Saturday, 25 February 2017

List of Data Elements for FISS Extract

Provider # 
Health Insurance Claim (HIC) Number 
Document Control Number (DCN) 
Type of Bill 
Original Paid Date 
Statement From Date 
Statement To Date 
Original Reimbursement Amount (claims page 10) 
Revised Reimbursement Amount (claim page 10) 
Difference between these amounts 
Original Deductible Amount, Payer A, B, C (Value Code A1, B1, C1) 
Revised Deductible Amount, Payer A, B, C (Value Code A1, B1, C1) 
Difference between these amounts 
Original Coinsurance Amount, Payer A, B, C (Value Code A2, B2, C2) 
Revised Coinsurance Amount, Payer A, B, C (Value Code A2, B2, C2) 
Difference between these amounts 
Original Medicare Lifetime Reserve Amount in the first calendar year period (Value Code 08) Revised Medicare Lifetime Reserve Amount in the first calendar year period (Value Code 08) Difference between these amounts 
Original Medicare Coinsurance Amount in the first calendar year period (Value Code 09) 
Revised Medicare Coinsurance Amount in the first calendar year period (Value Code 09) 
Difference between these amounts 
Original Medicare Lifetime Reserve Amount in the second calendar year period (Value code 10) Revised Medicare Lifetime Reserve Amount in the second calendar year period (Value code 10) Difference between these amounts 
Original Medicare Coinsurance Amount in the second calendar year period (Value code 11) 
Revised Medicare Coinsurance Amount in the second calendar year period (Value code 11) Difference between these amounts
Original Outlier Amount (Value Code 17) 
Revised Outlier Amount (Value Code 17)
Difference between these amounts Original DSH Amount (Value Code 18) 
Revised DSH Amount (Value Code 18) 
Difference between these amounts Original IME Amount (Value Code 19) 
Revised IME Amount (Value Code 19) 
Difference between these amounts Original New Tech Add-on (Value Code 77)
Revised New Tech Add-on (Value Code 77) 
Difference between these amounts 
Original Device Reductions (Value Code D4) 
Revised Device Reductions (Value Code D4) 
Difference between these amounts TOT CHRG – total billed charges (claim page 3) 
COV CHRG – total covered charges (claim page 3) 
Original Hospital Portion (claim page 14)
 Revised Hospital Portion (claim page 14) 
Difference between these amounts 
Original Federal Portion (claim page 14) 
Revised Federal Portion (claim page 14) 
Difference between these amounts
 Original C TOT PAY (claim page 14) Revised C TOT PAY (claim page 14) 
Difference between these amounts Original C FSP (claim page 14) 
Revised C FSP (claim page 14) Difference between these amounts 
Original C OUTLIER (claim page 14) 
Revised C OUTLIER (claim page 14)
 Difference between these amounts Original C DSH ADJ (claim page 14) 
Revised C DSH ADJ (claim page 14) 
Difference between these amounts Original C IME ADJ (claim page 14) 
Revised C IME ADJ (claim page 14) 
Difference between these amounts Original Pricer Amount Revised Pricer Amount 
Difference between these amounts Original PPS Payment (claim page 14) 
Revised PPS Payment (claim page 14) 
Difference between these amounts
Original PPS Return Code (claim page 14) 
Revised PPS Return Code (claim page 14)
 Original UNCOMP CARE AMT (claim page 40) 
Revised UNCOMP CARE AMT (claim page 40) 
Difference between these amounts Original VAL PURC ADJ AMT (claim page 40) 
Revised VAL PURC ADJ AMT (claim page 40) 
Difference between these amounts Original READMIS ADJ AMT (claim page 40) 
Revised READMIS ADJ AMT (claim page 40) 
Difference between these amounts Original HAC PAYMENT AMT (claim page 40) 
Revised HAC PAYMENT AMT (claim page 40) 
Difference between these amounts Original EHR PAY ADJ AMT (claim page 40) 
Revised EHR PAY ADJ AMT (claim page 40) 
Difference between these amounts Original PPS-ISLET-ADD-ON-AMT (Value Code Q7) 
Revised PPS-ISLET-ADD-ON-AMT (Value Code Q7) 
Difference between these amounts DRG 
MSP Indicator (Value Codes 12-16 & 41-43 – indicator indicating the claim is MSP; ‘Y’ = MSP, ‘blank’ = no MSP Reason Code 
HMO-IME Indicator 
Filler

Monday, 23 January 2017

List Of Medicare Modifiers

Modifier AI : Principal Physician of Record

Instructions

This modifier distinguishes the Principal Physician who oversees patient's care when performing evaluation and management (E/M) services and is only appended to an appropriate E/M code by that physician. It is imperative, so that other specialties may bill their claims for the same E/M code and not receive denials.

Correct Use

Append to initial/subsequent E/M codes only
        99221 – 99223 (Hospital-Initial)
        99231 – 99233 (Hospital-Subsequent)
        99291 (Critical Care)
        99304 – 99306 (SNF-Initial)
        99307 – 99310 (SNF-Subsequent)
Only principal physician of record appends to E/M code

Incorrect Use

Inappropriate for another physician to append (primary or specialty)

Claim Coding Example

Treatment Description : Principal physician of record initial inpatient visit

CPT 99222 /Modifier AI

Another specialty; initial inpatient visit, same day

99222

Modifier AY

Item or service furnished to ESRD patient - not for ESRD treatment

Instructions

If an End Stage Renal Disease (ESRD) facility needs to report a lab service (not related to ESRD treatment), they must include modifier AY to indicate item/service was not for treatment of ESRD.

Treatment : Assay of Creatinine
CPT 82565/ Modifier AY

Correct Use

ESRD facilities reporting Daptomycin revision
Separate payment available for J0878 Injection (Daptomycin, 1 mg) when furnished to an ESRD patient (not for ESRD treatment)

Incorrect Use

Inappropriate to bill J0890 with modifier AY
Consolidated billing requirement –not overridden with AY modifier
Modifiers CD, CE and CF (also known as 50/50 rule modifiers) no longer valid for use on independent laboratory claims

Correct Claim Coding

Treatment : Assay of Creatinine
CPT 82565 / Modifier AY

Modifier CR : Catastrophe/Disaster

Correct Use

This modifier must be submitted only when an item or service is impacted by an emergency or disaster.

Use for both institutional and non-institutional billing

Effective August 31, 2009: use of CR modifier is mandatory for applicable HCPCS codes on any claim for which Medicare Part B payment is conditioned directly or indirectly on the presence of a "formal waiver"

Formal Waiver: waiver of a program requirement that otherwise would apply by statute or regulation

Two types of formal waivers

Waiver of a requirement specified in Section 1135(b) of the Social Security Act. This may permit Medicare payment in a circumstance where payment would otherwise be barred.

Waiver based on a provision of the Title XVIII of the Act or its implementing regulations.

In the event of a disaster or emergency, CMS will issue specific guidance to Medicare contractors.

Incorrect Use

When there are no instructions from CMS to use the modifier

Item/service/claim was not affected by an emergency/disaster

Modifier GC

Service has been performed in part by a resident under the direction of a teaching physician

Correct Use

Append to service that has been completed by a resident in a teaching facility in part under direction and supervision of a teaching physician

Medicare does not pay for any service furnished by a medical student as defined in Internet Only Manual (IOM), Claims Processing Manual 100-04, Chapter 12, Section 100 This link takes you to an external website..

Append in second modifier field when supervising/teaching anesthesiologist is involved in two concurrent anesthesia cases with one resident (or "fellow"), he/she may bill usual base units and anesthesia time for amount of time present with resident throughout pre, intra and post anesthesia care.

Incorrect Use

Append to service when teaching physician is not involved with any part of care

Teaching Physician Documentation

Teaching physicians shall personally document that they performed the service or were physically present during key or critical portions of the service and their participation in the management of the patient. 

The physician is able to refer to the resident's documentation; however, a statement by the attending (teaching) physician is required and must include essential and independent documentation to tie into the resident's documentation. Without such documentation, no reimbursement can be made.

Examples: Acceptable

Patient became hypoxic and hypotensive. I spent 45 minutes while the patient was in this condition, providing fluids, pressor drugs and oxygen. I reviewed the resident's assessment and plan of care.

Unacceptable

I saw the patient and agree with the resident.

NOTE: In a time based setting, such as critical care, time spent teaching does not count towards the critical care time of the physician; nor does the time the resident spent with the patient. Only time spent together with the patient or the teaching physician alone can be counted towards critical care time.

Modifier GJ

"Opt out" physician or practitioner emergency or urgent services

Instructions

In an emergency or urgent care situation, a physician/practitioner who opts out may treat a Medicare beneficiary with whom he/she does not have a private contract and bill for such treatment. In such a situation, the provider may not charge the beneficiary more than what a nonparticipating physician/practitioner would be permitted to charge and must submit a claim to Medicare on the beneficiary's behalf.

Correct Use

Example - Physician was called in to see a patient in the emergency room whom he has not seen before and no contract was signed

Claim Coding Example

CPT Code : 99282
Modifier GJ

Incorrect Use

Opt out physician to append for non-emergent services that have a private contract with patients.

Resource

Modifier GV

The attending physician is not employed or paid under agreement by the patient's Hospice provider.

Instructions

This modifier must be submitted when a service meets the following conditions, regardless of the type of provider:

Service was rendered to a patient enrolled in a Hospice.

Service was provided by a physician or non-physician practitioner identified as the patient's 'attending physician' at the time of that patient's enrollment in the Hospice program

Submit this modifier regardless of whether the services were related to the patient's terminal condition

Service was provided by a physician employed by the Hospice, you may not submit this modifier

Service was provided by a physician not employed by the Hospice and the physician was not identified by the beneficiary as his/her attending physician, you may not submit this modifier

Example:  An independent attending physician or independent laboratory interprets the surgical pathology (88305) from a patient with a terminal illness related service. 

The professional component is billed to the Medicare contractor. If there is no professional component (e.g., clinical lab tests), then the Part A Hospice should only be billed.

Date of Service

Treatment : Surgical pathology (professional component)
CPT 88305 /Modifier GV

Bill to Part B: Surgical pathology (technical component)
Bill to Hospice: 88305 TC

Same rules apply for diagnostic tests

Chest x-ray (professional component)
Bill to Part B: 71010 26GV

09/25/12
Chest x-ray (technical component)
Bill to Hospice: 71010 TC

Modifier GW

Condition not related to the patient's terminal condition

Instructions

Submit this modifier when a service is rendered to a patient enrolled in a hospice, and the service is unrelated to the patient's terminal condition.

All providers must submit this modifier when this condition applies.

Claim Coding Example

Patient is on hospice for congestive heart failure and goes to the office for a toe nail trim.  The procedure is unrelated. The GW modifier should be added to the CPT for the toe nail trim.

Modifier Q1

Routine clinical service provided in a clinical research study that is in an approved clinical research study

Correct Use

When a routine clinical service is performed as part of an approved clinical research study

Routine clinical services are defined as those items and services that are covered for Medicare beneficiaries outside of the clinical research study

Used for direct patient management within the study

Does not meet definition of investigational clinical services

Routine clinical services may include items or services required solely for the provision of the investigational clinical services (e.g., administration of a chemotherapeutic agent), clinically appropriate monitoring, whether or not required by investigational clinical service (e.g., blood tests to measure tumor markers) and items or services required for prevention, diagnosis, or treatment of research related adverse events (e.g., blood levels of various parameters to measure kidney function)

Incorrect Use

When service is not part of an approved clinical research study

Modifier Q0

Investigational clinical service provided in a clinical research study that is in an approved clinical research study

Correct Use

When an investigational service is performed as part of an approved clinical research study

Investigational clinical services are defined as those items and services that are being investigated as an objective within study

Investigational clinical services may include items or services that are approved, unapproved or otherwise covered (or not covered) under Medicare

Incorrect Use

When service is not part of an approved clinical research study

When service is not investigative in nature

Sunday, 22 January 2017

Modifier 90, 91, 99

Modifier 90

Reference (Outside) Laboratory

Instructions

Sometimes a clinical diagnostic independent lab, place of service (POS) 81, refers a specimen to another lab for testing, where a modifier 90 is appended.

Correct Use
  • Outside laboratory performs procedure, unrelated to treating/reporting physician
  • In most cases, lab furnishing the service would bill the claim
  • Possible for one lab to bill service performed by another lab
  • Referring = referring specimen to another laboratory for testing
  • Reference = lab that receives specimen from another lab and performs one or more tests on such specimen
  • Must append modifier 90 to referred laboratory test code
  • Item 20 mark "Yes" = outside lab
  • Purchase price must be reflected under charges
  • Complete item 32 with NPI, name and address where performed
  • Appropriate modifier 90 claims include two different Clinical Lab Improvement Amendment (CLIA) numbers
  • Reflect billing provider information
  • Laboratory where services were performed (reference lab)
  • Bill claims with modifier 90 and without modifier 90 separately
  • If no purchased services, leave item 20 blank

Inappropriate Use
  • Do not report modifier 90 with anatomic pathology and lab services
  • Do not append modifier 90 for drawing fee (36415)
  • Cannot be referenced out to another lab

Claim Coding Example

Treatment Description : Acute Hepatitis Panel

CPT 80074 / Modifier 90

Modifier 91

Repeat clinical diagnostic laboratory test

Instructions

This modifier is used for laboratory test(s) performed more than once on the same day on the same patient. Tests are paid under the clinical laboratory fee schedule.

Correct Use
  • For necessary tests to obtain subsequent (multiple) test results
  • For tests performed on the same patient on the same day
  • Used with laboratory tests paid under the clinical laboratory fee schedule
  • Clinical Lab Improvement Amendment (CLIA) Waived Test
  • If entity holds valid waiver certificate, append modifier QW

Incorrect Use

May not be used when there are standard HCPCS codes available that describe the series of results (e.g., glucose tolerance tests, evocative/suppression testing, etc.)

May not be used when tests are rerun to confirm initial results; due to testing problems with specimens and equipment; or for any other reason when a normal, one-time, reportable result is all that is required

Does not replace modifiers such as RT, LT, 50, E1-E4, FA, F1-F9, TA, and T1-T9

Claim Example – Pathology

Modifier 99

Multiple Modifiers (same line, same code)

Instructions

When more than four modifiers are needed to describe a service on the same code, replace with modifier 99.

Correct Use
  • Reflect all modifiers involved in Item 19 narrative or electronic equivalent
  • Replace with modifier 99 in Item 24D
  • Documentation must explain all modifiers involved
  • Includes informational and pricing modifiers
  • Certain modifiers may affect payment

Incorrect Use

In this situation, do not append other modifiers in Item 24D

Claim Coding Example

Patient had a Mohs removal (within 90 day global) on the left cheek and then another on the right cheek (RT) by the same provider, repeated twice (i.e., 79, 59, RT) and not enough modifier spaces.

Treatment Description : Mohs micrographic technique, including removal
CPT 17311 /Modifier 99

Saturday, 21 January 2017

Modifier 50, 51, 52, 53

Modifier 50

Bilateral Procedure

Instructions

When performing a procedure on bilateral body parts, append payment modifier 50 to the appropriate code performed at the same session. The bilateral adjustment is inappropriate for (a) physiology or anatomy codes or (b) code descriptor that specifically states it is a unilateral procedure and there is an existing bilateral procedure code.

Correct Use

One line appending modifier 50 or RT and LT using one unit of service
See Bilateral Surgery Rules within Medicare Physician Fee Schedule (MPFS) Indicator Descriptions

Incorrect Use
  • Inappropriate to apply an already "bilateral description" code.
  • Do not append to procedures for midline organs such as the bladder, uterus, esophagus or nasal septum.
  • Inappropriate to report when performed on different areas of same side of body.

Claim Coding Example

Treatment Description : Total Knee Arthroplasty

CPT 27447 /Modifier 50

Modifier 51

Multiple Procedures. When multiple procedures, other than Evaluation and Management (E/M), Physical Medicine and Rehabilitation services or provisions of supplies (e.g., vaccines) are performed at the same session by the same individual, the primary procedure or service may be reported as listed. Multiple procedure rules apply to the secondary procedure or service.

Instructions

Do not append modifier 51 to the additional procedure code. The Medicare claim processing system has a hard coded logic to append it to the correct procedure code. CPT also lists codes that are modifier 51 exempt.

Correct Use

Below are situations when multiple procedure rules apply.
  • Append when same physician performs more than one surgical service at same time (Indicator 2)
  • Append when technical component of multiple diagnostic procedures, Multiple Procedure Payment Reduction (MPPR) rule apply (Indicator 4)
  • Append when multiple surgical procedures are done on same day but billed on two separate claims

Incorrect Use
  • Do not append modifier 51 to additional procedure code
  • Do not append to add-on codes (See Appendix D in the CPT manual)
  • Do not append to all lines of service
  • Do not append when two or more physicians each perform distinctly, different, unrelated surgeries on same day to same patient

Modifier 52

Partially Reduced or Eliminated Services

Instructions

This modifier is used to indicate partial reduction, cancellation or discontinuation of services for which anesthesia is not planned. The modifier provides a means for reporting reduced services without disturbing the identification of the basic service. It also identifies a situation where a physician reduces or eliminates a portion of a service or procedure.

Correct Use
  • Indicate statement "reduced services" in Item 19 in CMS-1500 claim form (or electronic equivalent)
  • Include brief reason for reduction
  • Documentation includes complete reduction reason retained in patient's record
  • To determine charge amount, reduce normal fee by percentage of service not provided
  • E.g., if 75% of normal service provided, reduce amount billed by 25% 
  • Medicare claims processing system reimburses lower of actual charge or fee schedule allowance  
Example: Provider performs 75% of service and appends modifier 52

Medicare Physician Fee Schedule (MPFS) allowed amount* : $100

Reduced Billed Amount ($100 x 75%) : $ 75
*Medicare recognizes that many providers use one standard fee schedule for all insurance carriers. Therefore, reducing the charge amount may differ from the example.

Incorrect Use
  • Do not confuse with "terminated procedure" modifier 53
  • Inappropriate with E/M codes
  • Inappropriate with facility billing
  • Not for use in Ambulatory Surgical Center (ASC) or outpatient hospital
Special Appeal Instructions
  • When submitting the Redetermination request
  • Separate, concise statement explaining necessity for allowable reduction
  • Submit operative report and/or chart notes
Claim Coding Example

This bilateral procedure was performed on one eye (unilateral) only. Since the code is allowed at a bilateral rate, the provider must append modifier 52 to reduce charges. In this case, it is not appropriate to use RT or LT.

Treatment Description : Fundus photography with interpretation/report; bilateral
CPT 92250 /Modifier 52

Modifier 53

Discontinued Procedure (professional services only)

Instructions

This 53 modifier allows the physician community to state the surgical procedure was discontinued due to extenuating circumstances or a threat to patient well-being.  

Correct Use
  • Append in first pricing position.
  • Under certain circumstances, physician may elect to terminate surgical or diagnostic procedure.
  • Surgical or diagnostic procedure started and discontinued by physician.
  • Prior to or after anesthesia is administered.
  • Bill Medicare the percentage of service completed (see second example below).
  • Medicare Claims Processing System does not automatically reduce payment.
Incorrect Use

Inappropriate with E/M or anesthesia codes
Do not use to report elective procedure cancellation, in the operating suite, prior to patient's anesthesia induction and/or surgical preparation
Inappropriate to use for Ambulatory Surgery Center (ASC) or hospital facility claims
Use facility modifiers 73 or 74
Do not confuse with "reduced procedure" modifier 52

Claim Coding Example

Treatment Description : Sigmoidoscopy; flexible; diagnostic

CPT 45330 /Modifier 53

Claim Reduction Fee Example

Provider performs 60% of service, reducing charges and appends modifier 53.

Medicare Physician Fee Schedule (MPFS) Allowed* : $200

Bill Reduced Amount ($200 x 60%) : $120

*Medicare recognizes that many providers use one standard fee schedule for all insurance carriers. Therefore, reducing the charge amount may differ from the example.

Friday, 20 January 2017

Modifier 54, 55, 58

Modifier 54

Surgical Care Only. When a physician or other qualified health care professional performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding modifier 54 to the usual procedure code.

Instructions

Modifier 54 is used to explain that the surgeon performed the surgical procedure only and is relinquishing a part or all of the postoperative days to another physician.

Correct Use

Surgeon performs surgery only
Bill surgical date of service
Append modifier 54 to surgical code

Incorrect Use

Do not append modifier 54 if patient is under surgeon's care for the full 10 or 90 days of postoperative care

Do not append on ASC facility or assistant surgeons services

Claim Coding Example

An orthopedic surgeon performs an open tibial shaft fracture (27759) but relinquishes care to another physician for postoperative care.

Date     Treatment Description CPT/Modifier Units
3/9/16 Open tibial shaft fracture 27759 54 1

Modifier 55

Postoperative Management Only. When a physician or other qualified health care professional performs the postoperative management and another physician performed the surgical procedure, the postoperative component may be identified by appending a modifier 55 to the surgical procedure.

Instructions

Modifier 55 is used when the surgeon is either relinquishing all or part of the postoperative days to another physician.

Correct Use
  • Surgeon performs part of postoperative care
  • Submit claim with two lines using same date of service and procedure code;  append modifier 55 to line 2
  • Include date span in Item 19 narrative of CMS-1500 claim form or electronic equivalent
  • Submit claim with number of units as 1
  • Physician rendering additional postoperative care
  • Submit claim with surgery date and procedure code
  • Include date span of assumed care in Item 19 narrative of CMS-1500 claim form or electronic equivalent
  • Submit claim with number of units as 1

Incorrect Use
  • Do not append modifier 55 when surgeon performs surgery only: no postoperative care
  • See instructions on modifier 54
  • Do not append modifier 55 if patient is under surgeon's care for full 10 or 90 days of postoperative care
  • Do not append on ASC facility or assistant surgeons claims

Claim Coding Example

An orthopedic surgeon performs an open tibial shaft fracture (27759) and bills the surgery with modifier 54. The partial postoperative care (modifier 55) is provided by the surgeon for the initial 45 days (March 10 - April 23) and is then turned over to another physician for the remailing 45 days (April 24 - June 7).

Date Treatment Description CPT/Modifier Units
3/9/2016 Open tibial shaft fracture 27759 54 1
3/9/2016 Open tibial shaft fracture 27759 55 1

Comment field showing dates care provided

Date Treatment Description CPT/Modifier Units
3/9/2016 Open tibial shaft fracture 27759 55 1

Comment field showing dates assumed care

Modifier 58

Staged or Related Procedure or Service During Postoperative Period by Same Physician

Instructions

The same physician planned, at the time of the original surgery/procedure, a return trip to the operating or procedure room within the 10 or 90 day post op days

Correct Use

Treatment of problem requiring a return to the operating/procedure room

More extensive than original procedure

Unanticipated clinical condition

Therapy following a diagnostic, surgical procedure                               
Each case requires surgical documentation and evaluation Modifier 58 appropriate for example; hardware removal was planned as part of therapeutic approach involving multiple, staged procedures to the surgical intervention

Physicians in the same specialty, same group are to bill and are reimbursed as a single physician

Use modifier 78 for treatment problems unplanned requiring return trip to operating room

If hardware removed in unplanned surgery return for a complication, (e.g. infection of the wound site or rejection of the hardware itself), modifier 78 appropriate

Incorrect Use

Not appropriate for E/M or assistant surgery services

Claim Coding Example

Patient has excision (11606) with a 10 day global and a complex repair closure (13101) planned 9 days after the surgical date, then append modifier 58 to the closure.

Treatment Description : Excision, malignant lesion trunk, arm, legs

CPT 13101 / Modifier 58

11606 : Repair closure

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