Original Effective Date: July 7, 2009 Revision Date: February 1 st, 2014 MODIFIERS Policy s are used to increase accuracy in recording patient encounters and compensation. A modifier provides the means by which a provider can report or indicate that the service rendered has been altered by one or more specific circumstances, but does not change the service definition or code. Neighborhood Health Plans accepts all standard CPT and HCPCS modifiers submitted in accordance with the appropriate CPT or HCPCS procedure code(s). Certain modifiers, when submitted appropriately, will impact compensation. The absence of the appropriate modifier or the use of an inappropriate modifier may result in a claim denial. Policy Limitations This policy applies to all places of service in accordance with the National POS code set in conjunction with AMA guidelines, NCCI guidance, and state requirements where applicable. Member Cost Sharing The provider is responsible for verifying at each encounter and when applicable for each day of care when the patient is hospitalized, coverage, available benefits, and member out-of-pocket costs; copayments, coinsurance, and deductible required, if any. Neighborhood Health Plan suggests that providers do not bill the member for services prior to adjudication of claim(s) in order for the accurate member responsibility to be calculated. Any member responsibility for copayments, coinsurance, and/or deductible will be reflected on the Explanation of Payment (EOP) and the member s Explanation of Benefits (EOB). Service Limitations use is subject to the requirements set forth in this policy, in conjunction with NHP s Provider Manual when applicable. Anesthesia s Physicians must report the appropriate anesthesia modifier to indicate by whom the service was performed. Reimbursement AA Anesthesia service personally performed by physician 100% of anesthesia contract allowable AD QK QX Medical supervision by a physician for more than 4 concurrent procedures Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals CRNA service with medical direction by a physician 3 ASA base units at anesthesia contract allowable Neighborhood Health Plan 1 Provider Payment Guidelines
Anesthesia s (continued) Reimbursement QY Medical direction of one Certified Registered Nurse Anesthetist by an Anesthesiologist QZ CRNA service; without medical Not a covered service direction by a physician 47 Anesthesia performed by surgeon No additional reimbursement for anesthesia by a surgeon, assistant surgeon, nursing staff or any other non-anesthesiologist professional during a procedure P1-P6 Physical Status s No additional reimbursement 22 (Increased Procedural Services) NHP requires medical documentation when claims are submitted with modifier 22. Claims submitted without additional documentation will not considered for additional compensation. 22 should not be used in the following circumstances: Increased procedure complexity due to a surgeon s choice of approach When submitting the surgery using an unspecified procedure code 25 (Significant, Separately Identifiable E/M Service) NHP reimburses participating providers for the provision of medically necessary evaluation and management (E/M) services billed with -25 in accordance with National Correct Coding Initiative (NCCI) when the member s medical records indicate that a significant, separately identifiable service was performed on the same day. Category Preventive Medicine and Problem-Focused E/M Services Multiple Problem Focused E/M Services E/M Services within a Global Period Comments Reimbursement will be made for two different E/M services on the same day, only when a provider submits a problem-focused office visit procedure code with a preventive medicine procedure code and the appropriate modifier is appended to the problem-focused service code; modifier discount may apply. If the appropriate modifier is not submitted, the problem-focused visit will be denied as included in the preventive medicine visit. Reimbursement will be made for more than one E/M procedure code for a single date of service when such services are rendered by providers, including mid-level practitioners, of different specialties. Only one E&M service is allowed for a single date of service for the same provider group (same TIN#) and same specialty regardless of the place of service. Reimbursement will be made for E/M services rendered during the global period when the service is distinct and unrelated to the primary procedure, and supported in the member s medical record. Critical Care Services Reimbursement will not be made for any E/M service when billed with a critical care service. Neighborhood Health Plan 2 Provider Payment Guidelines
Service Limitations (continued) 33 (Preventive Services) 33 should be appended to the listed CPT/HCPCS codes contained in the U.S. Preventive Services Task Force List which have a category A or category B rating. Please refer to NHP s Preventive Services Provider Payment Guideline for a comprehensive list of services and codes. https://www.nhp.org/provider/paymentguidelines/preventive_services.pdf 59 (Distinct Procedural Service) 59 should be appended to identify procedures and/or services that are distinct and unrelated. Medical record documentation must clearly support the different session and/or procedure, not normally performed on the same day by the same physician and/or group. 59 should only be used in absence of a more descriptive modifier and does not alter the reimbursement impact when billed in conjunction with another modifier. 59 is not allowed to be used when reporting multiple E/M services, please see 25. Tables 1 The following modifier tables are intended to provide guidance in proper use of modifiers. The following modifiers can impact reimbursement. Reimbursement Impact/Comments 22 Increased Procedural Services 120% of fee schedule allowable after medical record review 24 Unrelated E&M service by same physician during post- op period 100% of contract allowable amount only when the service and diagnosis are not related to the surgical procedure May require medical record review 25 Significant, separately identifiable E&M Please -25 details service by same physician on same day of procedure or service 26 Professional Component Professional component of allowed amount 32 Mandated Services Not covered 33 Preventive Service Please see 33 details 50 Bilateral procedure 150% of contract allowable 51 Multiple procedure 50% of the contract allowable, unless otherwise specified. 52 Reduced Services 53 Discontinued Procedure 25% of fee schedule allowable 54 Surgical care, only 75% of fee schedule allowable 1 tables may not be all inclusive Neighborhood Health Plan 3 Provider Payment Guidelines
Tables (continued) Reimbursement Impact/Comments 55 Post-op management, only 25% of contract allowable 56 Pre-op management, only 25% of contract allowable 59 Distinct procedural service Please see 59 details 62 Two Surgeons 62.5% of contract allowable 66 Surgical Team 62.5% of contract allowable Medical documentation is required 73 Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC) Procedure Prior to the Administration of Anesthesia. 74 Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC) Procedure After Administration of Anesthesia 78 Unplanned return to OR for related procedure during post-op period 75% of contract allowable 80 Assistant Surgeon 16% of contract allowable 81 Minimum Assistant Surgeon 16% of contract allowable 82 Assistant Surgeon (when qualified 16% of contract allowable resident surgeon not available) AS Physician assistant, nurse practitioner, or 16% of contract allowable clinical nurse specialist as assistant-atsurgery GM Multiple patients on one ambulance trip QK QX Medical direction of 2, 3, or 4 concurrent anesthesia procedures involving qualified individuals CRNA service with medical direction by a physician QY Medical direction of one Certified Registered Nurse Anesthetist by an Anesthesiologist SL State Supplied Vaccine No reimbursement Append to Vaccine code Neighborhood Health Plan 4 Provider Payment Guidelines
Tables (continued) The following modifiers should be appended when submitting claims for Early Intervention services. AH AJ GN GO GP HN TD TJ Clinical Psychologist Clinical Social Worker Services delivered under an outpatient speech pathology plan of care Services delivered under an outpatient occupational therapy plan of care Services delivered under an outpatient physical therapy plan of care Bachelor s degree level RN Program group, child and/or adolescent The following modifiers should be appended when submitting claims for Durable Medical Equipment/Disposable Medical Equipment supplies and/or items. KH Use for first month rental of capped rental items KI Use for 2nd and 3rd month rental of capped rental items KJ Use for months 4 to 13 for rental of capped rental items KR Rental item, partial month Bill (1) unit = (1) day rental Billed charges must reflect daily charge MS 6 months maintenance/servicing fee, reasonable necessary parts and labor which are not covered under any manufacturer or supplier warranty NU New Equipment RR Rental Item The following modifiers are required to be appended when reporting Serious Reportable Events (SRE). Please also refer to the Serious Reportable Events & Provider Preventable Conditions Provider Payment Guideline at https://www.nhp.org/provider/paymentguidelines/serious_reportable_events_7-2012.pdf PA Surgical or other invasive procedure on wrong body part PB Surgical or other invasive procedure on wrong patient PC Wrong surgery or other invasive procedure on patient Neighborhood Health Plan 5 Provider Payment Guidelines
Tables (continued) The following modifiers should be appended when submitting claims for Ambulance transport claims. Use a combination of codes to make a two-digit modifier to report services. The first digit indicates the place of origin and the second digit indicates the destination. D E G H I Diagnostic/therapeutic site other than P or H Residential, domiciliary, custodial facility (nursing home, not skilled nursing facility) Hospital-based dialysis facility (hospital or hospital related) Hospital Site of transfer (e.g. airport or helicopter pad) between types of ambulance J N P R S X Non-hospital based dialysis facility Skilled nursing facility (SNF) Physician s office (includes HMO nonhospital facility, clinic, etc.) Residence Scene of accident or acute event Intermediate stop at physician s office en-route to hospital (includes HMO nonhospital facility, clinic, etc.) The following modifiers are required when reporting Developmental Testing services, and should be appended to CPT 96110. U1 U2 U3 U4 screening tool with no behavioral health need identified when administered by a physician, independent nurse midwife or independent nurse practitioner. screening tool and a behavioral health need was identified when administered by a physician, independent nurse midwife or independent nurse practitioner. screening tool with no behavioral health need identified when administered by a nurse midwife screening tool and a behavioral health need was identified when administered by a nurse midwife Neighborhood Health Plan 6 Provider Payment Guidelines
Tables (continued) U5 U6 U7 U8 screening tool with no behavioral health need identified when administered by a nurse practitioner screening tool and a behavioral health need was identified when administered by a nurse practitioner screening tool with no behavioral health need identified when administered by a physician assistant screening tool and a behavioral health need was identified when administered by a physician assistant Through the 340B Drug Pricing Program, providers qualifying as 340B-covered entities are able to acquire drugs at significantly discounted rates, and are not eligible for the Medicaid Drug Rebate Program. The following modifier is required to be reported when submitting claims for qualifying 340B Drugs. NHP is required to report on all claims which are submitted as 340B qualifying. UD Physician-administered 340B drugs in an office or clinical setting The following modifiers are use to report site specific services. E1-E4 FA-F9 TA-T9 RT LT LD RC Eyelids Fingers Toes Right Left Left anterior descending coronary artery Right coronary artery Neighborhood Health Plan 7 Provider Payment Guidelines
Comments Descr AI Principal Physician of Record GC GD GH This service has been performed in part by a resident under the direction of a teaching physician Units of Service exceed medically unlikely edit value and represents reasonable and necessary Diagnostic i mammogram converted from screening mammogram on same day Service is to be billed with modifier under the teaching physicians NPI Medical documentation maybe required Only the diagnostic films will be reimbursed. Applies to HCPCS G0204 and G0206 References Current year, American Medical Association CPT and HCPCS release Publication History Topic: s Owner: Provider Network Management 2009/07/24 Original documentation 2011/05/17 Modifies added, genetic testing code comments, references and disclaimer updated 2011 08 22 Added AI modifier 2013/02/01 Added UD 02/01/2014 Annual update; new format; addition of KR, GD, GH s This document is designed for informational purposes only. Claims payment is subject to member eligibility and benefits on the date of service, coordination of benefits, referral/authorization/notification and utilization management guidelines when applicable, adherence to plan policies and procedures, claims editing logic, and provider contractual agreement. In the event of a conflict between this payment guideline and the provider s agreement, the terms and conditions of the provider s agreement shall prevail. Neighborhood Health Plan utilizes McKesson s claims editing software, ClaimCheck, a clinically oriented, automated program that identifies the appropriate set of procedures eligible for provider reimbursement by analyzing the current and historical procedure codes billed on a single date of service and/or multiple dates of service, and also audits across dates of service to identify the unbundling of pre and post-operative care. Please refer to Neighborhood Health Plan s Provider Manual Billing Guidelines section for additional information on NHP s billing guidelines and administration policies. Questions may be directed to Provider Network Management at prweb@nhp.org. Neighborhood Health Plan 8 Provider Payment Guidelines
Neighborhood Health Plan 9 Provider Payment Guidelines