MODIFIERS Kandy Morris CPC CPMA CPB CEMC CCSP

MODIFIERS Kandy Morris CPC, CPMA, CPB, CEMC, CCS-P, CPO-C

What Are Modifiers? Modifiers are two digit codes appended to a CPT code that indicates that a service or procedure has been altered by a specific circumstance, but has not changed in its basic definition “Strictly alters the code definition”

Why do we use Modifiers? Modifiers are used for a variety of reasons, including: Claims can be incomplete or inaccurate without a modifier Coding to the highest level of specificity requires modifier use Appropriate use of modifiers get services reimbursed that might otherwise be denied Allows for proper reimbursement (increased or decreased) based on the procedure/service circumstances …………. and to avoid hearing your physician saying……….

Why aren’t my claims getting paid……?

Where to find Modifiers CPT Book - Appendix A HCPCS Level II - Appendix 2

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 reduced or increased Only part of a procedure was performed A service or procedure was provided more than once A bilateral procedure was performed Unusual events occurred

Modifier Categories Global CCI Package Modifiers or Bundling Modifiers Evaluation and Management Only Modifiers Number of Surgeon Modifiers “Other” Modifiers

Global Modifiers

What is the “Global” Period? Also known as the global surgical package. CMS and AMA have the same definition. Per CPT Guidelines, the following services are always included in addition to the operation: Local or topical anesthesia Subsequent to the decision for surgery, one related E/M encounter on the date immediately prior to or on the date of the procedure (including history and physical) Immediate postoperative care Writing orders Evaluating the patient in the post-anesthesia recovery area Typical postoperative follow-up care

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

Modifier – 24 Unrelated E/M Service by Same Physician During a Postoperative Period: (Appended to the E&M code only) Used when a physician provides a surgical service related to one problem, and then during the postoperative period provides an E&M service that is unrelated to the surgery. Diagnosis code selection is critical to indicate the reason for the additional E&M service Modifier Category: E/M Only & Global Package

Modifier - 24 Example: Patient came in for a post-operative visit. He is 12 weeks s/p discectomy. During the exam the pt c/o severe headaches with visual changes, proceeded 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

Modifier – 25 Significant, Separately Identifiable E/M by the Same Physician on the Same Day of the Procedure or other service (Append to E&M Code Only) Indicates that on the day of a procedure or other service, the patients condition required an additional E&M service above and beyond the usual pre and post-op care associated with the procedure performed. E&M service elements must be clearly documented to justify that a visit took place beyond the elements necessary to perform the procedure. Modifier Category: E/M Only & Global Package

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 patient’s knee joint needs to be performed. Report: 9921 X(25) & 20610

Modifier – 26 Professional Component (Appended to procedure code) Certain procedures are a combination of a physician component and a technical component. When the physician component is reported separately, add -26 to the CPT code to identify that the physician’s component ONLY is being billed.

Modifier – 26 Professional Component (Appended to procedure code) 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

Modifier - 26 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 physician’s 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 2 D echocardiography using the hospital equipment. The physician provides the written interpretation. Report: CPT Codes 93307(26)

Modifier – 54 Surgical Care Only (Appended to the surgical procedure codes only) Physician service to the patient was only the intra-operative procedure. (The physician is paid a portion of the global package and another physician will perform the pre & post-operative care) There should be 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 physician who performed the procedure 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, and performed the procedure. Follow-up care was provided by a local surgeon. The Neurosurgeon would report 61321 -54

Modifier – 55 Post Operative Management Only (Appended to the surgical procedure codes only) Modifier 55 is reported when one physician performed the postoperative management only; another physician performed the surgical procedure Example: While on vacation in Vail, the patient had a skiing accident. A local Orthopedist in Vail did the pre-operative & intra-operative procedure. The patient’s physician at home provides all the post-op care and would bill by adding a -55 to the surgical procedure code.

Modifier – 56 Pre Operative Management Only (Appended to the surgical procedure codes only) Modifier 56 is reported when one physician performed the preoperative care and evaluation and another physician performed the surgical procedure Example: Internist does pre-op work-up on a patient having a laparoscopic cholecystectomy by a general surgeon who travels to the area monthly. Internist would bill 47562 -56

Modifier-57 Decision for Surgery (Appended to E&M code only) The purpose of this modifier is to report an E&M service on the day before or on the day of a major surgery (90 day global period) which results in the initial decision to perform the surgery Without using this modifier on the E&M code the E&M will be denied as “included in the Global period of the surgical procedure”. Example: Patient comes to the emergency department with sudden onset of acute abdominal pain. GYN physician evaluates patient & determines that patient has a twisted ovarian cyst. Physician admits patient to OR for a right salpingo-oophorectomy. CPT codes report are 99223(57) & 58720. Modifier Category: E/M Only & Global Package

Modifier-58 Staged or Related Procedure by the Same Physician during the Postoperative Period (Appended to surgical code) The purpose of this modifier is to report the performance of a procedure or service during the postoperative period for one of the following circumstance's: planned or staged more extensive than the original procedure therapy following a surgical procedure This modifier is used to report a staged or related procedure by the same physician during the postoperative period of the first procedure Modifier -58 is used ONLY during the global surgical period for the original procedure

Modifier – 58 Clinical Examples Example # 1: 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 # 2: 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 the muscle flap was planned at the time of the initial surgery Modifier Category: Global Package

Modifier-62 Co-Surgeon When two or more surgeons with different specialties submit claims for the same operative session for the same beneficiary and same date of service, all providers must use the co-surgeon modifier. When two different providers bill the same CPT code, same patient and same date of service and one of the providers bills with modifier 62, the other provider must also bill with modifier 62. Note, however, that modifier 62 may only be used when the cosurgeons are of different specialties and are working simultaneously.

Modifier-62 Clinical Examples Example # 1: A provider bills for CPT code 61548, Hypophysectomy or excision of pituitary tumor, and bills with modifier 62, for a patient on date of service March 8, 2014. A different provider bills for the same service for the same patient on the same date of service because he/she was the co-surgeon, yet did not bill with modifier 62. The second surgeon was overpaid for failing to properly apply modifier 62. Example # 2: A provider bills for CPT code 49652, Laparoscopy, Surgical repair, ventral, umbilical, spigelian or epigastric hernia, and bills with modifier 62, for a patient on July 2, 2014. A different provider bills for the same service for the same patient on the same date of service because he/she was the co-surgeon, yet did not bill with modifier 62. The second surgeon was overpaid for failing to properly apply modifier 62.

Modifier-76 Repeat Procedure by the Same Physician (Appended to procedure code) Modifier -76 is used when it is necessary to report a repeat of the same procedure on the same day Medicare considers two physicians, in the same group with the same specialty performing services on the same day as the same person Appropriate Usage: On procedure codes that cannot be quantity billed Report each service on a separate line, using a quantity of one and append 76 to the subsequent procedures The SAME physician performs the services Inappropriate Usage: Appending to a surgical code Appending to each line of service Repeat services due to equipment or other technical failure For services repeated for quality control purposes

Modifier - 76 Medicare considers two physicians, in the same group with the same specialty performing services on the same day as the same physician For all procedure codes that cannot be quantity billed always use quantity of “ 1” To avoid denials, bill all services performed on one day on the same claim For repeat clinical diagnostic laboratory tests, use modifier 91 if the service can not be quantity billed Modifier Category: Global Package

Modifier-77 Repeat Procedure by Another Physician (Appended to procedure code) Repeat procedure by a different physician; use when it is necessary to report repeat procedure performed on the same day Appropriate Usage: A different physician performs the repeat services Inappropriate Usage: Appending to a surgical procedure code Appending when the repeat procedure is performed by the same physician Appending to E&M codes Modifier Category: Global Package

Modifier – 77 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 77 modifier and provide documentation to support the need for a repeat CXR.

Modifier-78 Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the Postop Period (Appended to procedure code) The purpose of this modifier is to report a related procedure performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure) and requires use of the operating/procedure room Modifier -78 should NOT be used if a complication does not require use of the operating/procedure room Modifier -78 may be used to report procedure performed on the same day (usually in emergency situations) Modifier Category: Global Package

Modifier – 78 Example: Pt brought to recovery room S/P abdominal surgery. Dressings became saturated, vital signs were unstable. Pt brought back to OR for exploration postop hemorrhage Report: CPT Codes 35840(78) “Complication” modifier Modifier Category: Global Package

Modifier-79 Unrelated Procedure/Service by Same MD during the Post-op Period (Appended to procedure code) The purpose of this modifier is to report services during the postoperative period that are unrelated to the original procedure The procedure must be performed by the same physician, and modifier 79 is appended to the procedure code Claim should be submitted with a different diagnosis and documentation should support the different diagnosis and medical necessity Modifier Category: Global Package

Modifier - 79 Example: A cataract removal of the right eye(90 day global) is performed on Jan. 5 th. On Feb. 12 th, the same physician performs a cataract removal on the left eye. Report: CPT Code 66984(79)

“Other” Modifiers

Modifier-22 Unusual Procedural Services (Appended 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% Must be accompanied by an operative report with a letter explaining additional time required to support modifier -22 use

Modifier-22 Unusual Procedural Services (Appended to procedure code) Operative/Procedure Note Key Terms: Increased risk; difficult; extended; complication; prolonged; unusual findings; unusual contamination controls; hemorrhage, blood loss over 600 cc; etc Additional physician work due to complications or medical emergencies may warrant use of 22 Documentation MUST support the substantial additional work and the reason for the additional work (i. e. , increased intensity, time, technical difficulty of procedure, severity of patient’s condition, physical and mental effort required) Overuse can trigger an audit, if you find yourself consistently using modifier -22, chances are you are using the wrong CPT

Use of Modifier - 22 Appropriate Use: Inappropriate 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) Partial colectomy with accidental laceration of vessel resulting in additional time for repair

Modifier-50 Bilateral Procedure (Appended to procedure code) Used to report bilateral procedures that are performed at the same operative session (bi = two, lateral = side; both sides) Modifier -50 is used to report diagnostic, radiology and surgical procedures Modifier -50 should only be applied to services and/or procedure performed on identical anatomic sites, aspects, or organs (arms, legs, eyes, breasts) Modifier -50 is NOT applicable to: Procedures that are bilateral by definition Procedures with descriptions including the terminology as “bilateral” or “unilateral” When removing a lesion on the right arm and one on the left arm (RT/LT should be used)

Modifier-50 Bilateral Procedure (Appended to procedure code) Modifier -50 CAN be appended to codes with a bilateral indicator of “ 1” or “ 3” on the Medicare Physician Fee Schedule https: //www. cms. gov/apps/physician-fee-schedule/search-criteria. aspx Some payers require the bilateral procedure to be report on a single line with -50; however some may require the procedure to be reported on two separate lines using RT/LT modifiers (check with the individual payer for their bilateral billing policy)

Modifier – 51 Multiple Procedures (Append to Procedure Code) Used when multiple procedures, other than E/M services, performed at the same session by the same provider Reimbursement is subject to 100% of the allowable charge for the primary code and 50% of the allowable charge for each additional procedure code Example: Patient presents for removal of a malignant lesion on the face with a complex repair of the defect Report: Line 1: 11641 Line 2: 13152(51) Paid at 100% of Allowed Paid at 50% of Allowed

Modifier - 51

Modifier-52 Reduced Service (Appended to procedure code) This modifier is used to report a service or procedure that is partially reduced or eliminated at the physician’s election Modifier -52 is NOT used to report an elective cancellation of a procedure before surgical preparation in the operating suite Modifier -52 should NOT be used if the procedure is discontinued after administration of anesthesia The presence of modifier -52 will reduce the payment of the service. Depending upon the payer

Modifier-53 Discontinued Procedure (Appended to procedure code) Used to indicate that a surgical or diagnostic procedure was started but discontinued due to extenuating circumstances that threaten the patient’s well-being This modifier is used to report services or procedures when discontinued after anesthesia is administered to the patient This modifier is NOT used to report an elective cancellation of a procedure or prior to the patient’s anesthesia induction and/or surgical preparation in the operating suite; including situations where cancellation is due to patient instability Modifier -53 should NOT be used when a laparoscopic or endoscopic procedure is converted to an open procedure Modifier -53 should NOT be appended to E/M codes

CCI or Bundling Modifiers

What is CCI or NCCI? CMS developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims. The CMS developed its coding policies based on coding conventions defined by the American Medical Association’s CPT manual, national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practices, and a review of current coding practices NCCI (National Correct Coding Initiative ) edits, which are released by CMS quarterly, define when two procedures HCPCS/CPT codes may not be reported together except under special circumstances. If an edit allows use of NCCI associated modifiers, the two procedure codes may be reported together if the two procedures are performed at different anatomic sites or different patient encounters Edits can be viewed @: https: //www. cms. gov/National. Correct. Cod. Init. Ed/01_overview. asp

• Modifier-59 Distinct Procedural Service (Appended to procedure code) The purpose of this modifier is to identify procedures or services that are not usually reported together but appropriate under the circumstance. This may represent the following: A different session or patient encounter A different procedure or surgery A different site or organ system A separate incision or excision A separate lesion A separate injury (or area of injury in extensive injuries) Modifier -59 should only be used if no other modifier more appropriately describes the relationships of the two or more procedure codes (i. e. RT/LT, T 1 -T 10, etc. ) Modifier 59 should NOT be appended to an E/M code

CMS is establishing the following four new HCPCS modifiers (referred to collectively as -X{EPSU} modifiers) to define specific subsets of the -59 modifier: -XE Separate Encounter: A Service That Is Distinct Because It Occurred During A Separate Encounter. Separate surgical operative session on the same date of service (e. g. 8 AM surgery with one procedure, 4 PM surgery with second procedure code). If a patient came in for an outpatient EKG, then comes back later in the day for blood work, the blood work would require an XE modifier. Patient comes to the facility for an x-ray of their hip as a result of an injury. The results are sent to the physician’s office who calls the patient and has them return to the radiology department for a CT of their hip due to possibility of a hairline fracture all on the same day. -XS Separate Structure: A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure. From an NCCI perspective, the definition of different anatomic sites includes different organs or different lesions in the same organ. However, it does not include treatment of contiguous structures of the same organ. Injection into tendon sheath, right ankle (20550) and injection into tendon sheath, left ankle (20550 -XS). Right pectoralis major muscle flap (15734) and right rectus abdominis muscle flap (15734 -XS)

-XP Separate Practitioner: A Service That Is Distinct Because It Was Performed By A Different Practitioner. The patient is seen in the office by a family practice physician, who in the course of the visit encounters a problem outside their scope of ability so calls in (or arranges an immediate transfer to) a specialist physician at the same claim to perform the needed service. -XP modifier still unclear, but probable scenario: The patient is seen by one provider who in the course of treating a patient encounters a problem outside his scope of ability so calls in another doctor to perform the service. Patient goes to their family physician due to a cold, after being seen by their physician the are sent to their respiratory physician for breathing treatments, all on the same day. -XU Unusual Non-Overlapping Service: The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service. A diagnostic procedure is performed. Due to the findings, a decision is then made to perform a therapeutic/surgical procedure. (This may or may not occur in the same procedure room during the same session/encounter. ) For example, diagnostic cardiac angiography leads to therapeutic angioplasty. Patient is seen in the OR for an EGD procedure in the recovery room the patient is noted to be short of breath and a fever, patient receives a chest x-ray to rule out pneumonia. Excision of two non-contiguous lesions on the same structure or body area that might typically be bundled together can be separated by this modifier.

CMS will continue to recognize the -59 modifier, but notes that Current Procedural Terminology (CPT) instructions state that the -59 modifier should not be used when a more descriptive modifier is available. While CMS will continue to recognize the -59 modifier in many instances, it may selectively require a more specific - X{EPSU} modifier for billing certain codes at high risk for incorrect billing. For example, a particular NCCI PTP code pair may be identified as payable only with the -XE separate encounter modifier but not the -59 or other -X{EPSU} modifiers. The -X{EPSU} modifiers are more selective versions of the -59 modifier so it would be incorrect to include both modifiers on the same line. The combination of alternative specific modifiers with a general less specific modifier creates additional discrimination in both reporting and editing. As a default, at this time CMS will initially accept either a -59 modifier or a more selective - X{EPSU} modifier as correct coding, although the rapid migration of providers to the more selective modifiers is encouraged. However, please note that these modifiers are valid even before national edits are in place. MACs are not prohibited from requiring the use of selective modifiers in lieu of the general 59 modifier, when necessitated by local program integrity and compliance needs.

Number of Surgeons Modifiers

How to Determine if Multiple Surgeons Are Allowed To determine whether the services of more than one surgeon may be submitted to Medicare with CPT Modifiers 62, 66, 80, 81, 82 or AS, refer to the Medicare Physician Fee Schedule database (MPFSDB): Access the database directly from the CMS Web Site at www. cms. gov/apps/physician-fee-schedule/overview. aspx/ Select Physician Fee Schedule Search from the left area of the Web page Refer to the column headings applicable: ‘Co Surg’, ‘Team Surg’, or Asst Surg’ 0 = Co-surgeons not permitted for this procedure 1 = Co-surgeons may be paid if supporting documentation is supplied to establish medical necessity 2 = Co-surgeons permitted. No documentation is required if twospeciality requirement in met

Modifier – 62 Two Surgeons (Append to Surgical Procedure) Two surgeons (each in a different specialty) work together to perform a specific procedure If two surgeons (each in a different specialty) are required to perform a specific procedure, each surgeon bills for the procedure, and both surgeons need to report the same surgery code with the modifier 62. Example: Thansphenoidal Hypophesectomy, Neurosurgeon and ENT both report 61548(62) Warning: If one surgeon bills with a modifier “-62” and one surgeon bills with no modifier, the payer may deny or suspend the claim with the modifier for review. Coordination of billing is key to proper reimbursement for each surgeon!

Modifier – 80 Assistant Surgeon (for MD’s, DO’s) Modifier – 81 Minimal Assistant Surgeon Modifier – 82 Assistant surgeon (when qualified resident surgeon not available) Modifier – AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery

HCPCS Level II Modifiers Alpha or alphanumeric Provide additional information just like CPT modifiers Found in HCPCS Manual Can be used on Level I CPT codes and/or Level II HCPCS codes

Examples of HCPCS Modifiers LT: Left side RT: Right side GA: Waiver of liability statement on file RR: Rental (for DME) F 1: Left hand, 2 nd digit F 6: Right hand, 2 nd digit GP: Services delivered under an outpatient physical therapy plan of care

Modifiers – Work Comp/Colorado Modifier – 00 All providers should indicate whether they are billing for the total component for a radiology service

Questions? ? ? Feel free to email me directly at mzkandyd@gmail. com Kandy Morris CPC, CPMA, CPB, CEMC, CCS-P, CPO-C 2015 Las Vegas Chapter Vice President Physicians Choice, LLC 2657 Windmill Pkwy, Suite# 590 Henderson, NV 89074 Phone: 702. 550. 8769/Fax: 702. 543. 7095