Tips for Understanding Modifiers

Presented byVivian Washington, CPC, COC, CPC-I

April 17, 2015

1

Disclaimer This presentation is for education purposes only. The information presented is not intended to be legal advice. The information presented was current at the time presented and when applicable, based upon information published by the American Medical Association (AMA) and Centers for Medicare and Medicaid Services (CMS).  Vivian Washington, CPC, COC, CPC-I makes no representation, guarantee or warranty, express or implied, that this compilation is error-free or that the use of this publication will prevent differences of opinion or disputes with Medicare or other third-party payers, and will bear no responsibility or liability for the results or consequences of its use.

2

A two-digit numeric or alpha-numeric character reported with a HCPCS level I and II code, when appropriate.

What is a Modifier

3

To give more information needed to process a claim.

To indicate special circumstances that affect a service without affecting the service or procedure description

To ‘legally’ unbundle Medicare or other Third-party Payer’s CCI edits.

Why Use Modifiers?

4

22-99

CPT® MODIFIERS

5

Increased Procedural ServicesAdd modifier 22 to a surgical procedure when

the physician’s work required to perform the procedure is more than is typically needed.

Check that the physician documented the reason’s shy the work performed was more than typically performed

6

Unusual Anesthesia Add modifier 23 to an anesthesia procedure when the

provider administers general anesthesia for a procedure that does not normally require it or administers anesthesia due to unusual circumstances.

EXAMPLE: -A trauma patient who is combative when providers

attempt any type of treatment for injuries -A patient undergoing dental procedures who cannot

remain awake due to extreme anxiety -A mentally ill patient who physically abuses providers -A small child who is anxious and uncooperative

7

Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period

Append modifier 24 to an E/M service when the provider renders an E/M during the patient's global surgery period, but the E/M is not related to the patient's surgery.

8

CRITERIA:The E/M service occurs during the postoperative period of another procedure.The current E/M service is unrelated to the previous procedure.The same physician (or tax ID or same group and specialty) who performed the previous procedure provides the E/M.The patient's diagnosis documented must meet medically necessity for the visit.

9

CONT’D

Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service

Append modifier 25 to an E/M service when the provider renders an E/M to the patient on the same day as another service or procedure.

10

The medical documentation has to justify performing the separate E/M service. The patient's condition may warrant the same provider performing a separate E/M service and another service or procedure on the same day.

A provider may also render two E/M services to the same patient on the same day. Append modifier 25 to the second E/M service to prove that it was separate from the first E/M.

11

CONT’D

TRUE or FALSE1.I can always use this modifier when I did not plan the procedure.2.I can always use this modifier when the diagnoses are different.3.I can never use this modifier when the diagnoses are the same.

12

CONT’D

Professional Component

Append modifier 26 to a code to show that the physician provided the supervision and interpretation portion of the service.

13

Mandated Services

Append modifier 32 to a code to show that a third party mandated that the provider perform the service.

Mandated services are defined as required services, such as those required by a third party payer, governmental, legislative, or regulatory requirement, and you can identify these services by adding modifier 32 to the basic procedure.

14

Preventive Services

Append modifier 33 to services which are preventive, such as screenings for specific diseases. Do not append modifier 33 to services that are inherently screening services and contain the word screening in the descriptor, such as a screening mammogram.

15

Anesthesia by Surgeon

Append modifier 47 to a procedure when the surgeon who performs the procedure also administers the regional or general anesthesia.

16

Bilateral Procedure

Append modifier 50 to a diagnostic, radiology, or surgical procedure code when the provider performs it on both sides of the body during the same operative session.

17

Multiple Procedures

Append modifier 51 to subsequent procedures. e.g., the second, third, fourth procedure, if the same provider performs multiple procedures for the same patient during the same encounter.

18

Reduced Services

Append modifier 52 to a procedure to show that the physician did not perform the complete procedure in the code descriptor.

19

Discontinued Procedure

Append modifier 53 to a diagnostic or surgical procedure when the physician begins a procedure and then decides to terminate it, since continuing the procedure will threaten the patient’s health.

20

Surgical Care Only

Append modifier 54 to a procedure when the provider performs the procedure but does not provide the preoperative or postoperative management.

21

Postoperative Management Only

Append modifier 55 to a procedure when the provider renders the postoperative management but does not provide the preoperative or intraoperative services.

22

Preoperative Management Only

Append modifier 56 to a procedure when the provider renders the preoperative management but does not provide the intraoperative or postoperative services.

23

Decision for Surgery

Append modifier 57 to an E/M service if the provider decides to perform surgery the day of the E/M service or the day before.

24

Staged or Related Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period

Append modifier 58 to a procedure occurring during the postoperative period when the procedure is planned or staged.

25

Distinct Procedural Service

Append modifier 59 to identify a procedure that is distinct or independent from other non E/M services that the provider performs on the same day.

26

Which is correct?

35201 – 59 and 35002or

35201 and 35002 - 5927

New for 2015XE - Separate encounterXP - Separate practitioner XS - Separate structure XU - Unusual non-overlapping service

X{EPSU}

28

Two Surgeons

Append modifier 62 to procedures where two providers work together as primary surgeons, each performing a distinct part of the procedure.

29

Procedure Performed on Infants less than 4 kg

Append modifier 63 to a procedure that a provider performs on neonates and infants weighing up to 4 kg, or 8.8 pounds.

30

Surgical Team

Append modifier 66 to a procedure code when the provider who performed the procedure was part of a surgical team performing a highly complex or difficult procedure.

31

Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional

Append modifier 76 to a procedure or service that the same provider repeats after performing the initial procedure.

32

Repeat Procedure by Another Physician or Other Qualified Health Care Professional

Append modifier 77 to a procedure or service that a different provider repeats after another provider performed the initial procedure.

33

Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period

Append modifier 78 to an unplanned procedure that requires the patient to return to the operating room. The unplanned procedure is related to an initial procedure. The provider performs the unplanned procedure during the initial procedure's postoperative period.

34

Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period

Append modifier 79 to a procedure that is unrelated to the original procedure that the same provider performed and is performed during the original procedure's postoperative period.

35

Assistant Surgeon

Append modifier 80 to a procedure code for an assistant surgeon when he assists an operating, or principal, surgeon during an entire procedure.

80

36

Minimum Assistant Surgeon

Append modifier 81 to a procedure code for an assistant surgeon when he assists an operating, or principal, surgeon during part of a procedure.

81

37

Assistant Surgeon (when qualified resident surgeon not available)

Append modifier 82 to a procedure code for an assistant surgeon when he assists an operating, or principal, surgeon during an entire procedure because a medical resident was unavailable to assist.

38

Reference (Outside) Laboratory

Append modifier 90 to a laboratory or pathology test when a reference, or outside, laboratory performs the test instead of the treating or reporting provider.

39

Repeat Clinical Diagnostic Laboratory Test

Append modifier 91 to a repeat lab test on the same day for the same patient.

40

Alternative Laboratory Platform Testing

Append modifier 92 to a lab test in the form of a kit or transportable instrument that consists of a single use, disposable, analytical chamber.

41

Multiple Modifiers

Append modifier 99 to a procedure or service as the first modifier when there are also two or more additional modifiers applicable to the service or procedure.

42

27 - Multiple Outpatient Hospital E/M Encounters on the Same Date

73 - Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC) Procedure Prior to the Administration of Anesthesia

74 - Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC) Procedure After Administration of Anesthesia

OUTPATIENT HOSPITAL MODIFIERS

43

COMMON and NEW

HCPCS MODIFIERS

44

Principal physician of record The admitting or attending physician who is

overseeing the patient’s care while in an inpatient or nursing facility setting.

Append to initial/subsequent E/M facility visit codes only

EXAMPLE

AIAI

45

Dr. Medi's Bill  Principal physician of record initial inpatient visit

99222 AI

Dr. Care's Bill  Another specialty; initial inpatient visit, same day

99222

Waiver of liability statement issued as required by payer policy, individual case

Indicates that the physician’s office has a signed advanced beneficiary notice (ABN) retained in the patient’s record.

Example: The medical reason for performing this test does not meet medical necessity and the provider is expecting a denial. Therefore, prior to performing the service the beneficiary was given an ABN that explained that the claim would be denied.

http://www.wpsmedicare.com/j5macpartb/resources/modifiers/modifier-ga.shtml

GAGA

46

Item or service statutorily excluded, does not meet the definition of any Medicare benefit or, for non-Medicare insurers, is not a contract benefit

EXAMPLEPatient transport is for a non-covered condition

that does not meet the definition of any Medicare benefit. The provider is expecting a denial.

http://www.wpsmedicare.com/j5macpartb/resources/modifiers/modifier-gy.shtml

GYGY

47

Item or service expected to be denied as not reasonable and necessary

Example: The medical reason for performing this test does not meet medical necessity and the provider is expecting a denial. However, the provider did not give an ABN to the patient prior to performing the service.

http://www.wpsmedicare.com/j5macpartb/resources/modifiers/modifier-gz.shtml

GZGZ

48

49

THE END

References

CPT®, HCPCSAAPC Procedureal Coding Expert

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8863.pdf

https://med.noridianmedicare.com/web/jeb/topics/modifiers

50