CHAPTER 14 MODIFIERS Copyright 2014 by Saunders an

CPT Modifiers • Used to describe alterations to CPT code • Full list, CPT,

Modifier Functions • Altered (i. e. , more or less) • Bilateral • Multiple • Only portions of service (i. e. , professional service only) • More than one surgeon • Unusual service Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 3

-22 Increased Procedural Service • Indicates services significantly greater than usual written report with • Accompanied by ______ supportive documentation • Describes increased physician work Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 4

-23 Unusual Anesthesia • Use of anesthesia where no anesthesia or ____ local would be the norm – Example: Highly agitated senile patient anesthesia codes • Only used with _____ • Written report with submission of modifier may be required Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 5

-24 Unrelated E/M Services by Same Physician or Other Qualified Health Care Professional During a Postoperative Global Period • E/M Service not related to surgery is separately billable – Use -24 on E/M ___ code only – If E/M provided during post-op global period, no separate payment for E/M related to surgical procedure – Example: Patient is in global period for hip surgery and is now seen for a fractured collarbone Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 6

-25 Significant, Separately Identifiable E/M Service, Same Physician or Other Qualified Health Care Professional and Same Day of Procedure or Other Service • Documentation must support service – Example: Patient seen for sinus congestion, provider performs H&P, prescribes decongestant, notes lesion on back, and removes • Code: Procedure + E/M-25 – Example: A patient seen on consultation by pain management and subsequent to rendering an opinion was given a nerve injection. Modifier -25 is placed on E/M code Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 7

-26 Professional Component • Professional component (physician, -26 ___) • Technical component (technician + equipment, -TC ___) • Example: Radiologist reviews x-rays (-26) taken by supervised technician (-TC) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 8

-32 Mandated Service • Mandated by payer, workers’ comp, or official body • Not request of patient, patient’s family, or another physician – Example: Workers’ Comp requests examination of person currently receiving disability benefits Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 9

-33 Preventive Services • Patient Protection and Affordable Care Act of 2010 requires coverage without cost • United States Preventive Services Task Force grades preventive services – Grade A: substantial – Grade B: moderate Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 10

-47 Anesthesia by Surgeon • Physician administers regional or general ______ anesthesia – Acts as surgeon & anesthesiologist • Only used with Surgery codes • No separate payment when used on Medicare patients Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 11

-50 Bilateral Procedure • Bilateral – Example: Procedure on hands • Caution: Some codes describe bilateral procedures; in these cases do not apply modifier -50 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 12

-51 Multiple Procedure—Three Types • Same Procedure, Different Sites ____ – Example: Multiple lacerations repaired Same Operative Session • Multiple Operation(s), _____ Multiple Times • Procedure Performed _______ – Example: Trigger point injections (20552) (Cont’d …) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 13

-51 Multiple Procedure (…Cont’d) • List most resource intense first (highest RVU value) • Next other procedure(s) + -51 (unless code is 51 exempt or an add-on code) • Usual payment: 1 st procedure 100%, 2 nd 50%, 3 rd 25% • Medicare: 1 st procedure paid 100%, 2 nd– 5 th paid 50%, more than 5, priced manually Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 14

-52 Reduced Services • Service reduced from code description • Physician directed reduction • Documentation substantiates reduction • Not for patients unable to pay fee • Submit full charge, payer will adjust – Example: Lip shave (40500) but advancement flap not performed = 40500 -52 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 15

-53 Discontinued Procedure • Surgical/diagnostic procedures • Started then stopped due to patient’s condition • Does not apply to presurgical discontinuance (Cont’d…) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 16

-53 Discontinued Procedure (…Cont’d) • DO NOT USE -53 WHEN: – Patient cancels scheduled procedure – With E/M codes – With time-based code Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 17

-54 Surgical Care Only • Physician provides only procedure (______) intraoperative • Documented patient ______ transfer must be in record – Some payers require copy of transfer Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 18

-55 Postoperative Management Only • Physician provides only care after hospital discharge – If transferred while patient hospitalized, report postop management with subsequent hospital codes 99231 -99233 • Documentation of transfer in medical record • Surgery code billed with -55 modifier and surgery date of service • Bill after first postoperative visit Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 19

-56 Preoperative Management Only • Physician provided only preoperative care • Not acceptable for Medicare – Requires surgical code with modifier -56 Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 20

Usual Reimbursement for Portions, Surgical Package • 10% preoperative • 70% intraoperative • 20% postoperative payer determines portions • Each _____ Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 21

-57 Decision for Surgery Used With • E/M, 99201 -99499 • Medicine, 92012 -92014 ophthalmologic ______ services • Medicare: Only for preop period of major surgery (day before or day of) – 90 day global Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 22

-58 Staged/Related by Same Physician or Other Qualified Health Care Professional During Postoperative Period • Subsequent procedure planned or related to the first surgery – During postop of previous surgery in series – Example: Multiple skin grafts completed in several sessions – Global period starts over (Cont’d…) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 23

-58 Staged/Related by Same Physician or Other Qualified Health Care Professional During Postoperative Period (…Cont’d) • Do not use when code describes a session – Example: 67208: lesion destruction of retina, ___ or ____ sessions one more Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 24

-59 Distinct Procedural Service • Different session or encounter • Different procedure • Different site • Separate incision, excision, lesion, injury • Do not use when another HCPCS modifier is appropriate (Cont’d…) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 25

-59 Distinct Procedural Service (…Cont’d) • Example: Physician removes several lesions from patient’s leg, also notes and biopsies a mole of torso – Biopsy code for mole + -59 – Indicates biopsy distinct procedure, not part of lesion removal Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 26

-62 Two Surgeons co-surgeons (equals) • Both function as _____ • Usually different specialties • Each surgeon reports same surgery code appending -62 • Each surgeon dictates his/her portion of procedure Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 27

-63 Procedure Performed on Infants Less Than 4 kg • Kilogram: 2. 2 lb (4 kg = 8. 8 ___ lb) • Small size increases complexity • Use with all Surgery section codes except Integumentary and those exempt by parenthetical notes Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 28

-66 Surgical Team • Team: Several physicians (3 or more) with various specialties plus technicians and other support personnel • Very complex procedures • Payers may increase payment Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 29

-76 Repeat Procedure/Service by Same Physician or Other Qualified Health Care Professional • Note: “Same Physician or Other Qualified Health Care Professional” • Used to indicate necessary repeated typographical error service, not ______ – Example: X-rays before and after fracture repair – Aerosol treatment for an asthma attack repeated in 90 minutes (94640 -76) Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 30

-77 Repeat Procedure/Service by Another Physician or Other Qualified Health Care Professional • Note: “Another Physician or Other Qualified Health Care Professional” • Performed by one individual, repeated by another individual • Submitted with a written report to establish ______ necessity may be requested medical Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 31

-78 Unplanned Return to Operating/Procedure Room Same Physician Following Initial Procedure for a Related Procedure During Postoperative Period • For complication of first procedure – Example: Patient has outpatient procedure in morning, was returned to operating room in afternoon with severe hemorrhage • Indicates not typographical error • Does not change global period time Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 32

-79 Unrelated Procedure or Service by Same Physician or Other Qualified Health Care Professional During Postoperative Period • Example: Several days after discharge for procedure, patient returns for an unrelated procedure/service – Diagnosis would be different – Remember the E/M ___ code would have -24 – If surgery is unrelated to original procedure, a new global period starts Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 33

-80 Assistant & -81 Minimum Assistant Surgeons • -80 Assistant – Reimbursed at 15– 30% – Payers identify procedures for which they reimburse assistant • -81 Minimum Assistant Surgeon – Services at a level less than that described in -80 (Assistant ____ Surgeon) – Reimbursed at 10%, if at all Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 34

-82 Assistant Surgeon • Teaching hospitals: – Have residents who assist as part of education—no fee, no modifier -82 qualified resident – Must demonstrate no _______ available • Unavailability documented in written report Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 35

-90 Reference (Outside) Laboratory • Physician has business relationship with outside lab • Physician pays lab • Physician bills payer for lab services • Cannot use for Medicare Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 36

-91 Repeat Clinical Diagnostic Laboratory Test • Repeat same laboratory tests on same day for multiple test results • Not tests rerun ____ to confirm original test results • Not malfunction _____ of equipment or technician error Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 37

-92 Alternative Laboratory Platform Testing • Indicates kit or transportable instrument • Usually single use, disposable • Example: 86701, HIV test kit Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 38

-99 Multiple Modifiers • Used when service needs more than one modifier but payer

CMS-1500 Figure: 14. 2 (Courtesy U. S. Department of Health and Human Services, Centers for Medicare and Medicaid Services) • CMS-1500 has places for multiple modifiers Copyright © 2014 by Saunders, an imprint of Elsevier Inc. Slide 40