifier 59 While CMS will continue to recognize the 59 modifier in many instances, it may selectively require a more specific X{EPSU} modifier for billing certain codes at high risk for incorrect billing. For example, a particular NCCI PTP code pair may be identified as payable only with the XE separate encounter modifier but not the 59 or other X{EPSU} modifiers. The X{EPSU} modifiers are more selective versions of the 59 modifier so it would be incorrect to include both modifiers on the same line. Modifier 59 However, please note that these modifiers are valid even before national edits are in place. MACs are not prohibited from requiring the use of selective modifiers in lieu of the general 59 modifier, when necessitated by local program integrity and compliance needs. Modifier 59 Use of these modifiers vs. modifier 59 Do not use one of these modifiers with modifier 59 on the same claim line. According to CPT guidelines, modifier 59 should be used only when no other descriptive modifier explains why distinct procedural circumstances exist. Therefore, these new modifiers should be used instead of modifier 59 to describe why a service is distinct. The CPT definition for modifier 59 has also been revised with a notation that references using these new Level II HCPCS modifiers 14
Modifier 59 Medical Affairs Response: BCBSM will be accepting the new modifiers indicated below for the same procedures currently eligible for modifier 59. We do expect to receive additional CMS program guidance in the future, regarding the Distinct Procedural Services, at which time we will discuss further with our physician staff to determine if additional changes would be required. However, unless or until CMS provides additional guidance on selective editing or any guidance wherein modifier 59 is given additional restrictions for its use, we will continue to edit the same as 59 currently does in CXT today. Modifier 59 BCN take on changes to utilization of Modifier 59: Modifier 59 is not required to override the edit between procedure code *11100 and any of the following codes: *11040 *11042, *11055 *11057, *11200, *11300 *11301, *11305, *11307, *11310, *16000, *16020, *17000, *17250 and *17260. Reporting modifier 59 with *11100 and any of these codes could result in an incorrect reduction in reimbursement. Procedure code *11100 and any of the listed codes will process without a modifier. (This applies to all BCN products except BCN Advantage and BCN 65.) Modifier 59 for BCN continued When reporting another injection along with an immunization, you must report modifier 59 on the injection procedure. If both services are provided and modifier 59 is not indicated, an edit may occur between the injection administration code and the immunization administration code. For its commercial membership, BCN recognizes modifier 59 as valid but does not allow it to automatically override all edits allowed in the National Correct Coding Initiative Manual. The codes for which modifier 59 will override appropriate edits and increase payment are listed in the Addendum in this document. (The Addendum applies to all BCN products except BCN Advantage and BCN 65. For BCN Advantage, the CMS listing is followed.) 15
Modifier 59 insight from Priority Health Effective Jan. 1, 2015, four new modifiers will more effectively identify distinct services that are typically considered inclusive to another service. Utilizing these modifiers will assist in more accurate coding that better describes the procedural encounter. These modifiers, collectively known as X {ESPU}, will be accepted for all lines of business on both professional and facility claims. See more at: http://www.priorityhealth.com/provider/manual/billing andpayment/modifiers/xe xs xp xu#sthash.mxm30ofu.dpuf Modifier 59 insight from Priority Health Documentation requirements: As always, providers must maintain adequate documentation in the medical record. Documentation must support the modifier use for separate services. Although one of these modifiers may be appended to a claim line on first submission, this does not guarantee reimbursement for these services. Medical records may be required to validate use of modifier. Addenda or amendments to the documentation will not be accepted after a claim has been denied. If a claim line is denied due to a clinical edit and you submit a corrected claim using modifier XU, XS, XP, or XU for that claim line, we will require medical records in order to process the corrected claim. Modifier 59 insight from Priority Health CPT codes that require medical records when submitted with X modifiers: Cardiovascular system 36215 36218, 38220 Digestive system 44005, 45378, 45380, 45381, 49000, 49320 Integumentary system 11055 11057, 19120, 19125, 19260, 19290, 19291, 19295, 19301, 19303, 19307, 19316, 19318, 19325, 19328, 19330, 19340, 19357, 19361, 19370, 19371, 19380 Urinary/reproductive systems 52000, 52310, 57100, 57268, 58555, 58660 16
Modifier 59 insight from Priority Health CPT codes that require medical records when submitted with X modifiers: Musculoskeletal system 20600, 20604 20606, 20610, 20650, 20670, 20680, 22214, 22224, 22425, 22505, 22520, 22521 22524, 22551, 22552, 22554, 22585, 22600, 22610, 22612, 22614, 22630, 22633, 22634, 22800, 22802 22804, 22830, 22842, 22845, 22846, 22848, 22850 22852, 22855, 23700, 24300, 25259, 26340, 27570, 27860, 28110, 28230, 28232, 28310, 28725, 29805 29807, 29821 29824, 29870, 29884 Nervous and ENT systems 63005, 63012, 63030, 63035, 63042, 63045 63048, 63055 63057, 63075, 63076, 63081, 63082, 69210, 69990 These are for the ASC reporting only: When a surgical or diagnostic procedure is discontinued, modifier 73 or 74 is required in order to administer payment appropriately. Modifier 73 is reported when the surgical or diagnostic procedure was discontinued before the anesthesia was administered. Modifier 74 is reported when the surgical or diagnostic procedure was discontinued after the anesthesia was administered. Who am I? Kathy Jo Uecker CMPE, EFPM, NCP, CPC, COC AHIMA trained for ICD 10CM/PCS AHIMA Ambassador Medical Informatics Solutions, LLC Phone 248/851 3124 Ext 109 Mobile 269/420 9404 Kuecker@mis llc.com 17