Basic Current Procedural Terminology and HCPCS Coding 2018

Basic Current Procedural Terminology and HCPCS Coding 2018 Edition Chapter 3: Modifiers © 2018 American Health Information Management © 2018 American Health Information. Association Management Association

Use of Modifiers • Appended to CPT code to provide more information Example: 27440–LT Arthroplasty, knee, tibial plateau; Dash between code and modifier is for illustration only; not submitted on claim (Modifier indicates that the repair was performed on the left knee) 2 © 2018 American Health Information Management Association

Use of Modifiers May increase payment Example: Myringotomy with insertion of PE tubes 69436– 50 (Modifier 50 for bilateral procedure would increase payment) 3 © 2018 American Health Information Management Association

Use of Modifiers May decrease payment Example: 54150 Circumcision; using clamp or other device with regional dorsal penile or ring block If the procedure was performed without dorsal penile or ring block, append modifier 52 (may decrease payment) 4 © 2018 American Health Information Management Association

Use of Modifiers May prevent denial Example: Two lesions removed from patient’s left arm (one near wrist and another from upper arm) Codes: 11403, 11403– 59 Without use of modifier 59, it may appear as a duplicate coding error and could be denied by payer. NOTE: Modifier XS (Separate Structure, a service that is distinct because it was performed on a separate organ/structure) is also applicable. 5 © 2018 American Health Information Management Association

New Modifiers in 2018 • Modifier 96 Habilitative Services • Modifier 97 Rehabilitative Services

Appendix A • Complete list of CPT modifiers with definitions • List of selected modifiers (CPT and HCPCS) approved for hospital outpatient use 7 © 2018 American Health Information Management Association

Level II National Codes Modifiers • Locate complete list of modifiers (CMS website) • Examples of Level II modifiers: –NU (new equipment) –SB (nurse midwife) 8 © 2018 American Health Information Management Association

Use of F or T modifiers • FA–F 9 reserved for digits of hand,

Anesthesia-specific CPT Modifiers • • • P 1 P 2 P 3 P 4 P 5 • P 6 10 Normal healthy patient Patient with mild systemic disease Patient with severe systemic disease that is a constant threat to life Moribund patient who is not expected to survive without the operation Declared brain-dead patient whose organs are being removed for donor purposes © 2018 American Health Information Management Association

Physician Use vs. Hospital Use of Modifiers Physician Use Only 53 Discontinued Procedure Hospital Use Only 73 Discontinued Outpatient Procedure Prior to Anesthesia Administration 74 Discontinued Outpatient Procedure After Anesthesia Administration 11 © 2018 American Health Information Management Association

Discontinued Procedure: “No Anesthesia Required” • Hospitals instructed to use modifier 52 (Reduced Services) if a procedure with no planned anesthesia was discontinued. • Conscious sedation (for example, Versed) is not considered anesthesia • Check CMS Transmittals for current modifier guidelines 12 © 2018 American Health Information Management Association

Genetic Testing Code Modifiers • Located on AMA website • Provide diagnostic granularity Example: 5 D HD, commonly called Huntington (Huntington’s disease) 13 © 2018 American Health Information Management Association