AAHAM Conference Part A Modifiers Presented by Provider Outreach and Education April 2015
DISCLAIMER This information release is the property of Noridian Healthcare Solutions, LLC. It may be freely distributed in its entirety but may not be modified, sold for profit or used in commercial documents. The information is provided as is without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice. All models, methodologies and guidelines are undergoing continuous improvement and modification by Noridian and CMS. The most current edition of the information contained in this release can be found on the Noridian website at http://www.noridianmedicare.com and the CMS website at http://www.cms.gov The identification of an organization or product in this information does not imply any form of endorsement. CPT codes, descriptors, and other data only are copyright 2015 American Medical Association. All rights reserved. Applicable FARS/DFARS apply. April 2015 2
Upcoming Part A Webinars Date Time (CT) Webinar Title 4/28/15 1:00 PM Rural Health Centers (RHC) 4/29/15 1:00 PM Part A to Part B Rebilling 5/07/15 1:00 PM Modifiers 5/12/15 1:00 PM Utilizing the Benefit Period 5/19/15 1:00 PM Modifiers Register Now! JE https://med.noridianmedicare.com/web/jea/education/training-events JF https://www.noridianmedicare.com/parta/train/workshops/index.html April 2015 3
Upcoming Part A Webinars Date Time (CT) Webinar Title 5/20/15 1:00 PM Comprehensive Outpatient Rehabilitation Factor (CORF) Services 6/11/15 1:00 PM Inpatient Psychiatric Facility (IPF) PPS 6/23/15 1:00 PM Avoiding Common Claim Errors 6/25/15 1:00 PM NCCI/OCE/MUE Register Now! JE https://med.noridianmedicare.com/web/jea/education/training-events JF https://www.noridianmedicare.com/parta/train/workshops/index.html April 2015 4
Agenda Noridian Updates ICD-10 Updates Modifier Basics Provider Specific Modifiers Service Specific Modifiers Other Modifiers Resources April 2015 5
Helpful Acronyms CAH CERT CPT CRNA E&M ER ESA ESRD HCPCS Critical Access Hospital Common Error Rate Testing Current Procedural Terminology Certified Registered Nurse Anesthetist Evaluation and Management Internet Only Manual Erythropoietin Stimulating Agent End Stage Renal Disease Healthcare Current Procedural Coding System April 2015 6
Helpful Acronyms IOM MPFS NCCI OIG OPPS RA ZPIC Internet Only Manual Medicare Physician Fee Schedule National Correct Coding Initiative Office of Inspector General Outpatient Prospective Payment System Recovery Auditor Zone Program Integrity Contractor April 2015 7
Noridian Updates
Self-Paced Training https://www.noridianmedicare.com/parta/train/workshops/archive.html Workshop Archive/Educational Tools Self-Paced Training/Tutorials April 2015 9
Reason Code Guidance https://www.noridianmedicare.com/parta/train/education_center/reason_code_guidance.html April 2015 10
ICD-10 Update
Mapping ICD-9 to ICD-10 Codes for Medical Policies NCDs are on CMS website, including related Change Request http://www.cms.gov/medicare/coverage/coverage GenInfo/ICD10.html Lab NCDs also updated http://www.cms.gov/medicare/coverage/coveragege ninfo/labncdsicd10.html CR 8348 instructed that all ICD-10 LCDs and associated ICD-10 articles were to be published on the Medicare Coverage Database (MCD) no later than April 10, 2014 Policies listed under Future Policies so public has plenty of time to review mappings and provide feedback on concerns April 2015 12
Claims Processing System Readiness Three standard systems used for claims processing: FISS-Part A MCS-Part B VMS-DME Maintained by an outside entity that CMS hires as a the standard system maintainer (SSM) Noridian tests all releases and changes, focusing on local changes (another national contractor also tests) April 2015 13
Endeavor Local Systems Are Ready Diagnosis used in display under claims status and appeals submission April 2015 14
Provider Testing Two types of testing as outlined by CMS: Front-end (acknowledgement testing) Pass EDI front-end edits Determine if codes used are valid End-to-End End-to-end testing takes the testing a step further, processing claims through all Medicare system edits to produce and return an accurate Electronic Remittance Advice (ERA) Testers should be verifying payment or denial Some are looking at payment amounts, especially on Part A claims April 2015 15
Front-End (Acknowledgement Testing) Upcoming Testing June 1-5, 2015 During the designated weeks, CMS is monitoring activities and will report the results Testing can be completed before or after testing week Testing Guidelines: Test files must have the "T" in the ISA15 field to indicate the file is a test file. Send ICD-10 coded test claims that closely resemble claims currently submitted. Use valid submitter ID, NPI, and PTAN combinations. Use current dates of service on test claims Do not use future dates of service or the claim will be rejected April 2015 16
End-to-End Testing MLN Matters 8867 Will receive remittance advice if claims pass front-end edits and are not returned to provider (RTP) by FISS Had to volunteer and register and agree to certain testing conditions Send 50 claims Provide list of provider numbers, Medicare numbers, etc One week to send claims Contractors asked to choose a variety of provider types, provider sizes Had to choose clearinghouses, at least 5, but no more than 15 for each round 50 participants for each contractor will be selected from the volunteers to represent a broad cross-section of provider types, claims types, and submitter types CMS approves selected testers and all approved/non-approved are informed by CEDI/EDI through an email April 2015 17
Results From Round 1 End-to-End Testing 661 participated Approximately 1,400 National Provider Identifiers (NPIs) were registered to test, equally split between direct submitters and clearinghouses/billing agencies Overall, participants in the January 26 to February 3 testing were able to successfully submit ICD-10 claims and have them processed through our billing systems: Reasons for rejected claims: 3% - Invalid submission of ICD-9 diagnosis or procedure code 3% - Invalid submission of ICD-10 diagnosis or procedure code 13% - Non-ICD-10 related errors, including issues setting up the test claims (e.g., incorrect NPI, Health Insurance Claim Number, Submitter ID, dates of service outside the range valid for testing, invalid HCPCS codes, invalid place of service) April 2015 18
Round 3 End-to-End Testing Volunteers must register by April 17, 2015 Testing week will be July 20-24, 2015 Announced on March 13, 2015 Acceptance/non-acceptance notice will be sent by May 8, 2015 April 2015 19
FAQ Will ICD-9 codes be accepted on claims with from DOS of discharge/through dated on or after October 1, 2015? No What will happen to claims containing ICD-9 codes for services on or after October 1, 2015? Direct data entry institutional claims return to provider Paper claims reject as unprocessable Electronic claims reject front-end or as unprocessable April 2015 20
FAQ[2] Can a claim contain both ICD-9 & ICD-10 codes? No, however submitters can do a mix of ICD-9 and ICD-10 in the same electronic claim file Can ICD-10 codes be used on claims prior to October 1, 2015? No. April 2015 21
CMS ICD-10 Resources CMS www.cms.gov/icd10 CMS ICD-10-CM/PCS the next generation in coding www.cms.gov/medicare/coding/icd10/downloads/icd- 10Overview.pdf ICD-10-CM Classification Enhancements www.cms.gov/medicare/coding/icd10/downloads/icd- 10QuickRefer.pdf September 2013 ICD-10-CM/PCS billing and payment frequently asked questions www.cms.gov/outreach-and-education/medicare-learning- Network-MLN/MLNProducts/Downloads/September-2013-ICD-10- CM-PCS-Billing-Payment-FAQs-Fact-Sheet-ICN908974.pdf April 2015 22
Noridian ICD-10 Resources Part A JF www.noridianmedicare.com/parta/news/docs/i cd10_update.html EDISS ICD-10 web page http://www.edissweb.com/blue/news/icd10- coming.html Road to 10 http://www.roadto10.org/ April 2015 23
Modifiers Basics
Modifier Basics Two digit codes appended to CPT/HCPCS codes Provide additional information about CPT/HCPCS codes Required on some services May Directly/indirectly affect payment May be Informational Only April 2015 25
Ambulance Modifiers
Ambulance Origin/Destination Modifiers D Diagnostic / therapeutic site (other than P / H) ASC and IDTF E Residential, domiciliary, custodial facility, assisted living G Hospital-based dialysis facility (ESRD) H Hospital I J Site of transfer (airport, helicopter pad) Non hospital-based dialysis facility (ESRD) April 2015 27
Ambulance 2 Origin/Destination Modifiers N Skilled nursing facility (swing bed) P Physician s office (freestanding ER non-hospital based, urgent care, clinics) R Residence (private only) S Scene of accident or acute event (origin only) U Unclassified ambulance service X Intermediate stop at physician s office on way to hospital (destination only) April 2015 28
Ambulance 3 Additional Modifiers QL Patient pronounced dead after ambulance called QM Ambulance service provided under arrangement by a provider of services QN Ambulance service provided directly by a provider of services TQ Basic life support transport by a volunteer ambulance provider April 2015 29
Anatomical Modifiers
Eyelids Used when a surgical or diagnostic procedure are performed: E1 E2 E3 E4 Service was performed on upper left eyelid Service was performed on lower left eyelid Service was performed on upper right eyelid Service was performed on lower right eyelid April 2015 31
Hand Modifiers Left Hand FA Left hand, thumb F1 Left hand, second digit F2 Left hand, third digit F3 Left hand, fourth digit F4 Left hand, fifth digit Right Hand F6 Right hand, second digit F7 Right hand, third digit F8 Right hand, fourth digit F9 Right hand, fifth digit April 2015 32
Foot Modifiers Left Foot TA Left foot, great toe T1 Left foot, second digit T2 Left foot, third digit T3 Left foot, fourth digit T4 Left foot, fifth digit Right Foot T5 Right foot, great toe T6 Right foot, second digit T7 Right foot, third digit T8 Right foot, fourth digit T9 Right foot, fifth digit April 2015 33
Right vs. Left side modifiers LC Left circumflex coronary artery LM Left main coronary artery LT Left Side RC Right coronary artery RI Ramus intermedius coronary artery RT Right Side April 2015 34
Critical Access Hospital (CAH)
Anesthesia AA Anesthesia services performed personally by an anesthesiologist QY Medical direction of one CRNA/AA (Anesthesiologist's Assistant) by an anesthesiologist QK Medical direction by a physician of two, three, or four concurrent anesthesia procedures QZ CRNA service without medical direction by a physician. April 2015 36
HPSA/PSA Modifiers AQ For dates of service on or after January 1, 2006, physician providing a service in an unlisted health professional shortage area (HPSA) should report this modifier. AR For dates of service on or after January 1, 2005, physician providing services in an unlisted physician scarcity area (PSA) should report this modifier. April 2015 37
PQRS Modifiers 1P 2P Performance Measure Exclusion Modifier due to Medical Reasons. Includes: Not Indicated (absence of organ/limb, already received/performed, other); Contraindicated (patient allergic history, potential adverse drug interaction, other). Performance Measure Exclusion Modifier due to Patient Reasons: Includes: Patient declined; economic, social, or religious reasons; other patient reasons. http://www.cms.gov/medicare/quality-initiatives-patient-assessment- Instruments/PQRS/How_To_Get_Started.html April 2015 38
PQRS Modifiers2 3P 8P Performance Measure Exclusion Modifier due to System Reasons includes. Includes: Resources to perform the services not available; insurance coverage/payer-related limitations; other reasons attributable to health care delivery system. Performance Measure Reporting Modifier. This modifier facilitates reporting a case when the patient is eligible but an action described in a measure is not performed and the reason is not specified or documented. MLN 5640 April 2015 39
Practitioner Modifiers AI AE AH AK GC Principal Physician of Record. CAHs report this modifier to identify the primary physician overseeing the patient's care from other physicians who may be furnishing specialty care. Services rendered in a CAH by a nutrition professional/registered dietician. Services rendered in a CAH by a clinical psychologist. For a non-participating physician service, a CAH must place modifier AK on the claim. This service has been performed in part by a resident under the direction of a teaching physician. April 2015 40
Practitioner Modifiers2 GF SB Services rendered in a CAH by a nurse practitioner (NP), clinical nurse specialist (CNS), certified registered nurse (CRN) or physician assistant (PA). (The GF modifier is not to be used for certified registered nurse anesthetist (CRNA) services. If a claim is received and it has the GF modifier for CRNA services, the claim is returned to the provider.) Also, while this national GF modifier includes CRNs, there is no benefit under Medicare law that authorizes payment to CRNs for their services. Accordingly, if a claim is received and it has the GF modifier for CRN services, no Medicare payment should be made. For dates of service prior to January 1, 2011, bill this modifier to represent services by a certified nurse-midwife. April 2015 41
Practitioner Modifiers3 62 Two surgeons. When two surgeons work together as primary surgeons performing distinct part(s) of a single reportable procedure, each surgeon should report his/her distinct operative work by adding the modifier 62 to the single distinct procedure code. Each surgeon should report the cosurgery once using the same procedure code. If additional procedure(s) (including add-on procedures) are performed during the same surgical session, separate codes may be reported without the modifier 62 added. Note: If a co-surgeon acts as an assistant in the performance of additional procedure(s) during the same surgical session, those services may be reported using separate procedure code(s), with modifier 80 or modifier 81 added, as appropriate. April 2015 42
Practitioner Modifiers4 80 Assistant surgeon 81 Minimum Assistant Surgeon 82 Assistant Surgeon (when qualified resident surgeon not available) AS Physician Assistant, Nurse Practitioner, or Clinical Nurse Specialist services for assistant-at-surgery, nonteam member. April 2015 43
Telehealth Telehealth codes G0108, G0109, G0420, G0421, 96153, 96154, 97804, 99231 99233, 99307 99310 GQ Telehealth service rendered via asynchronous telecommunications system GT Telehealth service rendered via interactive audio and video telecommunications system Change Request 7049 April 2015 44
Clinical Trail, Device and Drug Modifiers
Clinical Trail Modifiers Q0 (zero) Investigational clinical service provided in a clinical research study that is in an approved clinical research study. Report Modifier Q0 (zero) on Category B Investigational Device Exemption (IDE) code along with the IDE number on the claim. Q1 Routine clinical service provided in a clinical research study that is in an approved clinical research study. The Q1 modifier must be billed in conjunction with diagnosis code ICD-9 code V70.7 or ICD-10 code Z00.6, effective September, 28, 2009. April 2015 46
Device Modifiers FB FC Item provided without cost to provider, supplier or practitioner, or credit received for replaced device (e.g. under warranty, replaced due to defect, free samples) FB cannot be submitted with FC. Partial credit received for replacement device. FC cannot be submitted with FB. April 2015 47
Drug Modifier JW Drug amount discarded/not administered to any patient. JW modifier is required for any claims with discarded drugs. April 2015 48
End Stage Renal Disease (ESRD)
ESRD Modifiers AY EM ED EE Item or service furnished to an ESRD patient that is not for the treatment of ESRD. Emergency reserve supply for ESRD benefit only. In the event that the schedule was changed, the provider should note the changes in the medical record and bill according to the revised schedule. For patients beginning to self-administer an Erythropoietin Stimulating Agent (ESA) at home receiving an extra month supply of the drug, bill the one month reserve supply on one claim line and include modifier EM. Hematocrit level has exceeded 39% (or hemoglobin level has not exceeded 13.0 g/dl) for 3 or more consecutive billing cycles immediately prior to and including the current cycle Hematocrit level has not exceeded 39% (or hemoglobin level has not exceeded 13.0 g/dl) for 3 or more consecutive billing cycles immediately prior to and including the current cycle April 2015 50
GS G1 ESRD Modifiers2 Dosage of Epoetin Alfa (EPO) or Darbepoietin Alfa has been reduced and maintained in response to hematocrit or hemoglobin level. Most recent Urea Reduction Ration (URR) reading of less than 60% G2 Most recent URR reading of 60% to 64.9% G3 Most recent URR reading of 65% to 69.9% G4 Most recent URR reading of 70% to 74.9% G5 G6 Most recent URR reading of 75% or greater ESRD patient for whom less than seven dialysis sessions have been provided in a month. April 2015 51
ESRD Modifiers3 JA Effective for claims with dates of services on or after January 1, 2012, all facilities billing for injections of ESA for ESRD beneficiaries administered intravenously. JB Effective for claims with dates of services on or after January 1, 2012, all facilities billing for injections of ESA for ESRD beneficiaries administered subcutaneously JE Administered via dialysate - Append the JE modifier to all ESRD claims where drugs and biologicals are furnished to ESRD beneficiaries via the dialysate solution on claims with dates of service on or after July 1, 2013. April 2015 52
ESRD Modifiers4 Q3 Liver Kidney Donor Surgery and Related Services. All covered services (both institutional and professional) for complications from a Medicare covered transplant that arise after the date of the donor s transplant discharge will be billed under the recipient s health insurance claim number and are billed to the Medicare program in the same manner as all Medicare Part B services are billed. Internet Only Manual (IOM), Medicare Claims Processing Manual, Publication 100-04, Chapter 3, Section 90 April 2015 53
ESRD Modifiers5 V5 V6 V7 V8 Vascular catheter (alone or with any other vascular access) Arteriovenous graft (or other vascular access not including a vascular catheter in use with two needles) Arteriovenous Fistula Only (in use with two needles) Dialysis access - related infection present (documented and treated) during the billing month. Reportable dialysis access-related infection is limited to peritonitis for peritoneal dialysis patients or bacteremia for hemodialysis patients. Facilities must report any peritonitis related to a peritoneal dialysis catheter, and any bacteremia related to hemodialysis access (including arteriovenous fistula, arteriovenous graft, or vascular catheter) if identified during the billing month. For individuals that receive different modalities of dialysis during the billing month and an infection is identified, the V8 code should only be indicated on the claim for the patient s primary dialysis modality at the time the infection was first suspected. Non-access related infections should not be coded as V8. If no dialysis-access related infection is present during the billing month by this definition, providers should instead report modifier V9. April 2015 54
ESRD Modifiers6 V9 No dialysis-access related infection, as defined for modifier V8, present during the billing month. Dialysis access-related infection, defined as peritonitis for peritoneal dialysis patients or bacteremia for hemodialysis patients must be reported using modifier V8. Providers must report any peritonitis related to a peritoneal dialysis catheter, and any bacteremia related to hemodialysis access (including arteriovenous fistula, arteriovenous graft, or vascular catheter) using modifier V8. April 2015 55
Evaluation & Management (E&M) Modifiers
E&M Modifiers 25 Significant, separately identifiable E&M service by the same physician on the same day as the procedure or other service. The physician may need to indicate that on the day a procedure or service was performed, the patient s condition required a significant, separately identifiable E&M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed. The E&M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E&M services on the same date. This circumstance may be reported by adding the modifier 25 to the appropriate level of E&M service. 27 Multiple Outpatient Hospital E&M Encounters on the Same Day. Hospitals may append modifier 27 to the second and subsequent E&M code when more than one E&M service is provided to indicate that the E&M service is "separate and distinct E&M encounter" from the service previously provided that same day in the same or different hospital outpatient setting. When reporting modifier 27, report with condition code G0 (zero) when multiple medical visits occur on the same day in the same revenue centers. April 2015 57
Laboratory Modifiers Medicare Claims Processing Manual, Publication 100-04, Chapter 16
Laboratory Modifiers 90 Reference lab. Used to indicate a lab test was sent to a referral (outside) lab, e.g., lab procedure performed by a party other than the treating or reporting laboratory. 91 Repeat clinical diagnostic laboratory test. In the course of treatment of the patient, it may be necessary to repeat the same laboratory test on the same day to obtain subsequent (multiple) test results. Under these circumstances, the laboratory test performed can be identified by its usual procedure number and the addition of the modifier 91. Note: This modifier may not be used when test are rerun to confirm initial results; due to testing problems with specimens or equipment; or for any other reason when a normal, one-time, reportable result is all that is required. This modifier may not be used when other code(s) describe a series of test results (e.g., glucose tolerance test, evocative/suppression testing). This modifier may only be used for laboratory test(s) performed more than once on the same day on the same patient. April 2015 59
Laboratory Modifiers ET Attestation that the laboratory test(s) were ordered in conjunction with emergency treatment. For hospital claims with dates of service on or after April 1, 2012, for services rendered to ESRD beneficiaries that include an emergency room service with revenue code 04Xx on a line item date that differs from the line item date of service for the related laboratory test(s) the hospital must include the modifier ET to attest that the laboratory test(s) were ordered in conjunction with the emergency services. This is necessary to recognize that emergency services often span two calendar days. For hospital claims for services rendered to beneficiaries in a Skilled Nursing Facility (SNF) where services related to the Emergency Room (ER) encounter span more than one service date, hospitals must identify those services by appending a modifier ET to those line items. The reporting of the ET modifier will alert Common Working File (CWF) that these are related ER services performed on subsequent dates so the SNF Consolidated Billing (CB) edits in CWF will be bypassed. April 2015 60
Laboratory Modifiers L1 QP Provider Attestation that the Hospital Laboratory test(s) is not packaged under Outpatient Prospective Payment System (OPPS). Panel test. Documentation is on file showing that the laboratory test(s) was ordered individually or ordered as a CPT recognized panel other than automated profile codes 80002-80019, G0058, G0059, and G0060. Medicare Claims Processing Manual, Publication 100-04, Chapter 16 April 2015 61
Outpatient Rehabilitation (Therapy) Modifiers
Outpatient Therapy GN GO GP CH CI Service delivered under an outpatient speech language pathology plan of care Service delivered under an outpatient occupational therapy plan of care Service delivered under an outpatient physical therapy plan of care 1 percent impaired, limited or restricted. Therapy Severity/Complexity Modifiers. Therapy Severity/Complexity Modifier. At least 1 percent but less than 20 percent impaired, limited or restricted. Therapy Severity/Complexity Modifier. April 2015 63
Outpatient Therapy CJ CK CL CM CN At least 20 percent but less than 40 percent impaired, limited or restricted. Therapy Severity/Complexity Modifier. At least 40 percent but less than 60 percent impaired, limited or restricted. Therapy Severity/Complexity Modifier. At least 60 percent but less than 80 percent impaired, limited or restricted. Therapy Severity/Complexity Modifier. At least 80 percent but less than 100 percent impaired, limited or restricted. Therapy Severity/Complexity Modifier. At least 100 percent limited or restricted. Therapy Severity/Complexity Modifier. April 2015 64
Outpatient Therapy KX Therapy exceeds the therapy financial limitation or therapy cap and qualifies for the therapy cap exception. Providers should add the KX modifier to each claim line for an outpatient therapy service procedure when the beneficiary is qualified for exception to the therapy caps through either the automatic process or the manual process of exception. Providers should not add the KX modifier to line items that would not be eligible for exception if the service was provided after the cap is reached. That is, if the services would require a manual exception if the cap is exceeded and that exception has not yet been approved, providers should not bill for that service using the KX modifier. April 2015 65
Surgery Modifiers
Modifier 50 Used when billing bilateral procedure Bill on 1 line April 2015 67
Modifier 51 Multiple procedures other than E&M performed at same session, by same physician on same patient on same day Do not use with add on codes Do not use on all claim lines of service Not required for billing, Noridian will append if necessary April 2015 68
Modifier 52 Partially Reduced or Eliminated Services Should be used: When charge is reduced Not performing all services indicated in CPT description Services were modified from normal service due to physician s decision When documentation supports normal complete service was not provided Should not be used: For discontinued services When patient can not afford full services On time based codes With E&M services April 2015 69
Modifier 59 - Clarification Distinct procedural service on same DOS by same physician Different anatomical sites Different sides of body Different procedure, or Different session Still valid modifier but not as repeat modifier Refer to IOM Pub. 100-04, Ch. 1, Sec. 120 Check CCI-Edits list Indicator 1 - allows for unbundling Indicator 0 cannot unbundle codes April 2015 70
Example of Modifier 59 Column 1 CPT 17000, Column 2 CPT 11000 Modifier indicator lists 1 (allowed) Column1/Column 2 Edits Column 1 Column 2 * = In existence prior to 1996 Effective Date Deletion Date *=no data Modifier 0=not allowed 1=allowed 9=not applicable 17000 11000 19980401 * 1 Modifier 59 is appended to Column 2 CPT code April 2015 71
X Modifier Subset of 59 Modifier XE XP XS XU Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter. Separate Practitioner, A Service That Is Distinct Because It Was Performed By A Different Practitioner. Separate Structure, A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure. Unusual Non-Overlapping Service, The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service. April 2015 72
Modifier 73 Discontinued out-patient hospital procedure prior to the administration of anesthesia Used to indicate a procedure requiring anesthesia was terminated due to extenuating circumstances or do to circumstances that threatened the well-being of patient after patient had been prepared for procedure (including procedural pre-medication when provided), and been taken to the room where procedure was to be performed, but prior to administration of anesthesia. CMS Internet Only Manual (IOM), Medicare Claims Processing Manual, Publication 100-04, Chapter 4, Section 20.6.4 April 2015 73
Modifier 74 Discontinued out-patient hospital procedure after administration of anesthesia. Used by facility to indicate that a procedure requiring anesthesia was terminated after the induction of anesthesia or after the procedure was started (e.g., incision made, intubation started, scope inserted) due to extenuating circumstances or circumstances that threatened the well-being of the patient. This modifier may also be used to indicate that a planned surgical or diagnostic procedure was discontinued, partially reduced or cancelled at the physician's discretion after the administration of anesthesia. CMS Internet Only Manual (IOM), Medicare Claims Processing Manual, Publication 100-04, Chapter 4, Section 20.6.4 April 2015 74
Modifier 76 Repeat procedure by same physician Can be used for x-rays and Injections Does not replace modifiers: RT, LT, 50, E1-E4, FA, F1-F9, TA, T1-T9 If billing procedure code two or more times for same date of service: First line CPT with no modifier Second and subsequent lines CPT with modifier 76 April 2015 75
Modifiers 77 77 Repeat procedure by another physician Add modifier to repeated service Can also be used for x-rays and injections Does not replace modifiers: RT, LT, 50, E1-E4, FA, F1-F9, TA, T1-T9 April 2015 76
Modifier 78 Return to operating room for a related procedure during postoperative period Original surgery code can only be used when identical procedure is repeated Complications must be documented Example 1: Date of Service Treatment CPT/Modifier Example 2: 1/24/15 Coronary artery bypass 33514 2/5/15 Explore chest wall 35820-78 Date of Service Treatment CPT/Modifier 1/10/15 Fractured femur repair 27470 1/12/15 Bone Abscess or Osteomyelitis 27303-78 April 2015 77
Other Modifiers
Hospital-Based Providers PO Services, procedures, and/or surgeries furnished at off-campus provider-based outpatient departments April 2015 79
Erythropoiesis Stimulating Agents (ESAs) All non-esrd claims billing HCPCS J0881 and J0885 must begin reporting one (and only one) of the following modifiers on same claim as ESA HCPCS: EA ESA, anemia, chemotherapy induced EB ESA, anemia, radiotherapy induced EC ESA, anemia, non-chemo/radio MLN 5699 April 2015 80
Other Modifiers CA Procedure payable only in the inpatient setting when performed emergently on an outpatient who expires prior to admission. The presence of modifier CA on the inpatient-only procedure line assigns the specified payment Ambulatory Payment Classification (APC) and associated status and payment indicators to the line. The packaging flag is turned on for all other lines on that day. Payment is only allowed for one procedure with modifier CA. If multiple inpatient-only procedures are submitted with the modifier CA, the claim is returned to the provider. If modifier CA is submitted with an inpatient-only procedure for a patient who did not expire (patient status code is not 20), the claim is returned to the provider. April 2015 81
Blood Modifier and Incorrect Procedure Modifiers BL PA PB PC Special acquisition of blood and blood products. Surgical or other invasive procedure on wrong body part Surgical or other invasive procedure on wrong patient Wrong surgery or other invasive procedure on patient April 2015 82
Disaster Modifier CR Catastrophe/disaster related. It is required when an item or service is impacted by an emergency or disaster and Medicare payment for such item or service is conditioned on the presence of a formal waiver. April 2015 83
Incarcerated Beneficiary Modifier QJ Services/items provided to a prisoner or patient in state or local custody, however the State or Local government, as applicable, meets the requirements in 42 CFR 411.4(B). For outpatient claims, providers shall append a modifier QJ on all lines with a line item date of service during the incarceration period. All associated charges should be billed as non-covered. April 2015 84
PET/CT Modifiers PI PS Positron Emission Tomography (PET) or PET/Computed Tomography (CT) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing. PET or PET/CT to inform the subsequent treatment strategy of cancerous tumors when the beneficiary s treating physician determines that the PET study is needed to inform subsequent anti-tumor strategy. MLN 6632 April 2015 85
Preventive Service Modifiers GG Diagnostic Mammography Performance and payment of a screening mammography and diagnostic mammography on same patient, same day. GH Diagnostic mammogram converted from screening mammogram on same day PT Colorectal cancer screening test; converted to diagnostic test or other procedure 33 Preventive Services April 2015 86
Waiver of Liability
Liability Modifiers GA GX Waiver of liability Statement Issues, as Required by Payer Policy. Advanced Beneficiary Notice (ABN) of Liability required. Modifier is used to signify a line item is linked to the mandatory use of an ABN when charged both related to and not related to an ABN must be submitted on the claim. Line item must be submitted as covered and Medicare will make the determination for payment. Notice of Liability Issued, Voluntary Under Payer Policy. This modifier should be used to report when a voluntary ABN was issued for a service. Lines submitted as non-covered and will be denied as beneficiary liable. April 2015 88
Liability Modifiers GY GZ Item or service is statutorily excluded or does not meet the definition of any Medicare benefit. Lines submitted as non-covered and will be denied. Item or service expected to be denied as not reasonable and necessary. Cannot be used when ABN is given, this will deny provider liable. Lines submitted as non-covered and will deny. Publication 100-04, the Medicare Claims Processing Manual, Chapter 1, section 60.4 April 2015 89
RESOURCES
References Noridian Modifier Web pages JE https://med.noridianmedicare.com/web/jea/topic s/modifiers;jsessionid=42f49f255ecc4ede9b E472608BADEA18 JF https://www.noridianmedicare.com/parta/train/e ducation_center/modifiers.html April 2015 91
References CMS Internet Only Manuals, Medicare Claims Processing Manual - http://www.cms.gov/regulations-and- Guidance/Guidance/Manuals/Internet- Only-Manuals-IOMs- Items/CMS018912.html?DLPage=1&DLSo rt=0&dlsortdir=ascending April 2015 92
References Centers for Medicare & Medicaid Services (CMS) National Correct Coding Initiative (NCCI) CMS Medically Unlikely Edits (MUEs) CMS Addendum A and Addendum B Updates April 2015 93
CMS Educational Materials MLN products downloadable Free of charge/free shipping Brochures Fact sheets Quick reference charts Web-based training MLN dedicated web pages MLN General Information http://www.cms.gov/mlngeninfo MLN Matters Articles http://www.cms.gov/mlnmattersarticles MLN Products http://www.cms.gov/mlnproducts MLN Web Guides http://www.cms.gov/mlnedwebguide April 2015 94
Questions? Thank you!