NYU School of Medicine Coding and Reimbursement Seminar Series MODIFIERS - The Key to Proper Reimbursement

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NYU School of MedicineCoding and Reimbursement
Seminar SeriesMODIFIERS - The Key to Proper
Reimbursement

• Presented by the Office of Reimbursement
  Compliance
• Gretchen L. Segado, MS, CPC
• Director of Reimbursement Compliance
• [phone]
• [phone] fax
• Gretchen.Segado_at_med.nyu.edu

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Todays Agenda

• What are modifiers?
• How are they used?
• Why do I care?

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What are modifiers?

• Modifiers are two digit codes appended to a CPT
  code that indicate that a service or procedure
  has been altered by a specific circumstance, but
  has not changed in its basic definition

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Three Levels of HCPCS Codes(Healthcare Common
Procedural Coding System)

• Level 1-CPT, Physicians Current Procedural
  Terminology
• Level 2-HCPCS National Codes
• Level 3-Local Codes assigned and maintained by
  individual state Medicare Carriers
• Eliminated by HIPAA as of Dec 31, 2003

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Modifiers denote that

• A service or procedure has both a professional
  and technical components
• A service or procedure was performed by more than
  one physician
• A service or procedure has been increased or
  reduced
• Only part of a service was performed
• A service or procedure was provided more than
  once
• A bilateral procedure was performed
• Unusual events occurred

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Examples

• 31237-50 (procedure done bilaterally)
• 99214-25 (office visit and procedure on same
  day)
• 33208-62 )two surgeons of differing specialties
  doing same procedure together)

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Two Ways to Report Modifiers on a Claim Form

• Modifier appended to the CPT code
• 49500-50
• Reported by using separate five-digit code along
  with the procedure code.
• Example 49500 plus
• 09950
• Method 1 is the most common usage

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Why arent my claims getting paid?
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Why arent my claims getting paid?

• Appropriate use of modifiers get services
  reimbursed that might otherwise be denied!!!
• Claims can be incomplete or inaccurate without a
  modifier
• Coding to the highest level of specificity
  requires modifier use

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What is the Global Period?

• Also known as the global surgical package
• No one standard definition
• Per CPT guidelines,
• The following services are always included in
  addition to the operation per se
• local infiltration, metacarpal/metatarsal/digital
  block or topical anesthesia

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What is in the Global Period?

• subsequent to the decision for surgery, one
  related E/M encounter on the date immediately
  prior to or on the date of procedure (including
  history and physical)
• immediate postoperative care, including
  dictating operative notes, talking with the
  family and other physicians
• writing orders
• evaluating the patient in the post-anesthesia
  recovery area
• typical postoperative follow-up care.

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Examples of Services Included in the Global Period

• Removal of staples 10 days after a surgical
  procedure
• A visit with a patient prior to surgery to answer
  any last minute questions
• A post-operative visit in the office to check on
  wound healing

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Examples of Services NOT Included in the Global
Package

• The visit where the decision to perform a
  procedure or surgery was made, even if on the
  same day as the procedure
• A visit during the post-op period for a problem
  unrelated to the surgery
• Without a modifier, these service will not get
  paid!!!!!!!

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Modifier -21Prolonged E/M ServicesAppend to EM
code

• When face-to-face or floor/unit service provided
  is prolonged or otherwise greater than that
  usually required for the highest level of EM
  code
• Unfortunately, the modifier rarely affects
  payment
• May only be used with the highest level of E/M
  service
• NOT a time based modifier

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Modifier -22Unusual Procedural ServicesAppend
to procedure code

• Indicates that procedure was more complicated or
  complex
• Alerts payers to unusual circumstances or
  complications during a procedure
• Increased work effort of 30-50

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Key terms

• Increased risk difficult extended
  complications prolonged unusual findings
  unusual contamination controls hemorrhage, blood
  loss over 600cc, unusual findings, etc.
• Additional physician work due to complications or
  medical emergencies may warrant use of -22

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Appropriate Use of Modifier -22

• Appropriate Use
• Partial colectomy in a patient with a tumor
  adherent to vascular structures requiring
  additional 60 minutes of dissection (due to
  increased risk and time)

• Inappropriate Use
• Partial colectomy with accidental laceration of
  vessel resulting in additional time for repair

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Modifier -23 Unusual AnesthesiaAppend to
Procedure Code

• Occasionally, a procedure requiring local or no
  anesthesia must be done under general anesthesia
  due to unusual circumstances.
• Example Child or adult unable to cooperate with
  procedure - requires anesthesia i.e. CT, MRI, XRT

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-23 Unusual Anesthesia

• Use the code once on the basic service procedure
  code
• Claim must be accompanied by documentation and
  cover letter by physician explaining the need for
  general anesthesia
• Not for use by the anesthesiologist
• Do not use for local anesthesia

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Modifier -24 Unrelated E/M Service by Same
Physician during a Postoperative Period Append
to EM code

• Used when a physician provides a surgical service
  related to one problem and then during the
  postoperative period provides an EM service
  unrelated to the problem requiring the surgery.
  Diagnosis code selection is critical to indicate
  the reason for the additional EM service.

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Modifier -24

• Example Patient came in for post-operative
  visit. He is 12 weeks s/p diskectomy. During the
  exam, pt c/o severe headaches with visual
  changes, preceded by an aura. The physician
  performs an expanded problem focused exam. His
  impression is migraine with medical decision
  making of low complexity.
• Report
• CPT Code 99213 24 Level 3, established
  patient office visit

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Services Not Included in Global Package

• Initial consultation or evaluation by the surgeon
  to determine the need for surgery
• Services of other physicians unless a transfer of
  care has been arranged
• Visits unrelated to patients surgical diagnosis
• Treatment for the underlying condition or an
  added course of treatment that is not part of
  normal recovery from surgery

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Services Not Included in Global Package

• Diagnostic tests and procedures
• Staged or clearly distinct surgical procedures
  during the post-op period
• Treatment for post-op complications requiring a
  return to the OR
• A more extensive procedure when a less extensive
  procedure fails

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Services Not Included in Global Package

• Supplies, such a surgical trays, splints and
  casting materials when certain surgical services
  are performed in the physicians office
• Immunosuppresive therapy for organ transplants
• Critical Care services unrelated to the surgery
  for a critically injured patient
• Pre-op evaluations outside of the global surgical
  period

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"Let's hope therere no post-op problems-it
complicates the billing."
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Clinical Examples for Modifier -24

• Appropriate Use
• Patient 80 - days s/p TURP. Reports to the office
  of the surgeon who performed the procedure
  complaining of right flank pain and abdominal
  pain. Diagnostic work-up reveals a kidney stone.
• Report 992XX-24 with diagnosis code for the
  kidney stone

• Inappropriate Use
• Patient returns for complaining of fever and
  wound tenderness in the global period of her
  C-Setion
• Report 99024 post-op visit

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Modifier -25Significant, Separately Identifiable
Evaluation and Management Service by the Same
Physician on the Same Day of the Procedure or
Other ServiceAppend to EM Code

• Indicates that on the day of a procedure or other
  service, the patients condition required an
  additional EM service above and beyond the usual
  pre and post-op care associated with the
  procedure performed.
• EM Service elements must be clearly documented
  to justify that a visit took place beyond the
  elements necessary to perform the procedure

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Modifier -25

• EXAMPLE
• An established patient is seen by the physician
  to evaluate his general osteoarthritis, benign
  HTN and NIDDM. While examining the patient, the
  physician determines that an arthrocentesis of
  the patients knee joint needs to be performed.
• REPORT
• CPT Codes 9921X-25 20610

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Clinical Example

• Appropriate Use
• Procedure Excision, rt. arm lesion
• Visit- Established Pt concerned about changes to
  a lesion on right arm. History taken, examination
  of arm and additional body areas for new and
  suspicious lesions performed. Physician decides
  to remove lesion.

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Clinical Example

• Inappropriate Use
• Patient presents for scheduled removal of lesion
  on right arm. Exam of arm to determine status of
  lesion performed and a general determination of
  the patients status prior to excision.

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Modifier -26Professional ComponentAppend to
procedure code

• Certain procedures are a combination of a
  physician component and a technical component.
  When physician component is reported separately,
  add -26 to the CPT code to identify that the
  physicians component only is being billed.
• EXAMPLE A 72 year old woman comes to the
  Emergency Room complaining of chest discomfort.
  The physician orders a complete 2D
  echocardiography using the hospital equipment.
  The physician provides the written
  interpretation.
• REPORT CPT Codes 93307-26

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Modifier -26

• For use by physicians when utilizing equipment
  owned by a hospital/facility
• Interpretations must be separate, distinct,
  written and signed
• Not all procedures have a professional/technical
  split!
• Refer to Medicare Fee Schedule to determine what
  procedures are eligible for this modifier
• Common Services billed with -26
• Radiology, Stress Tests, Heart Catheterizations

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Modifier -32Mandated ServicesAppend to EM Code

• Attach modifier 32 to mandated consultation /or
  other services.
• Usually mandated by courts, government agencies
  or an insurance entity

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Modifier -47Anesthesia by SurgeonAppend to
Procedure Code

• Regional or general anesthesia provided by
  surgeon may be reported by adding -47. Not to be
  used with local anesthesia
• This service is not covered by Medicare or
  Medicaid
• Do not use this modifier with anesthesia codes

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Modifier -50Bilateral ProcedureAppend to
procedure code

• Used to report bilateral procedures that are
  performed at the same operative session. Used
  only to services/procedures performed on
  identical anatomic sites, aspects or origins
  (arms, legs, eyes, breasts)
• Example Physician removes a foreign body from
  each of a patients ears without anesthesia.
• CPT Code 69200-50

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Modifier -51Multiple ProceduresAppend to
Procedure Code

• Multiple and related surgical procedures, other
  than E/M services, performed at the same session
  by the same provider.
• EXAMPLE Patient presents for removal of a
  malignant lesion on the face with complex repair
  of the defect
• REPORT CPT Codes 11641 13152-51

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Modifier -51

• Do not use -51 on procedures that are components
  of another procedure
• Do not use the -51 on the primary procedure, only
  on the secondary procedures (order procedures by
  RVU)
• Do not use -51 on procedures with a sign
  indicated in the CPT Manual

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Modifier -52Reduced Services

• Used to identify a procedure or a service that is
  partially reduced or eliminated at the physician
  s discretion.
• EXAMPLE A 50 year old woman presents to have 20
  skin tags removed.
• REPORT CPT Codes
• 11200 - removal of skin tags up to and
  including 15 lesions.
• 11201-52 - each additional 10 lesions
  

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Modifier -53Discontinued ProcedureAppend to
Procedure Code

• Used to indicate that a surgical or diagnostic
  procedure was started but discontinued, usually
  because of extenuating circumstances or those
  that threaten the patients well-being.
• Most often used when a physician elects to
  terminate a surgical or diagnostic procedure
• Usually used after the induction of anesthesia

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Modifier -53

• Differs from modifier -52 because in that a
  life-threatening condition precipitates the
  terminated procedure.
• Not used to report elective cancellation prior to
  induction of anesthesia or surgical prep,
  including situations where cancellation is due to
  patient instability

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Modifier 53Discontinued Procedure cont.

• EXAMPLE
• A 50 year old woman complaining of acute rectal
  bleeding. She was given a bowel prep,
  administered at home, and returned for a total
  diagnostic colonscopy. The procedure proceeds in
  the normal fashion, however the patient suddenly
  develops an erratic heart beat and the physician
  elects to discontinue the procedure.
• REPORT CPT CODE 45378 - 53

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Modifier -54Surgical Care OnlyAppend to
Procedure Code

• Physician service to the patient was only the
  intra-operative procedure. Another physician(s)
  will perform the Pre-operative and Post operative
  care.
• There should be an agreement for the transfer of
  care between physicians
• Do not use with procedure codes having a zero day
  global period
• Do not use -54 if physician is a covering
  physician (locum tenens) or part of the same
  group as the surgeon who performed the procedure

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Clinical Example

• A neurosurgeon travels to a rural location to
  perform a craniotomy for drainage of an
  intracranial abscess. He assessed the patient the
  day before surgery, and performed the procedure.
  Follow-up care was performed by a local surgeon.
• The neurosurgeon would report 61321-54

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Modifier -55 Postoperative Management Only

• While on vacation in Vail, Anna had a skiing
  accident. A local Orthopedist in Vail did the
  Pre operative and Intra-operative procedure and
  the patient went home.
• NYU physician provides all post-op care, and
  bills by adding a -55 to the surgical procedure
  code.

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Modifier -56Preoperative Management Only Append
to Procedure Code

• Pre operative evaluation was performed and
  decision was made to have the intra-operative
  procedure and post operative care done else
  where.
• Internist does pre-op work-up on a patient having
  a laporoscopic cholecystectomy by a general
  surgeon who travels to the area monthly.
  Internist would bill 47562-56

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MODIFIER -57DECISION FOR SURGERY

• E/M service on the day before or on the day of
  major surgery (90 day global period) which
  results in the initial decision to perform the
  surgery is not included in the global surgery
  payment.
• EXAMPLE Patient comes to the emergency
  department with sudden onset of acute abdominal
  pain. Gyn physician evaluates patient
  determines that patient has twisted ovarian cyst.
  Physician admits patient to OR for right
  salpingo oophorectomy.
• REPORT CPT Code 99223-57 58720

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Modifier 58Staged or Related Procedure by the
Same Physician during the Postoperative
PeriodAppend to Procedure Code

• Indicates that the procedure or service during
  the post-op period was either
• planned prospectively at the time of the original
  procedure
• More extensive than the original procedure
• For therapy following a diagnostic surgical
  procedure
• Without the modifier, the third-party payer could
  reject the claim because the surgery occurred
  during the post-op period

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Modifier -58

• Example 32 year old woman with breast cancer
  undergoes a mastectomy one week ago. Today, she
  is scheduled to have breast implants placed.
• Report 19342-58
• Example Sternal debridement performed for
  mediastinitis and it is noted that a muscle flap
  repair will be needed in a few days to close the
  defect
• Report 15734-58 since muscle flap planned at
  time of initial surgery

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Modifier -59Distinct Procedural ServiceAppend
to Procedure Code

• Indicates that a procedure or service was
  distinct or separate from other services
  performed on the same day. May represent a
  different session or patient encounter, different
  incisional site, separate lesion, or separate
  injury.
• Example An arthroscopic synovectomy was
  performed on the right knee for localized
  synovitis and a diagnostic arthroscopy was
  performed on the left knee for chronic pain
  syndrome.
• Report CPT Codes 29875 29870 - 59

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Modifier -62 Two surgeonsAppend to Procedure
Code

• 2 surgeons work together as primary surgeons
  performing distinct parts of a single procedure
• Each surgeon reports his/her distinct operative
  work by adding the -62 modifier to the procedure
  code and related add-on codes
• Example Transphenoidal Hypophesectomy
• Neurosurgeon and ENT both report 61548-62

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Modifier -62

• Appropriate Use
• Arthrodesis using anterior interbody technique,
  thoracic level.
• Thoracic surgeon performs a thoracotomy, exposes
  and later closes the site
• Orthopaedic surgeon performs the arthrodesis
• Both surgeons use CPT Code
• 22556-62

• Inappropriate Use
• Oncology surgeon performs a radical mastectomy.
  At same operative session the plastic surgeon
  then performs breast reconstruction. In this
  case, the surgeons are performing 2 distinct
  services and each uses separate CPT codes and -62
  is not required

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Modifier -63 Procedure Performed on Infants less
than 4kgAppend to Procedure Code

• Procedures performed on neonates and infants up
  to a present body weight of 4kg may involve
  significantly increased complexity and physician
  work
• Unless otherwise designated, should only be
  appended to services in 2000-69999 code series.
  Should not be appended to EM, Anesthesia,
  Radiology, Path/Lab, Medicine sections

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Modifier -66Surgical Team

• Highly complex procedures requiring concomitant
  services of several physicians, often of
  different specialties plus other highly skilled,
  specially trained personnel, various types of
  complex equipment

• Transplants
• Separation of conjoined twins
• Each participating physicians uses the modifier

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Modifier -76 Repeat Procedure by same physician
Append to Procedure Code

• Example Pt. was brought by an ambulance to the
  ER with multiple trauma. Pt. was intubated and
  chest X-ray was taken. Results showed tube was
  not in position, pulled and re-inserted.
• Report CPT Codes 31500
• 31500 76

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Modifier -77Repeat Procedure by Another
Physician Append to Procedure Code

• Example A PCP performs a chest x-ray in his
  office and observes a suspicious mass. He sends
  the patient to a Pulmonologist who, on the same
  day, repeats the CXR.
• The Pulmonologist should submit their claim with
  the and provide documentation to support the need
  for a repeat CXR.

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Modifier 78 Return to OR for a related procedure
during post-operative period Append to Procedure
Code

• Example Pt. brought to recovery room S/P
  abdominal surgery. Dressings became saturated,
  vital signs were unstable. Pt. brought back to OR
  for exploration post-op hemorrhage.
• Report CPT Codes 35840 78

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Modifier 79 Unrelated Procedure/Service by same
MD during the post-op period Append to Procedure
Code

• Example
• A repair of femoral hernia 49550 (90 day
  global) is performed on Jan. 5. On Feb. 12, the
  same physician performs an appendectomy.
• Report
• CPT Code 44950 79

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HCPCS Modifiers

• Alpha or alphanumeric
• Provide additional information just like CPT
  modifiers

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Examples

• AH- services by Clinical Psychologist
• F1-Left hand, second digit
• FP-service provided as part of Medicaid Family
  Planning Program
• GG-performance and payment of a screening
  mammogram and diagnostic mammogram on the same
  patient, same day

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GC ModifierAppend to both EM and Procedure Codes

• Used to indicate when a service has been
  performed in part by a resident under the
  direction of a teaching physician.
• Also applies to assistant surgeon on operative
  reports.

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GE Modifier Append to both EM and Procedure
Codes

• Service performed by a resident without the
  presence of a teaching physician under the
  primary care exception

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A Quick Self-Test for Compliance Practices in
Your Office

• Does your office review all pertinent
  documentation prior to appending a modifier?
• Do you monitor the activities of your billing
  office or service with respect to modifier usage?
• Do you randomly cross-check all billings
  performed by your office or service to be certain
  that claims submitted with modifiers are accurate
  and appropriate?

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Compliance Test cont.

• Do you make sure the staff is educated and
  updated on Medicare and Medicaid program changes?
• Are services billed to Medicare and Medicaid
  thoroughly documented?
• Are new billing employees and new physicians
  oriented on modifier reporting policies?

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The Answer to all those questions should be YES.
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A Quick Self-Test for Complaint Practices in Your
Office

• Do you allow your billing office or service to
  assign modifiers and subsequently report services
  on claims without conducting an intermittent
  review of claims?
• Does your billing office or service have carte
  blanche permission to correct and/or change codes
  for services that you have performed?

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• Is there evidence of inappropriate overpayment by
  the payer when a modifier is used?
• Does your billing office or service answer all
  Medicare and Medicaid inquiries regarding your
  services and claims on your behalf without your
  knowledge?

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The Answer to These Questions Should be NO!!!!!!!!
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Remember, Modifiers mean real money for your
practice!!!