Tuesday, 17 January 2017

Modifier 77, 78, 79

Modifier 77

Repeat procedure by another physician

Instructions

This modifier is appended to a repeated service from other physicians.

Correct Use
  • Service originally performed by another physician
  • Documentation must include reason for repeat procedure
  • E.g., suspicious findings in original x-ray or EKG

Incorrect Use

Not appropriate if repeated by same physician

Claim Coding Example

Physician and Treatment Description : Radiologic exam; spine, single view
CPT 72020 / Modifier 77

Radiologic exam; spine, single view

Modifier 78

Return to Operating Room for related surgery during post op period

Instructions

This modifier is appended to another surgical code for an unplanned return trip to the operating room during global post op (10 or 90 days).

Correct Use
  • Append 78 modifier in first position as the pricing modifier
  • E.g., Possible complications
  • Payment limited to allotted intra-op services only
  • Append modifier 58 if return procedure was staged or planned

Incorrect Use

If Medicare Physician Fee Schedule (MPFS) indicator list marked with "XXX", then no modifier needed as the code has no global dates

Claim Coding Example

Provider performs bypass on February 24, 2015, and then nine days later, because of a possible infectin, an unplanned return trip back to the operating room for a chest wall exploration.

Treatment Description : Coronary artery bypass

CPT 33514 / Modifier 78

Explore chest wall

35820

Modifier 79

Unrelated procedure or service by the same physician during the postoperative period.

Instructions

This modifier is used when an unrelated procedure or service, by the same physician, is performed during the postoperative period (10 or 90 day global) of the original procedure. A new post-operative period begins when the unrelated procedure is billed.

Correct Use
  • Only on surgical codes
  • Append modifier 79 in first position as pricing modifier
  • Not necessarily needing return to operating room
  • Failure to append could result in noncoverage
  • For repeat procedures on same day, append modifier 76

Incorrect Use

If Medicare Physician Fee Schedule (MPFS) indicator list marked with "XXX," no modifier is needed as there are no global dates

Claim Coding Example

Provider performs right toe amputation on May 24, 2015.
On June 25, 2015, a left foot amputation surgery was medically necessary within this 90 day global period

Date Treatment Description CPT/Modifier
5/24/15 Amputation big toe, RT 28820 TA
6/25/15 Amputation foot, LT 28800 79

Monday, 16 January 2017

Modifier 26

Professional Component (PC) 'interpretation' Only (separate from technical component for diagnostic, lab or pathology procedures).

Instructions

Indicates physician's interpretation or professional component reported separately (from technical component) for diagnostic, lab or pathology procedures

Check Medicare Physician Fee Schedule (MPFS) Indicator and Descriptor Lists

Certain codes are divided from global with TC/26 modifiers

Technical and professional component fees equal total global allowance

Report in first field as a payment modifier

Correct Use

Involves global, professional and technical
        E.g. 71010, 71010 26 and 71010 TC

Place of Service (POS) 21, 22 and 23 only Services appended with modifier 26

Facility pays technical portion with modifier TC

If 26 and TC are provided in different service locations (enrolled practice locations), the professional and technical must be billed separately

Incorrect Use

Not appropriate with evaluation and management (E/M) or 
Anesthesia codes

On or after July 1, 2012, an independent laboratory may not bill TC of a physician pathology service furnished to a hospital inpatient or outpatient

Cannot use separately if provider performed the global service (In this case, no modifier would be necessary)

Claim Coding Example

Treatment Description Cytopathology, in situ hybridization (e.g. FISH), urinary tract specimen with morphometric analysis, 3-5 molecular probes, each specimen; manual

CPT 88120 /Modifier 26

Sunday, 15 January 2017

Modifier 25

Indicates on the day of a procedure or other service, the patient's condition required a significant, separately identifiable Evaluation and Management (E/M) service above and beyond the other service provided or beyond the usual pre-operative and post-operative care associated with the procedure that was performed. 

This modifier should only be used if an E/M is being billed on the same day as a procedure.

Correct Use

This modifier may be used to indicate that an E/M service or eye exam, which is performed on the same day as a minor surgery (000 or 010 global days) and which is performed by the surgeon, is significant and separately identifiable from the usual work associated with the surgery.

Documentation in the patient's medical record must support the use of this modifier.

This modifier should not be submitted with E/M codes that are explicitly for new patients only: CPT codes 92002, 92004, 99201-99205, 99321-99323 and 99341-99345. These codes are listed as new patient codes and are automatically excluded from the global surgery package. They are reimbursed separately from surgical procedure and no modifier is required.  

New patient CPT codes required CPT modifier 25 when a separately identifiable E/M service is performed the same day as chemotherapy or non-chemotherapy infusions or injections as these are not considered surgery.

No supporting documentation is required with the claim when this modifier is submitted.

A different ICD-9 code from the one submitted with the minor surgery is not required with the E/M code. The diagnosis for the E/M service and the other procedure may be the same or different.

This modifier may be used to indicate that an E/M service was provided on the same day as another procedure that would normally bundle under the National Correct Coding Initiative (NCCI). In this situation, CPT modifier 25 signifies that the E/M service was performed for a reason unrelated to the other procedure.

Incorrect Use

A physician other than the physician performing the procedure.

Documentation shows the amount of work performed is consistent with that normally performed with the procedure.

Claim Example

A patient was seen to close a wound due to a motor vehicle accident (12032). They also checked for any neurological injury (99212). The 12032 has a 10-day global period, so modifier 25 is appended to 99212. (Per NCCI edits, 99212 does not bundle with 12032).

Date of Service : 08/02/12
Treatment : Layer closure of wounds of scalp
CPT  99212 /Modifier 25

12032

08/02/12

E/M visit – Verify neurological injury.

Saturday, 14 January 2017

Modifier 24

Unrelated Evaluation and Management (E/M) service performed by the same physician during the postoperative period

Instructions

This modifier can be used to indicate that an E/M service or eye exam, which falls within the global period of a major or minor surgery and is performed by a surgeon, is unrelated to the surgery.

This modifier can only be submitted with E/M and eye exam codes.

When this modifier is submitted, supporting documentation of an unrelated ICD-9 code and/or additional documentation may be requested to support that the E/M service is unrelated to the surgery.  

If the ICD-9 code for the E/M service clearly supports that the visit was unrelated to the surgery, there is no need to submit additional documentation.

Special Instruction for Ophthalmologists

If the exam and prior surgery were performed on different eyes, this information needs to be indicated in the appropriate field. HCPCS modifiers RT and LT may not be submitted with eye exam codes.

Correct Use

Do not use this modifier when the E/M is for a surgical complication or injection.

When documenting treatment of an infection of a wound, consider this part of post-operative care.

Do not use this modifier when the patient is admitted to a skilled nursing facility for a condition that is related to the surgery.

Do not use this modifier when the E/M is not clearly shown to be unrelated to the surgery in the medical record documentation.

Do not use this modifier outside of the post-op period of a procedure or on the same day as the procedure.

Coding Claim Example

The patient comes in for a lesion removal, which has 10 postoperative global days. Four days later, patient comes in for a new condition of upper respiratory infection (URI). Since the URI is a new, unrelated condition during the postoperative period, modifier 24 is appended to the E/M code. 

If modifier 24 is not appended to the E/M code, it will be denied as included in the global package of the surgery. The second diagnosis code must be unrelated to the lesion removal to allow for separate payment. Even though there are two separate unrelated diagnosis codes on the claim, the new diagnosis alone will not pay the claim.

Treatment Description : Destruction of premalignant lesion
CPT 17000 /Modifier PT

Modifier 24

CPT 99213E/M for upper respiratory infection (URI).

Friday, 13 January 2017

Modifier 22


Increased Procedural Services (surgical/procedures codes only)

Instructions
  • Must indicate the work performed is substantially greater than typically required
  • Technical difficulty
  • Severity of patient's condition
  • Increased intensity and time
  • Claims paid at profile unless appealed with documentation for appended modifier 22
  • Documentation includes separate paragraph titled Unusual Procedure
Correct Use

Report only with surgical procedure codes that have 0,10 or 90 day global periods

Clearly indicate why this case is beyond the usual range of difficulty

Do not use generalized statements such as: "Surgery took an extra two hours", "Patient was very ill" or "This was a difficult surgery." These statements do not explain why the surgery was unusual.

These issues do not necessarily warrant additional payment:
  • Surgery encountering adhesions
  • Surgery for an obese person
  • Surgery that takes longer than usual to complete
  • Specialized technology (E.g. laparoscope or laser)

Incorrect Use

Cannot submit with evaluation and management (E/M) procedures

Note: Noridian no longer requests additional claim documentation. The specific "Modifier 22 Form" has been removed from the website.

Special Appeals Process

When submitting the Redetermination request, a separate, concise statement explaining the necessity for additional reimbursement must be included.

Need operative report or separate letter

Medical Review addresses individually with no guarantee of additional payment 

Claim Coding Example

Treatment Description - Pharyngolaryngectomy, with radical neck dissection; with reconstruction
 
CPT 31395 / Modifier 22 

Thursday, 12 January 2017

Modifier RT, 47, 80, 81, 82, AS, GN, GO, GP

Modifier RT

Instructions

Used to identify procedures performed on right side of body. Refer to Medicare Physician Fee Schedule database (MPFSDB) to determine if HCPCS modifier RT is applicable to a particular procedure code

Correct Use

When body contains a right and left anatomical part of body and a service is performed on right anatomical part

Incorrect Use

When a procedure code specifies bi-lateral or a side of body

Note: Modifier RT does not affect allowed amount on a claim; however, lack of modifier can cause denials or development to occur

Modifier 47

Anesthesia by Surgeon

Instructions

Surgical allowable based on 50 percent of Medicare Physician Fee Schedule (MPFS)

Correct Use

Regional/general anesthesia provided by surgeon/attending surgeon only 

Append 47 modifier to basic surgical service/procedure only

Incorrect Use

Surgeon performs both surgery/anesthesia, separate payment not allowed

Anesthesiologist not covered with 47 modifier
Not appropriate with anesthesia codes or local anesthesia
Not appropriate with moderate sedation (99143 – 99145)
Not appropriate for monitoring general anesthesia provided by
Certified Registered Nurse Anesthetist (CRNA), intern, anesthesiologist or resident

Modifier 80

Assistant Surgeon

Instructions

Modifier 80 is appended to the surgical code when another surgeon is assisting at surgery. Check Medicare Physician Fee Schedule (MPFS) Indicator/Descriptor Lists. See Column A indicates if assistant at surgery allowed/not allowed.

Correct Use

Physician:

Assist-at-surgery allowed with appended modifiers 80, 81 or 82
Allowed = 16% of surgery fee schedule allowable 

Note: Non Physician Practitioner (NPP) or mid-level practitioner (PA, NP, CNS):
Append AS modifier only
Allowed equals 85% of surgical assist or 16% allowable

Incorrect Use

Inappropriate to bill AS modifier for physician surgical services 
Inappropriate to append modifier 58 (staging) with assistant surgery

Claim Coding Example

Per fee schedule indicator, descriptor 2 = payment restriction for assistants at surgery does not apply to this procedure. Assistant surgeon may be paid.

Treatment Description

CPT 43846 /Modifier 80

Gastric Bypass for Morbid Obesity

Modifier 81

Minimum assistant surgeon

Instructions

Modifier 81 is appended to the procedure code for an assistant surgeon who assists an operating or principal surgeon during part of a procedure. Check the Medicare Physician Fee Schedule (MPFS) Indicator/Descriptor Lists. Column A indicates if assistant at surgery is allowed.

Correct Use

Append to appropriate code when more than one assistant is involved or if one person assists during a portion of surgery. Includes physicians providing minimal assistance to primary surgeon. Must be used with Type of Service 8 codes. 

This modifier identifies surgical assistant services

Indicates exceptional medical circumstances exist

Indicates primary surgeon has policy of never involving residents in preoperative, operative or postoperative care of his/her patients

Claim Coding Example

Fee Schedule Indicator Descriptor 2 = Payment restriction for assistants at surgery does not apply to this procedure. Assistant surgeon may be paid.

Treatment Description -  Gastric Bypass for Morbid Obesity

Modifier 82

Assistant Surgeon – when qualified resident surgeon not available

Instructions

This modifier is used when minimal surgical assistance is needed, but a qualified resident was not available (documentation required). First, check Medicare Physician Fee Schedule (MPFS) Indicator/Descriptor List. Column A indicates if assistant at surgery allowed/not allowed.

Correct Use

Physician:
Assist-at-surgery allowed with appended modifiers 80, 81 or 82
Allowed = 16% of surgery fee schedule allowable 
Modifier 82 needs a statement that "no qualified resident surgeon was available"

Indicates exceptional medical circumstances exist
Primary surgeon must have a policy of never involving residents in preoperative, operative or postoperative care of his/her patients
Non Physician Practitioner (NPP) or mid-level practitioner (PA, NP, CNS):
Append AS modifier only
Allowed equals 85% of surgical assist or 16% allowable

Incorrect Use

Inappropriate to bill physician assistant surgical services with AS modifier
Inappropriate to append modifier 58 (staging) with any assistant surgery

Claim Coding Example

Per fee schedule indicator descriptor 2 = payment restriction for assistants at surgery does not apply to this procedure. Assistant surgeon may be paid.

Treatment Description

CPT 55866 /Modifier 82

Laparoscopy, surgical prostatectomy


Modifier AS

Physician Assistant (PA), Nurse Practitioner (NP) or Clinical Nurse Specialist (CNS) assistant at surgery services.

Instructions

Append this modifier to appropriate procedure codes when Non-Physician Practitioners (NPPs) are assisting a principal surgeon as an assistant surgeon. The assistant at surgery provides more than ancillary services. NPPs include a CNS, NP and PA.

Correct Use

The Medicare Physician Fee Schedule (MPFS) Indicator/Descriptor lists under column A will confirm if assistant at surgery is allowed.
2 = payment restriction for assistants at surgery does not apply to this procedure. Assistant surgeon may be paid).
NPP, mid-level practitioner or advance practice practitioner (APP)
Append this modifier only
NPP must accept assignment
NPPs are allowed 85% of 16% physician fee allowable or 14% of surgery

Incorrect Use

Inappropriate for NPPs to use modifiers 80, 81 or 82 (physician only modifiers) Modifier 80 (assistant surgeon), 81 (minimum assistant surgeon) or 82 (qualified resident surgeon not available) with physician (MD/DO) assisting at surgery

Modifier AT

Acute or Active Treatment

Instructions

This Chiropractic only AT modifier tells Medicare that this treatment should be covered as acute or active treatment.

Correct Use

Chiropractic manual manipulation of the spine service for acute therapy Involves codes 98940, 98941 and 98942 only

Corrective treatment supporting the manipulation
Not considered Maintenance therapy (see modifier GA)
Documentation MUST support acute/active/corrective treatment

Incorrect Use

Do not bill modifier AT with denial modifiers (GA, GX, GY or GZ) on same line  

Claim Coding Example

An established patient complains of upper back pain due to gardening.

Treatment Description

CPT 98941 /Modifier AT

Chiropractic Manipulative Treatment (CMT); spinal, three to four regions

Modifier GN

Services delivered under an outpatient speech language pathology plan of care

Correct Use

Submit modifier GN to indicate that the services were delivered under an outpatient speech language pathology plan of care.

If additional modifiers are required with the service, modifier GN must be submitted in the first or second modifier position.

Exception:  Claims from physicians (all specialty codes) and non-physician practitioners, including specialty codes "50, 89, and 97", may be processed without therapy modifiers for sometimes only therapy codes.

If specialty codes "65" and "67" are on the claim and an applicable HCPCS code is without one of the therapy modifiers (GN, GO, GP), the claim will be returned as unprocessable.

Modifier GO

Services delivered under an outpatient occupational therapy plan of care

Correct Use

Submit this modifier with services that were delivered under an outpatient occupational therapy plan of care. If additional modifiers are required with the service, HCPCS modifier GO must be submitted in the first or second modifier position.

Modifier GP

Services delivered under an outpatient physical therapy plan of care

Correct Use

Submit this modifier with services that were delivered under an outpatient physical therapy plan of care. If additional modifiers are required with the service, modifier GP must be submitted in the first or second modifier position.

Tuesday, 10 January 2017

Modifier AI, AY, CR, GC, GJ, GV, GW, Q1, Q0,

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

CPT/Modifier

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

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

CPT/Modifier

Assay of Creatinine

82565 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

CPT/Modifier

Assay of Creatinine

82565 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

CPT/Modifier

Surgical pathology (professional component)
Bill to Part B: 88305 26GV 01/14/12
Surgical pathology (technical component)
Bill to Hospice: 88305 TC

Same rules apply for diagnostic tests

Date of Service - Treatment - CPT/Modifier

09/25/12 - 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 rolled 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

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