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Modifier MadnessProvidence St. Joseph Health

WA/AK HFMA, September 2018

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THE COMMUNITIES WE SERVE

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Our Services – Including Mental Health and Chemical Dependency Services at 13 Ministries in 5 states

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OBJECTIVES

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Agenda

▪ CCI edits and MUE Limits

▪ Claim Edits

▪ Common Hospital Modifiers

▪ Automation & Lessons Learned

▪ Experiences with Clinical Departments

▪ Questions

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What is a Modifier?

–Modifiers can be two digit numbers, two character modifiers, or alpha-numeric indicators. Modifiers provide additional information to payers to make sure your provider gets paid correctly for services rendered.

If appropriate, more than one modifier may be used with a single procedure code; however, are not applicable for every category of the CPT codes. Some modifiers can only be used with a particular category and some are not compatible with others.

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National Correct Coding Initiative (NCCI)

– The NCCI was developed by CMS to prevent inappropriate payment of services that should not be billed by the same provider for the same patient on the same date of service. NCCI edits are used by Medicare carriers and other payers in adjudicating claims.

– The NCCI edits used to consist of two tables: “Column One/Column Two Correct Coding Edit Table” and “Mutually Exclusive Edit Table.” Effective April 1, 2012 with version 18.1, these tables were combined into one file: the Column One/Column Two Correct Coding edit file. The file contains edits, which are pairs of HCPCS codes that in general should not be reported together. Each edit has a Column One and Column Two HCPCS code. When a provider reports both codes of an edit pair, the Column Two code is denied and the Column One code is eligible for payment.

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Column 1 / Column 2 Table

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Modifier Indicator Definition

0 = (Not Allowed) There are no modifiers associated with NCCI that are allowed to be used with this PTP code pair; there are no circumstances in which both procedures of the PTP code pair should be paid for the same beneficiary on the same day by the same provider.

1 = (Allowed) The modifiers associated with NCCI are allowed with this PTP code pair when appropriate.

9 = (Not Applicable) This indicator means that an NCCI edit does not apply to this PTP code pair. The edit for this PTP code pair was deleted retroactively.

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Process for Modifier -59 ApplicationAsk yourself these questions when determining whether modifier -59 is appropriate:

1. Do the codes bundle together (based on CPT guidelines or CCI guidelines)?

– If no, code both without unbundling modifier

– If yes, move to question 2

2. Was the procedure distinct from other procedures (different site, session, patient, diagnosis, etc.)?

– If no, only bill the primary service and not the bundled code

– If yes, move to question 3

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Process for Modifier -59 Application

3. Does the CCI edit have a modifier indicator of 0?

– If yes, do not use modifier -59 and do not bill separately

– If no, move to question 4

4. Is there a better modifier (more specific) than modifier -59?

– If yes, use the other modifier to separately bill

– If no, use modifier -59 to separately bill

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Modifier 59 Defined

• Modifier -59 is “used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances. This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician.”

• In 2015 Modifier 59 was expanded to include the addition of 4 Sub-Sets: XE, XS, XP & XU - These are referred to as the “x” modifiers and are used instead of modifier 59 if the situation applies. Note: The “X” modifiers are used instead of Mod 59 when the situation applies. You would never add both and “x” modifier AND a 59 modifier – it is either one or the other.

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Modifier 59 Sub- Sets

➢ XE – Separate Encounter

This is used instead of modifier 59 to describe separate encounters that occurred on the same date of service.

Example - a patient comes in via ER, some type of procedure is performed in ER and then patient is sent to observation where subsequently another procedure is performed. If an NCCI edit appears on the CPT’s in question, then the addition of modifier XE would be appropriate.

➢ XS – Separate StructureThis is used instead of modifier 59 to describe two or more procedures that are performed on the same

date of service but were performed on a separate organ or body structure.

Example – two separate cultures are taken, at different locations (i.e. forearm & knee). The same culture test is run for both. If an NCCI edit appears on the Pathology CPT’s, then it would be appropriate to apply the XS modifier.

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Modifier 59 Sub- Sets (con’t)

➢ XP – Separate Practitioner

This would be used instead of modifier 59 to describe services that are distinct & separate because they were performed by different practitioners. There is still a lot of discussion on the particular use of this new “sub-set”. Just know that it is there - however the situations for its use is rare compared to the other “X” modifiers

➢ XU – Unusual Non-overlapping Services

This would be used instead of modifier 59 to describe services that are distinct because they are not part a component of the main service. This new “X” modifier will likely be the most used.Example: A patient presents to ER with acute back pain. An injection is administered to help alleviate

the pain. Patient is then sent to radiology where a CT with contrast of the spine is performed. This will cause an NCCI edit because an injection of contrast given during the CT is a component of the CT. However, since the injection that is being reported is for the injection of pain meds in the ER, modifier “XU” can be added to the injection code to reflect that it is separate from the CT.

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Caution using Modifier 59

• Modifier -59 may be appended:– To radiology, surgical, and other services as appropriate– Do not append to E/M services

• Modifier -59 should not be used:– If there is a HCPCS Level II modifier that better describes the circumstances (e.g.,-FA, -LT, or -RT)

• For example, a procedure performed on different digits should likely be reported using -FA, -F1, -F2, etc.

– Just to mitigate I/OCE and NCCI edits

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Other Options (Before Modifier -59)

Modifiers -76/-77/-91: repeat procedures:

• These modifiers are used to indicate when procedures are repeated—at a different session but on the same day as the original procedure.

• Modifiers -76 and -77 are for procedures, radiology services, and diagnostics. Modifier -91 is for clinical laboratory procedures.

• Each service repeated must be medically necessary. For example, the laboratory repeated tests must be to obtain subsequent reportable test values. It would not be used:

– For poor specimen collection

– To validate original results

– For stat results when the original has not yet been received

– If another code can be used to capture all the services (GTT, for example)

• The documentation should indicate that a lab procedure or service was distinct or separate from other lab services performed on the same day. This may indicate that a repeat clinical diagnostic laboratory test was distinct or separate from a lab panel or other lab services performed on the same day, and was performed to obtain subsequent reportable test values.

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Modifier -59 vs. modifier -91: which to use when?

We are to use modifier -59 when different types of specimens are obtained and can be used if the tests are run simultaneously, concurrently, or in separate sessions on the same date. This is to obtain multiple results. So “different types of specimens” is the key phrase here.

For example, if multiple bacterial blood cultures are tested, then code 87040; Culture, bacterial; blood, with isolation and presumptive identification, should be used to identify each culture procedure performed. Modifier -59 should be appended to the additional procedures performed to identify each additional culture performed as a distinct service.

Modifier -91 would be used when the physician specifically wants to repeat the same lab test, same specimen type at a later time on the same date to see if the result is different.

For example, if three subsequent potassium blood tests are ordered and performed on the same date as the initial test to obtain multiple results in the course of potassium replacement therapy, then code 84132; Potassium; serum, should be reported once for each blood test performed, and modifier -91 should be appended to the subsequent test codes to identify the repeat clinical diagnostic laboratory tests performed.

Not used:

•To rerun initial tests for confirmation of results

•If original testing had problems (bad specimen, equipment, etc.)

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Edit ExampleIf a Lab was done and CPT’s were added for both “with manual differential” and “without manual differential”, this is the edit that you will see. NO modifier should be added with this example. My process would be to remove one of these codes.

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Edit ExampleMany CPT codes include procedures (like imaging) that also have a separate CPT that can be added in error by the department where the procedure was performed.

49083 – Abd paracentesis with imaging guidance76942 – Ultrasound guidance for needle placement

49083 includes any imaging guidance so it would be inappropriate to submit both of these codes together on the claim.

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Medically Unlikely Edits (MUE)– Reflects that it is “unlikely” or “unreasonable” that the units of service billed is correct OR that it exceeds Medicare’s allowed units of service to be billed.

– MUEs were developed by CMS to reduce the paid claims error rate for Part B claims. An MUE for a HCPCS/CPT code is the maximum units of service that a provider would report under most circumstances for a single beneficiary on a single date of service.

– Not all HCPCS/CPT codes have an MUE.

– Changes to MUEs are published quarterly. Some MUE’s are not published.

– As with NCCI, modifier -59 may be used as a last resort for reporting units in excess of an MUE.

– If you bill over the MUE you may not be paid for anything on that line item

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Medically Unlikely Edits (MUE).

MUE Adjudication Indicator may be value of 1,2, or 3. 1 is a true line item2 is considered clinically impossible (rare to hit as edit)3 is considered DOS meaning across all charge lines billed for the same DOS & CPT/HCPC.

MUEs for HCPCS codes with an MAI of “3” are “per day edits based on clinical benchmarks”. MUEs assigned an MAI of “3” are based on criteria (e.g., nature of service, prescribing information) combined with data such that it would be possible but medically highly unlikely that higher values would represent correctly reported medically necessary services. If contractors have evidence (e.g., medical review) that UOS in excess of the MUE value were actually provided, were correctly coded and were medically necessary, the contractor may bypass the MUE for a HCPCS code with an MAI of “3” during claim processing, reopening or redetermination, or in response to effectuation instructions from a reconsideration or higher level appeal.

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Medically Unlikely Edits (MUE)

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Category 1 MUE EditCategory 1 Service Line Edit

▪ Charge is 87634 with units of service 3

▪ Example Edit: For Rev Code=0300, Px Code=87634 on line 5 (Service date: 08/20/2018): 2020 FAC MUE- HCPCS line item units exceed Medically Unlikely Edit maximum of 0000001 . (LID) [3087121104]

▪ Claim will be billed:

❖ 87634 with UOS 1 (covered)

❖ 87634 with UOS 1 (covered with Modifier 59)

❖ 87634 with UOS 1 (covered with Modifier 59)

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Category 2 MUE EditCategory 2 Date of Service Edit Policy

▪ Charge is 82607 with units of service 2

▪ Example Edit: For Rev Code=0301, Px Code=82607 on line 4 (Service date: xx/xx/xxxx): 2030 FAC MUE- HCPCS total units exceed daily allowed Medically Unlikely Edit maximum of 0000001 contrary to CMS policy. (LID) [3087121104

▪ Claim will be billed:

❖ 82607 with UOS 1 (covered)

▪ Most often we are removing anything above the 1 charge.

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Category 3 MUE Edit

Category 3 Date of Service Clinical ▪ Charge is 96365 with units of service 4

▪ Example Edit: For Rev Code=0940, Px Code=96365 on line 5 (Service date: 08/20/2018): 2020 FAC MUE- HCPCS line item units exceed Medically Unlikely Edit maximum of 0000002 . (LID) [3087121104]

▪ Claim will be billed:

❖96365 with UOS 2 (covered)

❖96365 with UOS 2 (not covered with Modifier GZ)

All units over what is MUE allowed are on the 1 line in non-covered with GZ modifier

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Modifiers used in Conjunction with an E/M code

Modifiers 25 & 27

Modifier Description

25 Identifies a significant separate evaluation and management (E/M) services provided on the same date as a procedure or other service.

Example: ER visit with a laceration repair. Modifier 25 is added to the ER E/M code.

27 Added when multiple E/M visits occur on same date of service. (This can occur in ER when a patient comes twice in 1 day or if billing has moved an E/M from another department in the facility onto the encounter you are currently coding.

NOTE: Modifier 25 & 27 are ONLY applied to E/M codes

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Modifier 25 Edit Example

▪ This indicates that Modifier 25 needs to be added to the E/M since there is also a “S” status code on same date of service (29505).

▪ Different consideration should be taken when reviewing E/M codes in an office vs an Emergency Room.

NOTE: Modifier 25 is ONLY added to the E/M codes. It would NEVER go on the associated Status ”S” or Status “T” code.

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Modifiers used in conjunction with radiology CPT’s

▪ When a Radiology Service is performed more than once, on the same date of service, then a modifier from this group would need to be added.

Modifier Description

76 Repeat radiology procedure by same physician- Example:Observation visit due to pleural effusion. Chest x-ray is performed twice on the 1st date of service to monitor the lungs. If the chest x-rays were performed by the same physician, then modifier 76 is added to only the repeat radiology CPT code, (i.e. 71010, 71010-76).

77 Repeat radiology procedure by different physician - same example as above, but a different physician performs the service.

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Modifiers used in conjunction with Laboratory Tests

▪ When the same lab test is performed on a patient, multiple times on the same date of service, then modifier 91 needs to be added to only the repeat laboratory CPT codes

Modifier Description

91 Repeat Clinical Diagnostic Laboratory Test- This does not apply to tests performed to simply confirm a lab result.

Example: ER visit due to uncontrolled diabetes. Insulin is administered and patient is monitored and advised to follow up with their primary physician. Lab

draws were taken to monitor patient’s glucose during the encounter. If the same lab test was performed, multiple times then only the repeat CPT’s would have modifier 91 added (i.e., 82947, 82947-91, 82947-91

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Other useful modifiers

▪ FY = X-ray taken using computed radiography

▪ Modifier JG = Drug or biological acquired with 340B Drug Pricing Program Discount [OPPS Effective 01/01/2018 / OR TB

▪ JW = Drug amount discarded/not administered to any patient

▪ Modifier PN = Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital.[Facility Effective Date 01/01/2017]

▪ PO = Non-excepted service provided at an off-campus, outpatient, provider-based department of a hospital.[Facility Effective Date 01/01/2017]

▪ Modifier KX = used to indicate the services rendered are Medically Necessary

▪ Modifier GN, GO, GP = Services delivered under outpatient Speech, Occupational, or Physical Therapy plan of care

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Other useful modifiers (cont)

▪ GA Waiver of Liability Statement issued as Required by payer policy. Used to report a required ABN was issued for a service and is on file. A copy of the ABN

does not have to be submitted but must be made available upon request.

▪ GX = Notice of Liability issued, Voluntary under payment policy. Used to report a voluntary ABN was issued for a service.

▪ GZ = Item or service Expected to be denied as Not Reasonable and Necessary. Used to Report and ABN was not issued for a service.

▪ GY = Notice of Liability not issued, Not Required under payment policy. Used to report that an ABN was not issued because an item or service is statutorily

excluded or does not meet definition of any Medicare Benefit.

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Automation Possibilities

▪ Adding modifiers GN, GO, GP for outpatient rehab services based on charge record or revenue code.

▪ Radiological guidance procedures include all radiological services necessary to complete the procedure. CPT codes for fluoroscopy (eg: 76000, 76001) should not be reported separately with a fluoroscopic guidance procedure. CPT codes for ultrasound (eg: 76998) should not be reported separately with an ultrasound guidance procedure.

▪ If you have different departments that charges separately and each are wanting to have their separate charges for revenue reporting needs consider automation in rolling charges.

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Experiences with Departments

▪ Write edits that prevent charges that should not be billed together

▪ Write process flows and prompts for techs to answer if they are using computerized equipment for application of FY

▪ Identify charges and adjust them to codes that impact Revenue or Productivity

▪ Departments can process some of their own modifiersER with Modifier 25, Lab with 91, Diagnostic imaging76/77

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References

▪ https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html

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Questions?