coding with modifiers

Coding with Modifiers

Oregon Medical AssociationOctober 29, 2009

Frann M. Britton, RN, CCS,CCS-P

2

CPT Categories

• Category I– Describe a procedure or service identified

with a 5-digit numeric CPT code– Generally based on the procedure being

consistent with contemporary medical practice– Being performed by many physicians in a

clinical practice in multiple locations

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CPT Categories

• Category II Performance Measurement– Are intended to facilitate data collection by

coding certain services and/or tests results that are agreed on as contributing to positive health outcomes and quality patient care.

– Tracking codes for performance measurement

– May be services that are typically part of an Evaluation and management service

4

CPT Categories

• Category II Performance Measurement– May be a component part of a service and are

not appropriate for Category I CPT codes.– Do not have relative value– No payment associated with these codes– Will decrease need for record abstraction and

chart review– Minimize administrative burden on physicians

and health plans

5

CPT Categories

• Category II Performance Measurement– Performance Measures Advisory Group

• Evidenced-based measurements with established ties to health outcomes

• Measurements that addresses clinical conditions of high prevalence, high risk, or high cost

• Well-established measurements that are currently being used by a large segment of the health care industry nation wide.

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CPT Categories

• Category II Performance Measurement

– The use of these codes is optional and is not required for correct coding.

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CPT Categories

• Category III Emerging Technology– Temporary set of tracking codes for emerging

technologies, services, and procedures.– Intended to facilitate data collection and

assessment of these services and procedures.

– Used for data collection purposes to substantiate widespread usage or in the FDA approval process.

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CPT Categories

• Category III Emerging Technology– Must have relevance for research, either

ongoing or planned.– Once approved by Editorial Panel are added

to Level I CPT codes– No relative values – Payment subject to payer policies – Archived after 5 years if not added to CPT

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HCPCS Coding System

• HCPCS – CMS‘s Health Care Common Procedure

Coding System– Developed in 1983 to standardize the coding

systems to process Medicare claims on a national basis.

– 2 levels CPT and HCPCS

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HCPCS Coding System

• Level I CPT– Makes up the majority of the HCPCS system

• Level II National Codes– Durable medical equipment– Ambulance services– Medical and surgical supplies, drugs– Orthotics, prosthetics, dental and eye services

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HCPCS Coding System

• Level II National Codes– 5 character alphanumeric codes– First character is a letter A-V (except I)

followed by 4 numeric digits (A4550)– Alphabetic (eg, RT) and alphanumeric (eg,

E2) modifiers– Updated annually by CMS– Required for reporting most medical services

and supplies provided to Medicare and Medicaid patients.

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National Correct Coding Initiative

• Edit of code pairs of CPT or HCPCS that are not separately payable except under certain conditions.

• Same beneficiary, same physician, same date• Promote national correct coding• Eliminate improper coding

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• Developed by CMS to prevent inappropriate payment of services that should not be reported together.

• 2 NCCI tables:– “Column One/ Column Two Correct Coding

Edit Table” and “Mutually Exclusive Edit Table”.

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• Each edit table contains edits of pairs of HCPCS/CPT codes in general should not be reported together.

• If a provider reports the two codes of an edit pair, the column two code is denied.

• When clinically appropriate to utilize an NCCI-associated modifier, both the column one and column two codes are eligible for payment.

15


• Column two codes are often a component of a more comprehensive column one code it is not true for many edits.

• The code pairs simply represents two codes that should not be reported together.

• Vaginal hysterectomy and total abdominal hysterectomy code together.

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• NCCI is used by all practioners, hospitals, providers or suppliers eligible to bill Medicare.

17


• Coding conventions defined in CPT

• Current standards of medical and surgical care

• Input from specialty societies

• Analysis of current coding practice

• Updated on quarterly basis

• Denial based on NCCI edits may not bill patient

18


• 2 columns, 1st lists CPT code

• 2nd (component) code, integral to Column 1

• Denied without modifier

• Mutually exclusive edit – 2 codes cannot reasonably be performed

together based on code definitions or anatomic considerations.

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Procedures and Global Period

All procedure on the Medicare Physician Fee Schedule are assigned a Global period of 000,010,090,XXX,YYY or ZZZ.

The global concept does not apply to XXX procedures.

The global period for YYY procedures is defined by the Carrier.

All procedures with a global period of ZZZ are related to another procedure, and the global period for the ZZZ code is determined by the related procedure.

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NCCI edits are applied to same day services by the same provider to the same beneficiary.

An E/M service is separately reportable on the same DOS as a procedure with global days, 000,010,090 under limited conditions.

Minor procedures global days are 000 or 10.

Major procedures have 90 global days.

21

Procedures and Global Period If an E/M is performed on the same date of service as a major surgical procedure for the purpose of deciding whether to perform this surgical procedure, append modifer -57 to the E/M.

The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E/M service.

A significant and separately identifiable E/M service unrelated to the decision to perform the minor surgical procedure is separately reportable with modifier-25.

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Medicare example:

“If a physician determines that a NEW patient with head trauma requires sutures, confirms the allergy and immunization status, obtains informed consent, and performs the repair, an E/M service is not separately reportable.

HOWEVER, if the physician also performs a medically reasonable and necessary full neurological examination, an E/M service may be separately reported”.

23


XXX procedures have inherent pre-procedure, intra-procedure and post-procedure work usually performed each time the procedure is completed.

(EKG’s. x-rays, ultrasounds)

This work should never be reported as a separate E/M.

An separate E/M can be reported with -25 if it is significant, separately identifiable.

24

NCCI Modifiers

• Anatomic modifiers • E1-E4, FA, F1-F9, TA, T1-T9, LC, LD, RC,LT,RT

• Global surgery modifier• -25 Significant E/M same day as Procedure• -58 Staged or related Procedure during Postop• -78 Unplanned Return to OR during postop• -79 Unrelated procedure during postop • -59 Distinct Procedure• -91 Repeat Clinical Diagnostic Lab• -27 Multiple Outpatient E/M on same Date

25

NCCI Modifiers

Important to use NCCI-associated modifiers only when appropriate

– Separate patient encounter– Separate anatomic sites– Separate specimens– Paired organs

26

Modifiers

Evaluation and Management Only

-24 Unrelated E/M Unrelated E/M during the postoperative period.

-25 Separate E/M

-57 Decision for Surgery

27

Modifiers


-24 Unrelated E/M Unrelated E/M during the postoperative period

• The same physician and unrelated to the original surgery

• Separate note if he/she evaluates the previous surgical site and determines the site requires care, this would not be part of the new encounter.

28

Modifiers


-25 Significant, separately identifiable E/M service performed by the same physician on the day of a procedure.

Modifier -25 is critical to appropriate communication about what happened in a patient encounter on a given date

• Procedures with 0,10, global days, endoscopies, XXX services.

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Modifiers • Modifier was added by CMS in 1992 to help reduce the

documentation burden on physicians.

• Says the provider went “above and beyond” the other service provided.

• Modifier-25 is not restricted to any level or SOS.

• The same diagnosis may accurately describe the nature or reason for the encounter and the procedure.

The record, however—should document an important,notable, distinct correlation with signs and symptoms tomake a diagnostic classification or demonstrate a distinctproblem.

30

Modifiers

• Evaluation and Management Only

• -57 Decision for Surgery is appended to an E/M only when that service represents the initial decision to perform a major surgical procedure.

• E/M the day prior to or day of a major procedure with a 90 day global period.

• Be prepared to submit consultation, visit or hospital note to support decision for surgery.

31

Modifiers-22 Unusual Procedure

• When the service provided is greater than that usually required for the listed procedure.

• Used in the following sections:– Anesthesia– Surgery– Radiology– Laboratory and Pathology– Medicine

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Modifiers-22 Unusual Procedure operative cases• Trauma extensive enough to complicate the particular

procedure and that cannot be billed with additional procedures

• Significant scarring requiring extra time and work• Extra work resulting from morbid obesity• Increased time resulting from extra work by the

physician• Needs a concise statement about how the service differs

from the usual• An operative report submitted with the claim

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Modifier -22

• Occasionally a provider may perform two procedures that should not be reported together based on an NCCI edit.

• If the edit allows use of NCCI-associated modifiers to bypass it and the clinical circumstances justify use of one of these modifiers, both services may be reported with the NCCI-associated modifier.

• If the NCCI edit does not allow use of NCCI-associated modifiers to bypass it and the procedure qualifies as an unusual procedural service, the physician may report the column one column one HCPCS/CPT code of the NCCI edit with modifier 22.

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Modifier -22

• The Medicare carrier cannot override an NCCI edit that does not allow use of NCCI-associated modifiers,

• The carrier has discretion to adjust payment based on modifier 22.

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Modifiers-26 Professional Component

– Certain procedures are a combination of a physician component and a technical component. When the physician component is reported separately add -26.

– If the radiologist owns the equipment, interprets the test, and pays the technologist, modifier TC and 26 do not apply.

– Physician does not own the equipment -26– Facility provided the equipment and technician –TC– CPT 76140 only has a professional component

modifier -26 would not be used.

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Modifiers-26 Professional Component

– CPT 51725 simple cystometrogram (CMG)

This code includes all supplies, equipment, and the technician’s work, including interpretation of the results.

If the physician only interprets the results and dictates a report, modifer -26 would be appended to the code.

The hospital would submit the same code with -TC

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Modifiers-50 Bilateral Procedure• Unless otherwise identified in the listings, bilateral

procedures that are performed at the same operative session should be identified with -50.

• Bilateral procedures are typically performed on both sides of the body (mirror image) during the same operative session.

• Append to unilateral code as a one-line entry, unit of one

• Modifier does affect payment 2nd pr at 50%

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Modifiers-50 Bilateral Procedure

• If the procedure is performed unilaterally and the descriptor indicates bilateral, append modifier-52.

• 69210 removal cerumen one or both ears• Do not use -50 code • Procedure performed unilaterally and descriptor

indicates bilateral add -52

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Modifiers-50 Bilateral Procedure

• Many payers will not accept -50 for radiology use LT and RT

• Medicare allows LT and RT instead of -50 when the code does not indicate a bilateral procedure.

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Modifiers-50 Bilateral Procedure bilateral code sets:

69210 Ear wax removal 1 or both ears

55300 Vasotomy, unilateral or bilateral

27158 Osteotomy, pelvis, bilateral

30801 Cautery and/or ablation, mucosa turbinates

unilateral or bilateral

40843 Vestibuloplasty; posterior, bilateral

35548 Bypass graft, with vein, unilateral

35549 Bypass graft, with vein, bilateral

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Modifiers

-51 Multiple Procedures• Used when multiple procedures, other than E/M,

are performed at the same session by the same provider, the primary procedure or service is listed first.

• -51 is add to the additional procedures.• List procedures in ranking order highest RVU

listed first.

• -51 not needed for Medicare

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Modifiers

-51 Multiple Procedures has 3 applications

• Multiple, related surgical procedures performed at the same session

• Surgical procedures performed in combination whether through the same or another incision or involving the same or different anatomy

• A combination of medical and surgical procedures performed at the same session

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Modifiers

-51 Multiple Procedures • Do not append -51 to E/M service• Do not append to “add- on “ codes• Do not append to “each additional” (finger fracture's, tendon repair)

• “List separately in addition to primary procedure.” (lesions, vertebral segments)

• Modifier 51 exempt symbol Ø

44

Modifiers

-51 Multiple Procedures • Two or more physicians at same operations

• Each surgeon reports his/her own CPT codes without modifer -51

• Modifier -51 same surgeon, same session, multiple procedures as long as they are not considered incidental or bundled

45

Modifiers

-51 Multiple Procedures

• 100% first procedure• 50% 2nd – 5th each additional• after 5th “by report basis”

• 100, 50, 25 Other payer specific payment policy

46

Modifiers

-52 Reduced Service – part of service or procedure reduced or eliminated at the physician’s discretion.

• Provides a means of reporting reduced services without disturbing the identification of the basic service.

47

Modifiers

-52 Reduced Service –

• May or may not affect reimbursement

• Chart note or op note should be sent with claim

• Not all carriers recognize

• Not recognized with E/M – CMS

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Modifiers

• -53 Discontinued Procedure

• When patients experience unexpected responses (hypotension, arrhythmia) causing a procedure to be terminated

• Procedure stopped due to patients life-threatening condition

• After anesthesia is administered to patient

• Payers cover only the primary procedure

• Not for laparoscopic or endoscopic procedure converted to an open procedure

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Modifiers

-54 Surgical Care Only

-55 Postoperative Management Only

-56 Preoperative Management Only

50

Global Surgical Package

• Refers to payment policy of bundling payment for the various services associated with an operation into a single payment covering;– Operation– Postoperative hospital visits– Normal typical follow-up care

51

Global Surgical Package

• CMS – Preoperative period begins one day prior to

surgery in or out of the hospital and continues for 90 days.

– Carefully monitored by Medicare – may lengthen preoperative period.

52

Modifiers


When one physician performed a surgical procedure and another provided preoperative and/or postoperative management.

53

Modifiers


– Intraoperative care only– Fracture reduction in the ED

• 69% of the global fee

• 25605-54 closed reduction distal radius

54

Modifiers


When one physician performed the postoperative management and another

performed the surgical procedure.

55

43770-54 Laparoscopy, gastric band

Bariatric surgery

43770-55 Laparoscopy, gastric band

Bariatric surgery

56

43770 Laparoscopy, gastric band Bariatric surgery

Work Expense Mal Practice

17.85 7.72 2.19

Pre 9% Intra 81% Post 10%

57

Modifiers


• Date of surgery plus number of days– 35321-55 x5 units

• Bill after patient is seen initially in f/u• Payment 10-20% of post-op allowable• Transfer of care documented

58

Modifiers

-56 Preoperative Management Only

When one physician performed the preoperative care and evaluation and another performed the surgical procedure.

59

Modifiers

- Needs to be communication between the surgeon and the physician providing either pre-op or post-op services.

- Discharge summary of the hospital or ASC

60

Modifiers

- Payment

- Modifier -56 based on the preoperative value of the global surgery fee

- Report date of surgery on 1500

- CPT 33400-56 Aortic valve repair

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Modifiers-58 Staged or Related Procedure or Service by the

same physician during the postoperative period

• Planned prospectively, more extensive than the original procedure or represents a therapeutic or diagnostic procedure or service

• Used during the global surgical period for the original procedure

• New postoperative period begins• Not used for return to the operating room for

treatment of a problem

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Modifiers

• If a diagnostic endoscopic procedure results in the decision to perform an open procedure, both procedures may be reported with modifier-58 appended to the CPT code for the open procedure.

• If the scope is a “scout” procedure to asses anatomic landmarks and or/extent of disease it is not report separately.

63

A surgeon performed a radical mastectomy (19200) on a 56-yr-old woman. The patient indicated that she preferred a permanent prosthesis after the surgical wound healed. The surgeon took the patient back to the operating room during the post-op period and inserted a permanent prosthesis.

CPT code:

64

A diabetic patient with advanced circulatory problems had three gangrenous toes removed from her left foot (28820, 28820-51, 28820-51). During the post-op it became necessary to amputate the patient’s left foot.

CPT code:

65

Rational:

• Because there is a possibility, in the light of the patient’s condition, that amputation might be necessary, this is considered a staged procedure.

66

• 35840 Exploration for postoperative hemorrhage thrombosis or infection; abdomen

• Code:

67

Modifiers • -59 Distinct Procedural Service

Documentation must support:• Different Session or Pt Contact• Different procedure or surgery

• Different site or organ system• Separate incision or excision• Separate lesion• Separate injury• Separate area of surgery in extensive injuries, not

ordinarily encountered or performed on the same day, by the physician

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Modifiers

• Modifier -59– For “exceptions” to the normal rules– By passes the NCCI edits– Using incorrectly – tells payer every service is

an exception– Leads to further review of a provider’s billing

practices– Inappropriate or indiscriminate use of the NCCI

modifiers could be considered fraudulent or abusive

69

Modifiers

• Modifier -59– Use of modifier -59 to indicate different

procedures/surgeries does not require a different diagnosis for each CPT/HCPCS code.

– Different diagnoses are not adequate criteria for use of modifier -59. The codes remain bundled unless the procedure are performed at different anatomic sites or separate encounters.

70

Modifiers

• Modifier -59– Different anatomic sites includes different

organs or different lesions in the same organ.– Does not include treatment of contiguous

structures of the same organ.• E.g. nail, nail bed, and adjacent soft tissue

constitutes treatment of a single anatomic site.

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Modifiers

• Modifier -59– Treatment of posterior segment structures in

the ipsilateral eye constitutes treatment of a single anatomic site.

– Arthroscopic treatment of a shoulder injury in adjoining areas of the ipsilateral shoulder constitutes treatment of a single anatomic site.

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Modifiers

• Modifier -59– CPT 38221 bone marrow, biopsy– CPT 38220 bone marrow, aspiration only– Code both if different anatomic sites same

incision do not code and do not use -59

– Medicare CPT 38221 and G0364 (bone marrow aspiration performed with bone marrow biopsy through same incision on the same DOS).

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Modifiers

• Modifier -59

• Should not be used when another, more descriptive modifier is available

• Documentation needs to be specific to the distinct procedure or service and be clearly identified in the medical record

• By passed NCCI edits

74

Modifiers

• Modifier -59

– CPT 87070 Culture bacterial, blood• Different site (both arms)

– CPT 87071 Culture bacterial; quantitative,

aerobic of two sites• Wound infection, lower leg with cultures from

proximal wound and distal wound site

75

Modifiers

• Modifier -59

– CPT 97597 Removal devitalized tissue Patient’s right hip and ankle

• 97597-59 later in the day debrided another 20sq cm

from the sacral area

76

Surgeon removed a soft tissue 3cm tumor from a patient’s left wrist in the outpatient surgery department. During the same operative session, a 0.8-cm lesion was excised from the patient’s right leg.

CPT code:

77

Patient had a total colonoscopy with random biopsies from the ascending colon, transverse colon and sigmoid colon. A hot biopsy destroyed a 3-mm polyp in the sigmoid colon.

CPT code:

78

70 yr old woman, with SOB under went chest x-ray single view. Later in the day the radiologist asked the patient to return for a more extensive study.

CPT code:

79

Modifiers

-62 Co-surgeon two surgeons performing distinct part(s) of a procedure

• Complexity of the procedure• The patient’s condition or both

• Additional surgeon is not acting as assistant but is performing a distinct portion of the procedure

80

Modifiers


• Each surgeon bills the same CPT/ICD• Separate operative reports to document

their level of involvement in the surgery• Spine surgery – physicians discuss in

advance what portion of the procedure each is expected to perform

81

Modifiers


• Spine surgery opens and closes only, -62 is appended to the primary procedure only

• -80 when needed to continue as assistant

82

Modifiers


• For surgical procedures • Endovascular repair (34800, 34802,

34804, 34812, 34813,34820, 34825)• Radiological procedures

– CPT 77778-26-62 urologist– CPT 77778-26-62 radiologist

83

Modifiers


• Review payer guidelines• Documentation must support need for 2

surgeons, • Each bills with same CPT/ICD codes• Each surgeon must dictate his/her own operative

report• Not used for surgeon acting as “the assistant

surgeon”

84

Modifiers

-63 Procedure Performed on Infants Less than 4 kg

• Increased complexity and physician work• Used only with codes from Surgery section of CPT• Only invasive surgical procedures

• Not for surgery that assumes the patient is a neonate or infant (eg. Surgery to correct a congenital abnormality) the relative value already reflects the additional work.

• Use -22 or -63 not both at same session

85

Modifiers

Modifier 66 Surgical Team

Highly complex procedures requiring theconcomitant services of different specialties,performing different portions of a procedure.

Heart transplant Lung transplantLiver, pancreas

86

Modifiers

Modifier 66 Surgical Team

• Each surgeon bills with -66 appended to the procedures

• Requires usually requires prior authorization

• Send op report

87

Modifiers

-76 Repeat Procedure by Same Physician

• Intended to describe the same procedure or service repeated rather than the same procedure being performed at multiple sites.

• Modifier indicates not a duplicate • Must be same procedure, same physician

88

Modifiers

-76 Repeat Procedure by Same Physician

– Surgical procedure –same date or during global– Medical – same date

• 93010 EKG• 93010-76 2 EKG’s same day• 71010-26 Chest x-ray• 71010-76-26 same day for chest tube placement

89

Modifiers

-77 Repeat Procedure by Another Physician

• Medical necessity must support reason for the repeat procedure

• Second physician is not affected by first physician’s service

90

Modifiers

-78 Return to the Operating Room for a Related Procedure during the Post-operative Period

– Subsequent procedure is related to the first and requires the use of the operating room

– May be used on the same day or during global period – Do not use the code for the original procedure– Repeat surgery is due to a complication of the original

procedure– Append modifier to each procedure performed that

requires treatment for the complication

91

Modifiers


– Do not use for procedures that indicate in the descriptor “subsequent, related, or redo”

– If the complication does not require return to the OR do not append -78

– Reimbursement intra-operative portion only– New global days do not begin– Use a complication diagnosis code not the same dx as

the original surgery

92

Modifiers


Complications of Surgical and Medical Care, Not Classified Elsewhere

• 998.11 Hemorrhage complicating a procedure• 998.32 Disruption of external surgical wound• 998.59 Post-operative wound infection

– 682.6 knee, 682.2 back, 041.12 MRSA

93

Modifiers


Mechanical Comp Internal Ortho Device • 996.42 Dislocation of joint• V43.64 Total hip

– Use with CPT 27265 only

94

Modifiers


Complications of Surgical and Medical Care, Not Classified Elsewhere

• 998.59 Post-operative wound infection

95

Medicare Operating Room

• Operating room or place equipped specifically for procedures.– Hospital operating room– Ambulatory surgery center– Cardiac cath suite– Laser suite– Endoscopy suite– ICU when patient to sick to move

96

Modifiers

-79 Unrelated Procedure or Service by Same Physician During the Postoperative Period

– Different diagnosis – Does not require a return to the OR– Is not limited to surgical procedures– Restricted to the same physician– Append -79 to all procedures that apply not just first– Begins new 90 day global period

97

Modifiers

80-82 Assistant Surgeons

– 80 Assistant Surgeon– 81 Minimum Assistant Surgeon– 82 Assistant Surgeon (when qualified

resident not available)

-AS Physician assistant, nurse practitioner,

clinical nurse specialist

98

ModifiersCo surgeon (-62) share responsibility for a surgical procedure, each serving as a primary surgeon during some portion of the surgery. Both must be surgeons, and usually of different specialties.

• CMS, to qualify as assistant the surgeon must actively assist. Must be involved in the actual performance of the procedure.

• To qualify for CMS definition of an assistant surgeon (-80), the assistant surgeon needs to be able to take over the

surgery should the primary surgeon become incapacitated.

• The surgical note should clearly document what the assistant surgeon did during the operating session.

99

Modifiers

-81 Minimum Assistant Surgeon

• Assistance for a short period of time

• Medicare 13% of allowable

• Work Comp

100

Modifiers

-82 Assistant Surgeon (When Qualified Resident Surgeon Not Available)

• Prerequisite unavailability of qualified resident (teaching hospitals)

101

Modifiers

-90 Reference (Outside) Laboratory

• Laboratory bills the physician and the physician office bills the insurance company.

• 36415 lab draw

• 80061-90 Lipid panel

102

Modifiers

-91 Repeat Clinical Diagnostic Test

• Necessary to repeat the same lab test– Not to:– Confirm initial test results– Due to testing problems encountered with

specimens or equipment– For any other reason, one-time reportable

result is all that is required

103

Modifiers


• Follow-up potassium level after treatment of hyperkalemia

• Repeat ABG’s• Drug testing for each drug

– 80100 Cocaine– 80100-91 methamphetamine– 80100-91 THC

104

Modifiers


• 82948 Glucose, blood, reagent strip

• 82948-91

• 82951 glucose, three specimens

105

Modifiers

-91 Repeat Clinical Diagnostic Test vs modifier -59

• -59 Same procedure for a different specimen

• Laboratory test that is performed more than once on the same day for the same patient. To obtain subsequent test results.

106

Modifiers

HCPCS Level II

• 33 Anatomic modifiers

• 10 Anesthesia modifiers

• 300 CMS

107

Modifiers

Anatomical - HCPCS

-LT Left side of the body

-RT Right side of the body

-FA Left hand – thumb

-T5 Right foot - Great toe

108

Modifiers

HCPCS Level II • -GA ABN signed• -QW CLIA waved test• -TC Technical component• -GY Item or service does not meet the definition of a Medicare benefit• -GZ Item or service expected to be denied as not reasonable and necessary

109

Modifiers

HCPCS Level II • -GY modifier : physicians, practitioners, or suppliers want to

indicate that the item or service is statutorily non-covered or is not a Medicare benefit.

• -GZ modifier: to indicate that they expect that Medicare will deny an item or service as not reasonable and necessary and they have not had an Advance Beneficiary Notification (ABN) signed by the beneficiary.

• -GA modifier: when physicians, practitioners, or suppliers want to indicate that they expect that Medicare will deny a service as not reasonable and necessary and they do have on file an ABN signed by the beneficiary.

110

Modifiers

HCPCS Level II

Foot Care

• Q7 One class A finding

• Q8 Two class B findings

• Q9 One class B and two class C findings

111

“Never Events”

Invasive procedures include a range of procedures from minimally invasive dermatological procedures• Biopsy, excision, and deep cryotherapy for

malignant lesions.• Extensive multi-organ transplantation• Percutaneous transluminal angioplasty and cardiac

catheterization.• Placement of probes or catheters requiring the entry

into a body cavity through a needle or trocar.

• Do not include– use of instruments such as otoscopes for examinations.– very minor procedures such as drawing blood.

112

“Never Events”

• A surgical or other invasive procedure is considered to be the wrong procedure if it is not consistent with the correctly documented informed consent for that patient.

113

“Never Events”

• Surgical or other invasive procedure is considered to have been performed on the wrong body part if it is not consistent with the correctly documented informed consent for that patient including surgery on the right body part, but on the wrong location on the body;

• Left versus right (appendages and/or organs), or at the wrong level (spine).

114

“Never Events”

• The event is not intended to capture changes in the plan upon surgical entry into the patient due to the discovery of pathology in close proximity to the intended site when the risk of a second surgery outweighs the benefit of patient consultation; or the discovery of an unusual physical configuration (e.g., adhesions, spine level/extra vertebrae).

115

Modifiers

HCPCS PC

• PA: Surgery Wrong Body Part

• PB: Surgery Wrong Patient

• PC: Wrong Surgery on Correct Patient

116

Modifiers

HCPCS

• PA: Surgery Wrong Body Part E876.7 Correct operation on wrong body part

• PB: Surgery Wrong Patient E876.6 Performance of operation on pt not scheduled for surgery

• PC: Wrong Surgery on Patient E876.5 Wrong operation correct patient (wrong device

implanted into correct surgical site

117

Modifiers

HCPCS PC

82 yr old male had surgery performed on his right knee for a torn meniscus. The left knee had the torn meniscus.

Code:

118

Questions

119

Resources

• http://www.cms.hhs.gov/Transmittals/downloads/R102NCD.pdf

• CPT 2009, Edition, American Medical Association• International Classification of Diseases, 2009 Edition• Coding with Modifiers, AMA• Center for Medicare and Medicaid Services, Program

Manual• Medicare Claims Processing Manual

coding with modifiers

Documents

levels cpt

hcpcs coding systemlevel

coding systems

medical services

hcpcs systemlevel

eye services

national basis

performance measurementmay