Monday, January 4, 2010

Modifiers Usage- CPT Coding

Definition: Modifier is a two character code that indicates a service or a procedure has been altered by some specific circumstance but has not changed in its definition or code.

Advantages of Modifiers:

1. To indicate a procedure performed has both Professional and Technical
2. To indicate a procedure performed more than one physician or more than in one location
3. A service has been increased or reduced or only a part of the procedure was performed.
4. A bilateral procedure was performed
5. A service or procedure was provide more than once
6. Unusual events occurred.
7. Modifiers may increase or decrease the reimbursement of a procedure or service.
8. Modifiers indicate additional information on a service performed

What is Professional and Technical Component:

In Professional Component involves the work done by the physician in interpreting the test by supervision.

Technical Component involves a procedure performed by the Technician.

Eg: 76830—26

Modifier 22: Unusual Procedural Services:
Services provide were greater than those usually required
Excessive blood loss for the particular procedure.
Extensive well documented adhesions in abdominal surgery.
Presence of excessively large surgical specimen
Other pathologies, tumors, malformations that directly interfere with the procedure but are not billed separately.
Additional face to face primary practitioner obstetrical care performed beyond the usual service for that high-risk condition.
The diagnoses must be for a high-risk condition
If it is determined, that modifier 22 is valid; up to an additional 25% of the allowance for the procedure will be reimbursed.

Modifier 24:
Definition: Unrelated Evaluation & Management Service by the same Physician during a Postoperative Period.
Modifier 24 is used when an unrelated service is performed during a postoperative period. Normally, evaluation and management services are denied if billed within a postoperative period. By using this modifier, you are indicating a separate, unrelated service was performed during the global period of the surgical procedure.
Only use modifier 24 with evaluation and management (E & M) procedure codes. These claims may be reviewed before processing or retrospectively after processing. If the modifier is valid for services performed, reimbursement will be allowed for the E&M code at our usual and customary allowance.
EX: A patient presents to clinic with painful foot who had knee surgery two days before the clinic visit.
Ex: A patient presents to clinic with abscess of trunk who gone abdominal surgery before two days.

Modifier 25:
Modifier 25 is used to describe separate, distinctly identifiable services from other services or procedures rendered during the same visit. Always attach the modifier to the evaluation and management code.
Ex: Patient presents for six month visit for cardiac problems. Patient mentions that a mole has become irritated and would like provider to look at it and possible remove it, Provider removes mole as well as doing an office visit for cardiac problems.
Office visit for the established patient; 99.213 and paring of the lesion 11055
Ex: Sally brought her daughter in for her 3-month preventative exam visit. During the visit, Sally mentioned her daughter was pulling at her ear and thought she might have an ear ache. The provider examined the ear and provided the 3- month preventive exam, including immunizations. The claim was coded as:
99212-25 (exam of the ear ache)99382 (preventive care)90707 (immunization)

Modifier 50:
Definition: Bilateral Procedure:
If a procedure that was performed at the same operative session.
If a bilateral procedure is eligible for bilateral reimbursement, the same procedure code is reported on two lines and modifier 50 is reported on the second line.
Ex: Jim had an Endoscope Maxillary antrostomy with removal of sinus contents, right and left. The procedure code should be reported on two lines with modifier 50 on the second procedure or line.
The claim would be coded as follows:

Modifier 51:
Definition: Multiple Procedures:
When multiple procedures performed on the same day or at the same session by the same provider.
When billing multiple surgeries the primary procedure (the procedure with the highest relative value unit) should be the first code listed on the claim.
Modifier 51 should not be applied to add-on codes.
Some of the CPT codes are 51 modifier
These can be found in Appendix F and are indicated by the CPT code with @ symbol
After the first eligible procedure is reimbursed at 100% of our usual and customary allowance, the remaining procedures are reimbursed at 50% up to five procedures. No documentation is required.

If you have multiple modifiers, modifier 51 must be in the first position,
John had several tumors removed from his left foot. The claim would be coded as follows:28043-51, LT28045-51, LT
Modifier 51 represents the multiple surgeries and is reported in the first position, or directly after the procedure code. Modifier LT is informational, reporting that the procedure was done on the left foot, and is in the second position
Medicare’s Usage: Medicare’s system will apply modifier 51 in the first position on all procedures. Documentation is required for services over five procedures on the same day. Medicare will reimburse up to 100% of the highest RVU procedure. All other procedures will be reimbursed at 50%

Modifier 52:
Definition: Reduced Services:
1. Under certain circumstances a service or procedure is partially reduced or eliminated at the physician’s discretion. Under these circumstances the service provided can be identified by its usual procedure number and the addition of modifier 52, signifying that the service is reduced.
A service or procedure may be partially reduced or eliminated at the MD’s discretion. If a procedure is not completed in its entirety, the procedure is to be billed with modifier 52
1. Uses: To report when services were not completed in its entirety.
EX: A previously scheduled procedure that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the wellbeing of the patient prior to or after administration of anesthesia.
Do not use this code to report the elective cancellation of the procedure prior to administration of anesthesia and/or surgical preparation of the patient in the operating room suite.

Modifier 53:
Definition: Discontinued Procedure:
If the intended procedure is started but terminated due to extenuating circumstances or those that threaten the well being of the member, attach modifier 53 to the code.
Do not use this code to report the elective cancellation of the procedure prior to administration of anesthesia and/or surgical preparation of the patient in the operating room suite.

Modifiers 54, 55 and 56:
Definition: (54) Surgical Care only, (55) Postoperative Management Only, (56) Preoperative Management only.
Modifier 54 is used when reporting intra-operative services.
Modifier 55 is used when reporting post-operative management.
Modifier 56 is used when performing the pre-operative care and evaluation only.

Modifier-54: Surgical Care Only: When one physician performs a surgical procedure and another provides preoperative and or postoperative management, Surgical services may be identified by adding modifier 54.

Modifier-55: Postoperative Management Only: When one physician performed the postoperative management and another physician performed the surgical procedure, the postoperative component may be identified by adding modifier 55.

Modifier-56: Preoperative Management only: When one physician performed the preoperative care and evaluation and another physician performed the surgical procedure, the preoperative component may be identified by adding modifier 56.

Definition: Decision for Surgery
Use Modifier 57 when an evaluation and management (E&M) service resulted in the initial decision to perform surgery.
Modifier 57 is not eligible when used with the E&M code when the E&M visits is for the preoperative history and physical prior to the surgical procedure.

Modifier 59
Definition: Distinct Procedural Service
· Modifier 59 is used to clearly designate when distinct, independent and separate multiple procedures are provided. The procedure must not be a component of another procedure.
Examples of when to use modifier 59:
Different procedures or surgeries
Surgery on different sites or organ systems
Separate incision/excision
Separate lesions
Treatment to separate injuriesDocumentation may be required to support the use of modifier 59.
Do not use modifier 59 on all procedures on the claim. This will negate the purpose of the modifier.
Ex: The practitioner did a cyst removal on the left knee. The second procedure is for an aspiration on the right knee. This claim would require additional consideration.The claim should be coded as follows:
The first line is the primary procedure performed on the left knee. Modifier 59 on the second procedure indicates a distinctly different procedure was performed on the right knee.
Modifier-62: Two Surgeons:
When two surgeons work together as primary surgeons performing a distinct parts of a operative work by adding modifier 62 for that procedure as along as both surgeons continue to work together as primary surgeons. Each surgeon should report the co surgery once using the same procedure code.
If Additional procedure are performed during the same surgical session separate codes may also reported with modifier 62, added.
Ex: If a co-surgeon act as as an assistant in the performance of an second procedure during the same surgical session, those services may be reported using separate procedure codes with the modifier 80 or modifier 82 added, as appropriate.

Modifier 66:
Definition: Surgical Team
Team surgery is the coordinated efforts of several surgeons often of different specialties performing highly complex procedures in the same surgical setting.
Team surgery may also refer to distinct, unrelated procedures on different body areas or organ systems using distinctly different CPT codes.
Each surgeon will bill using the procedure code describing their portion of the total treatment; using modifier 66 attached to the procedure code.
For qualified procedures, each surgeon will be reimbursed for the procedure he/she performed at 100% of the allowable.
The team surgeon may assist each other on their respective surgeries. If that is the case, use modifier 80 in the first position and modifier 66 in the second position on the appropriate procedure code.
If more than one surgical procedure is performed per surgeon, multiple surgery guidelines will apply.

Modifier 78:
Definition: Return to the operating room for a related procedure during the postoperative period.
Use this modifier when the subsequent procedure is related to the first and requires the use of the operating room during the post-operative global period. Report the proper CPT® code for the procedure performed at the operative session. Do not use the procedure code for the original surgery unless the identical procedure is repeated.
If allowable, procedures billed with modifier 78 will be allowed at the Medicare intra-operative percent of the standard allowable. Procedures not billed with modifier 78 during the global period will be denied as provider write off.
If more than one procedure is performed in the global period, the Medicare percent is applied after the multiple procedure reductions are applied. Documentation is required if billing an unlisted or by report procedure. Modifier 78 should be applied to each related code that is billed post-operatively.

Modifier 80:
Definition: (80) Assistant Surgeon, (81) Minimum Assistant Surgery, (82) Assistant Surgeon when qualified resident surgeon not available, (AS), Non- MD surgical assistant.
A physician acting as an assistant at surgery should bill modifier 80, 81, or 82 and is eligible for 20% reimbursement of the primary surgeons allowable, if procedures are eligible for assistance as determined by CMS.
Non-MD practitioners acting as an assistant at surgery should bill with modifier AS and are eligible for a 15% reimbursement of the primary surgeons allowable, if procedures are eligible for assistance as determined by CMS.
Exception: Non-MD practitioners submitting claims for our Healthy Option members, should use modifier 80.
The assistants claim must be billed with the same CPT code and in the same manner as the primary surgeon. If the surgeons claim must be reviewed, the same determinations will apply to the assistants claim.
Exception: For OB care and delivery services (when using procedure code 59510). If the primary surgeon bills with 59510, the assistant should bill with procedure code 59414, with appropriate modifier (80, 81,82 or AS).

Modifier SG:
Definition: Ambulatory Surgical Center (ASC) facility service or Surgical Suite service.
This modifier indicates or denotes the use of the facility and the equipment used in the surgery. Eligible services are reimbursed per provider contracted amount or billed changes, whichever is less.
When billing multiple modifiers, enter modifier SG in the first position.

Modifiers are used to communicate services that are in addition to the services described for the CPT® procedure or HCPCS code.
Assign modifiers that have payment impact in the first position.
Assign modifiers for anatomical designation in the second position.
Assign modifiers for specific specialties if appropriate.
For MD surgical assistants, use modifier 80, 81 or 82.
For Non- MD surgical assistants, use modifier AS.
Assign modifier 50 ONLY for bilateral procedures
Report the procedure code on both lines with modifier 50 on the second line.
Assign modifier 59 ONLY when distinct, independent and separate multiple procedures are provided.


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