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3C – Complications of Modifiers
3C – Complications of Modifiers
Katherine Abel, CPC, CPB, CPMA, CPPM, CPC-I
3C – Complications of Modifiers
• Review ways to analyze modifier use
• Learn the proper usage of the most common
modifiers
• Identify the correct way to utilize modifiers
• Understand the most common mistakes being
made with modifiers and how to fix them
• Review tough case examples and how modifiers
can affect your bottom line
Objectives
3C – Complications of Modifiers
Patient's Name Med
Rec#
DOS Doctor CPT Code Modifier ICD-9
Code
$
Charged
Ins Co. Corrected
/Refiled
Denial
Reason/Additional
Coments1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Denial Tracking
2
3C – Complications of Modifiers
3%
17%
3%
3%
8%
49%
3%
14%
Didn't Indicate if Medicare is Primary
Inclusive Procedure
Incomplete/Invalid Place of Service
Incorrect Entitlement Number or Name
Need Home Health Name and Upin #
Not Medically Necessary
Starred Procedure Performed as the Major
Service During a Subsequent Visit
UCR-Exced Claim Limit
Analyze
3C – Complications of Modifiers
Reports from practice management systems:
– Do all in-office procedures have an E/M with a
modifier 25?
– Is there a high use of modifier 59?
– Is modifier 22 used every time a certain procedure is
performed?
– Are there numerous denials for inclusive procedures?
Analyze
3C – Complications of Modifiers
• Adding modifiers 24, 25, 26, 58, 59, 76, 78, or 79 to a denied
service continues to be one of the top reasons for requesting
a review.
• Calling to add a modifier just because the service was
denied is not appropriate.
• Be prepared before calling in for a review. We have
experienced providers calling and asking to add a modifier.
Then when that modifier did not get the claim paid, they want
to try another one. This is inappropriate.
WPS Medicare Modifier Review Facts
6 Source: http://wpsmedicare.com/j8macpartb/resources/modifiers/modifier-25.shtml
3
3C – Complications of Modifiers
• 25 – Separately, identifiable E/M
• 57 – Decision for surgery
• 59 – Distinct procedural service
• 22 – Increased procedural service
• 52 – Reduced services
• 53 – Discontinued procedure
• 58 – Staged or related procedure
Problem Modifiers
3C – Complications of Modifiers
• 25 – Significant, separately identifiable E/M service
by the same physician on the same day of the
procedure or other service.
• 57 – Decision for surgery
Evaluation & Management Modifiers
3C – Complications of Modifiers
Significant, separately identifiable evaluation and management service by
the same physician on the same day of the procedure or other service
What is significant and separately identifiable?
Modifier 25
Source: https://oig.hhs.gov/compliance/physician-education/02payers.asp
4
3C – Complications of Modifiers
Q1. Please clarify whether a visit by the physician on the same day
as a screening colonoscopy is separately payable. Is a visit
always included in the reimbursement for the screening
colonoscopy?
A1. A visit is only payable if the documentation shows a significant,
separately identifiable service and meets the qualifications for modifier
25. This means the physician performed a great amount of additional
work above and beyond that normally performed prior to the procedure.
In addition, an auditor must be able to identify the significant amount of
additional work separately from that normally performed prior to the
procedure.
Modifier 25 – WPS Medicare
10 Source: http://www.wpsmedicare.com/j8macpartb/resources/provider_types/2009_0810_emglobpkg.shtml
3C – Complications of Modifiers
Typical pre-operative work included in Colonoscopy:
– Symptoms reviewed with patient
– Patient’s history reviewed
– Patient’s allergies and medications reviewed
– Pre-anesthetic exam with airway assessment and
cardiopulmonary evaluation
– Lab & X-ray studies reviewed
– Risks and benefits of the procedure are reviewed
– Informed consent obtained
Modifier 25
11
3C – Complications of Modifiers
HCPCS Descriptio
n
Global
Days
Pre
Op
Intra
Op
Post
Op 11400 Exc tr-ext b9+marg
0.5 cm<
010 0.10 0.80 0.10
11401 Exc tr-ext b9+marg
0.6-1 cm
010 0.10 0.80 0.10
11402 Exc tr-ext b9+marg
1.1-2 cm
010 0.10 0.80 0.10
11403 Exc tr-ext b9+marg
2.1-3cm/<
010 0.10 0.80 0.10
11404 Exc tr-ext b9+marg
3.1-4 cm
010 0.10 0.80 0.10
Modifier 25
12
5
3C – Complications of Modifiers
Office of Inspector General (OIG):
“Another example of upcoding related to E&M codes is misuse of Modifier
25. Modifier 25 allows additional payment for a separate E&M service
rendered on the same day as a procedure. Upcoding occurs if a
provider uses Modifier 25 to claim payment for an E&M service when
the patient care rendered was not significant, was not separately
identifiable, and was not above and beyond the care usually associated
with the procedure.”
Modifier 25
Source: https://oig.hhs.gov/compliance/physician-education/02payers.asp
3C – Complications of Modifiers
November 2005 OIG Report
“Thirty-five percent of claims using modifier 25 that
Medicare allowed in 2002 did not meet program
requirements, resulting in $538 million in improper
payments .”
Modifier 25
14 Source: https://oig.hhs.gov/oei/reports/oei-07-03-00470.pdf
3C – Complications of Modifiers
September 2013 – Hospital refunded $64,526
“Specifically, during a change in the billing system,
modifier 25 was automatically being added to the
E&M code when charges other than an E&M or
clinic lab service were provided for the same patient
on the same date of services.”
Modifier 25
15 Source: https://oig.hhs.gov/oas/reports/region7/71205031.pdf
6
3C – Complications of Modifiers
2013 OIG Workplan:
“Evaluation and Management Services—Use of Modifiers During the Global Surgery
Period
We will review the appropriateness of the use of certain claims modifier codes during the
global surgery period and determine whether Medicare payments for claims with
modifiers used during such a period were in accordance with Medicare requirements.
Prior OIG work found that improper use of modifiers during the global surgery period
resulted in inappropriate payments. The global surgery payment includes a surgical
service and related preoperative and postoperative E/M services provided during the
global surgery period. (CMS’s Medicare Claims Processing Manual, Pub. 100 -04,
ch. 12,§40.1.) Guidance for the use of modifiers for global surgeries is in CMS’s
Medicare Claims Processing Manual, Pub. 100-04, ch. 12,§30. (OAS; W-00-13-
35607; various reviews; expected issue date: FY2013; new start)
Modifier 25
16
3C – Complications of Modifiers
• Used to indicate the patient’s condition required a significant,
separately identifiable E/M service, above and beyond the usual pre-
and post-operative care associated with the procedure or service
performed.
• Should not be applied if only a scheduled procedure is performed.
Example: Patient presents for a scheduled cryosurgery of the cervix as
a result of an abnormal pap smear from a previous visit.
• Per Medicare, the procedure and office visit do not require a different
diagnosis codes.
Modifier 25
3C – Complications of Modifiers
• What about new patient visits?
• WPS Medicare list of false statements:
– I can always use this modifier for a new patient.
– I can always use this modifier when I did not plan a procedure.
– I can always use this modifier when the diagnoses are different.
– I can never use the modifier when the diagnoses are the same.
Modifier 25
Source: http://wpsmedicare.com/j8macpartb/resources/modifiers/modifier-25.shtml
7
3C – Complications of Modifiers
• Failure to append modifier 25 when appropriate will result in the denial of the E/M service
Examples for appropriate use:
• Patient presents for management of hypertension and diabetes. The patient also complains of a painful abscess located behind his ear. In addition to the E/M service for his chronic illnesses, the physician performs an incision and drainage of the abscess.
• Problem focused visit performed on the same day as a preventive medicine visit. The documentation must support a separate E/M service.
Modifier 25
3C – Complications of Modifiers
NHIC, Corp. J14 A/B Mac:
“NOTE: The most common cause for claim denial of
an unrelated E/M service billed on the same day as
another procedure or during the post operative
period for a non-surgery related reason is due to
the omission of
modifier -25”
Modifier 25
20 Source: http://www.medicarenhic.com/providers/pubs/REF-EDO-0058%20Modifier%20Billing%20Guide.pdf
3C – Complications of Modifiers
• NCCI – “Since minor surgical procedures and XXX procedures include pre-procedure, intra-procedure, and post-procedure work inherent in the procedure, the provider should not report an E&M service for this work. Furthermore, Medicare Global Surgery rules prevent the reporting of a separate E&M service for the work associated with the decision to perform a minor surgical procedure whether the patient is a new or established patient.“
• MCM (IOM) – “Carriers pay for an E/M service provided on the day of a procedure with a global fee period if the physician indicates that the service is for a significant, separately identifiable E/M service that is above and beyond the usual pre- and post-operative work of the procedure. “
Modifier 25
8
3C – Complications of Modifiers
Blue Cross Blue Shield of Alabama
• Criteria – E/M involves separate and unique conditions, services, procedures, incisions, excisions or
anatomical sites;
– Procedure and medically necessary E/M occur on the same day by the same provider;
– A decision is made to perform a minor procedure;
– The E/M service is above the usual preoperative, intraoperative, or postoperative care associated with the procedure that was performed and is no way related to the procedure code submitted;
– E/M visit is problem oriented and stands alone as a billable service
• Items that do not meet criteria – An E/M code is billed with major surgical procedures, chiropractic manipulations, or
polysomnography; or
– Lab or x-ray services are the only other services provided in additional to the E/M; or
– The sole reason of the visit was for the procedure; or
– The E/M service is not above and beyond the primary purpose of the patient encounter; or
– Documentation does not support the definition of the modifier; or
– To bypass a fragmented coding edit.
Modifier 25
Source: https://www.bcbsal.org/providers/policies/final/330.pdf
3C – Complications of Modifiers
Blue Cross Blue Shield of Tennessee
• Criteria – There is documentation of a significant, separately identifiable E/M service which must
contain the required number of key elements for the E&M service reported;
– The E/M service is provided beyond usual pre-operative, intraoperative, or postoperative care associated with a procedure performed on the same day;
– A symptom or procedure presents that prompts the E/M service (may not require a separate diagnosis);
– An initial hospital visit, an initial inpatient consultation, and a hospital discharge service is billed for the same date of service as an inpatient dialysis service;
– Critical care codes are billed within a global surgical period; or
– A medically necessary visit is performed on the same day as routine foot care.
• Items that do not meet criteria – E/M service that resulted in a decision for surgery;
– Ventilation management in addition to E/M services;
– Use on surgical codes;
– Use on same day of minor procedure;
– Use within global surgical period (pre- or postoperative care)
Modifier 25
Source: http://www.bcbst.com/providers/manuals/bcbstPAM.pdf
3C – Complications of Modifiers
• Appeal
– Does the documentation support two services?
– If I remove all of the documentation for one service,
do I still have enough documentation to support the
second service?
– Appeal letter –separate documentation into two
services and send with letter.
Modifier 25
9
3C – Complications of Modifiers
Pt comes in for FU of her HTN, hyperlipidemia, depression and has some musculoskeletal pain she is concerned about. She would like a skin lesion removed. She also requests a tetanus shot. She has some left shoulder pain that started about two weeks ago. It is not related to any increased activity, however. She points between her scapula and her spine when she brings her elbows back. No weakness in the upper extremities or numbness. No cough, no chest pain, no SOB.
Review of Systems: Essentially negative other than she has a lesion on her belly she would like looked at and removed if possible.
PHYSICAL EXAMINATION: Weight 241 #. BP 134/82. Pulse 68. Respiratory rate 16. Temperature 97. Eyes: anicteric. Ears: clear. Throat: normal. Neck: no JVD, no bruits. Abdomen reveals a flesh-colored lesion along the bra line, which is slightly irritated and erythematous. Extremities: no cyanosis, clubbing or edema. Shoulder reveals good ROM, some tenderness and spasm along the medial scapula on the left compared to the right. Distal neuro and vascular supply is grossly intact.
ASSESSMENT: HTN, hypercholesterolemia, musculoskeletal strain and depression.
PLAN: We will increase her Zoloft to 100 mg per pt request and have her stay on this for at least one year and wean off in the spring of next year. Today her lipids revealed LDL of 131, total cholesterol 220. We will continue with the Zocor given her two risk factors and her age. For HTN, continue Uniretic. Her abdomen was prepped and draped, and I cc of 1% Lidocame was administered subcutaneously. A sharp excision was performed on the lesion, which measured approximately ,5 cm, Hemostasis was achieved without any suture. Pt tolerated procedure well. Specimen was not sent because it is flesh-colored. Pt will FU as needed. Instructions were given for wound care.
Modifier 25?
3C – Complications of Modifiers
FoIIow-Up Note: The patient is a female with a long history of chronic intractable pain secondary to myofascial pain syndrome, scoliosis, four back surgeries, and greater trocanteric bursitis. She also has piriformis muscle syndrome. She has undergone trigger-point injections for quite some time. Her last set was about four months ago. She is getting married tomorrow and flying off to Kauai and would like to have some good pain relief for this. She comes back at this time for repeat trigger point injections.
Physical Exam reveals multiple trigger points throughout her lower back and buttocks and over the greater trocanteric bursa.
My Impression remains myofascial pain syndrome and left greater trocanteric bursitis.
My Recommendations included multiple trigger point injections for her.
Procedure: TRIGGER POINT INJECTION X 11
The patient agrees with the plan and accepts the risks. The patient was injected with eleven trigger points using a total of 33 cc. of 0.25% Marcaine and 40 mg. Depomedrol equally divided amongst the eleven trigger points. The ones injected were in the greater trocanteric bursa bilaterally in two places each, then four places on the right side in her lumbar paraspinous muscles, and three places on the left side in the lumbar paraspinous muscles, including the piriformis muscle bilaterally. The patient tolerated the procedures well without complications and was discharged to home. She was instructed to contact my office in about two weeks for follow-up.
Modifier 25?
3C – Complications of Modifiers
• Modifier 25 – Significant, separately identifiable EM service
by the same physician or other qualified health care provider
on the same day of the procedure or other service
– Minor procedure
– 0-10 global days
• Modifier 57 – Decision for Surgery
– Major procedure
– 90 global days
Modifier 25 vs 57
10
3C – Complications of Modifiers
HCPCS Mod Description Global Days
20612 Aspirate/inj ganglion cyst 000
20615 Treatment of bone cyst 010
20650 Insert and remove bone pin 010
20660 Apply, rem fixation device 000
20661 Application of head brace 090
Global Days National Physician Fee Schedule Relative Value File
Source: http://www.cms.gov/PhysicianFeeSched/01_Overview.asp#TopOfPage
3C – Complications of Modifiers
BlueCross BlueShield of Tennessee
• May not be valid when the E/M service is associated with a minor surgical procedure. Because the decision to perform a minor procedure is typically done immediately before the service, it is considered a routine pre-operative service and therefore not separately reimbursable.
• May be recognized as valid when used appropriately and there is documentation that the E/M service resulted in the initial decision to perform the service.
• Will not be recognized when the decision to perform the surgery was made in advance of the E/M visit.
• Is not appropriate when reported with non-E/M codes.
• Is not appropriate to report with the E/M service when performed for the pre-operative evaluation.
• Use of modifier 57 merely to bypass a bundling edit is inappropriate and will result in recoupment of erroneous reimbursement.
Modifier 57
Source: http://www.bcbst.com/providers/manuals/bcbstPAM.pdf
3C – Complications of Modifiers
Palmetto GBA:
“This modifier should not be submitted with E/M codes that are
explicitly for new patients only: CPT codes 92002, 92004, 99201-
99205, 99324 through 99328, 99281-99285, 99321-99323 and 99341-
99345. These codes are 'new patient' codes and are automatically
excluded from the global surgery package. This means that they are
reimbursed separately from surgical procedures. No modifier is
required in order for these codes to be separately reimbursed. These
codes are also automatically excluded from the global surgery
package.”
Modifier 57
30 Source: http://
http://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~Jurisdiction%2011%20Part%20B~Browse%20by%20Topic~Modifier%20Lookup~8EELFB4718?open&navmen
u=navmenu||
11
3C – Complications of Modifiers
WPS Medicare:
Append to Procedure codes:
– 92002-92014 E/M Ophthalmology Services
– 99201-99499 E/M all locations
Modifier 57
31 Source: http://wpsmedicare.com/j5macpartb/resources/modifiers/modifier-57.shtml
3C – Complications of Modifiers
DOS: January 31
CC: Follow up tibial osteomyelitis
PI: Patient is a 58-year-old male. He has had the tiial osteomyelitis treated with sterile
debridement and irrigation. He has a vac. He has been on IV Vancomycin and po
Levaquin.
PE: The vac is removed. He has gross purulence in the tibia calcaneal and in the
wound. There is draining puss.
IMP: Left tibial osteomyelitis
Plan: He is admitted to the hospital today. We essentially failed limb salvage with this
patient. He has had five or six debridements. He looked great at the time of
discharge last week. Apparently his wound looked good on Saturday and it has
worsened just over the last several days. We are going to recommend amputation at
this point. Please see H&P and hospital notes for further details. We will proceed
tomorrow.
Modifier 57?
32
3C – Complications of Modifiers
• 59 – Distinct Procedural Service
• 22 – Increased Procedural Service
• 52 – Reduced Services
• 53 – Discontinued Procedure
Surgical Modifiers
12
3C – Complications of Modifiers
• Distinct procedural service
• Used to indicate:
– Different surgical session
– Different procedure or surgery
– Different site or organ system
– Separate excision or incision
– Separate lesion or injury
Modifier 59
3C – Complications of Modifiers
Column
1
Column
2
Effective Date Deletion Date Modifier
11006 64550 20090401 20090401 9
11006 69990 20050101 * 0
11006 93000 20090401 * 1
Modifier 59
• Do not use modifier 59 if there is a more appropriate modifier
• Review NCCI edits for Medicare and payers who use CCI Edits
Source: http://www.cms.gov/NationalCorrectCodInitEd/NCCIEP/list.asp#TopOfPage
3C – Complications of Modifiers
• Example: Column 1 Code/Column 2 Code 45385/45380
– CPT Code 45385 - Colonoscopy, flexible, proximal to splenic
flexure; with removal of tumor(s), polyp(s), or other lesion(s) by
snare technique
– CPT Code 45380 - Colonoscopy, flexible, proximal to splenic
flexure; with biopsy, single or multiple
• Policy: More extensive procedure
• Modifier -59 is:
1) Only appropriate if the two procedures are performed on
separate lesions or at separate patient encounters.
NCCI Edits Example
Source: http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Downloads/modifier59.pdf
13
3C – Complications of Modifiers
Example of proper use:
A provider destroys 1 pre-malignant lesion on the
patient’s left forearm (17000) and performs a biopsy
of 1 lesion on the patient’s left shoulder (11100).
Modifier 59 is appropriate because there are separate
lesions.
Modifier 59
3C – Complications of Modifiers
BlueCross BlueShield of Tennessee
Modifier 59 will only be recognized as valid to bypass edits when: – Combination of procedure codes represent procedures that would
not normally be performed at the same time;
– Different session or patient encounter is documented in patient’s medical record;
– Surgical procedures performed are not through the same incisional site (Note: doesn’t matter if instrumentation changes if incision or presentation is the same);
– Surgical knee procedures involving multiple compartments of the same knee; or
– Another modifier is not more appropriate.
Modifier 59
Source: http://www.bcbst.com/providers/manuals/bcbstPAM.pdf
3C – Complications of Modifiers
BlueCross BlueShield of Tennessee
Questions to ask regarding Modifier 59: – What is the rationale for the existing edit?
– Is the edit a NCCI edit with an indicator ‘0’? If so, there is no appropriate modifier to allow edit bypass.
– Was the procedure performed in a separate setting, different time, or different encounter?
– Is there sufficient documentation to support the separateness and distinction of the two procedures?
– Was the procedure truly separate and/or is it unusual to perform these procedures at the same session?
Modifier 59
Source: http://www.bcbst.com/providers/manuals/bcbstPAM.pdf
14
3C – Complications of Modifiers
Regence BCBS - Invalid use of modifier -59:
– Procedures in the same ipsilateral joint (including differing compartments)
performed by open, scope, or combined open/scope technique, including added
port or incisional sites. [Per Regence reimbursement policy the edits are
applicable per entire joint and not per compartment within a joint]
– Procedures in the same anatomical site (e.g. digit, breast, etc), even with incision
lengthening or contiguous incision.
– CPT identified “separate” procedures performed in the same session, same
anatomic site, or orifice.
– Scope procedure converted to open procedure.
– Incisional repairs are part of the global surgical package, including deliveries.
– Contiguous structures in the same anatomic site, organ system, or joint.
40 Source: http://www.or.regence.com/provider/library/policies/reimbursement-policies/modifiers/modifier-59-distinct-procedural-service.html
3C – Complications of Modifiers
Horizon Blue Cross and Blue Shield of New Jersey
• Incorrect use of Modifier 59 is NOT appropriate when:
– Appending modifier 59 with E/M codes
– Used in lieu of Modifier 25
– Another modifier is more appropriate
– Horizon BCBSNJ’s Medical Policy deems that the service is not
medically appropriate
Modifier 59
Source: https://services5.horizon-bcbsnj.com/eprise/main/horizon/content/homepage/GeneralMsgnew/gen_2008.12.23_14.
37.06
3C – Complications of Modifiers
OPERATION:
Excision of right posterolateral lesion 6 mm, left hairline lesion 7 mm, and anterior midline lesion 6 mm with intermediate defect closure 9 mm, 11 mm, and 9 mm.
DESCRIPTION OF PROCEDURE:
The patient was brought to the procedure room. Using loupe magnification, lesions were all examined with the patient's cooperation and participation. The lesions were then outlined as elliptical excisions and the areas infiltrated with lidocaine-epinephrine solution. The lesions were then excised to the level of subcutaneous tissue. The wounds were then closed by slight undermining the wound edges with re-approximation with 4-0 PDS deep dermal subcutaneous closure and 5-0 Prolene suture.
Modifier 59?
15
3C – Complications of Modifiers
PROCEDURE:
Excision of skin cancers x 2 right leg.
DESCRIPTION OF PROCEDURE:
The patient was prepped and draped in the usual fashion in the supine position under local anesthesia. IV sedation was given. Prior to incision, 1 gram of Ancef was given IV piggy back. An elliptical incision was made around the anterior skin lesion and mass and the full thickness skin was taken down past the subcutaneous tissues to the muscle layer and was excised circumferentially. A short suture was marked superiorly and the long suture laterally. Hemostasis was acquired. The wound was then closed using interrupted, 3-0 Vicryl sutures of the subcutaneous tissues and 3-0 Nylon suture for the skin. Of note, the second lesion was also excised using elliptical incision. This was on the inferior medal aspect of the right leg. This was taken down and removed full thickness of skin. A short suture marked the area superiorly and the long suture laterally. Hemostasis was acquired and was good. This wound was then closed using interrupted 3-0 Nylon sutures in an interrupted fashion. Dressings were applied. At the end of the operation, the sponge and needle count were correct X 2. Estimated blood loss was less than 5 cc.
The patient was then transported to the recovery room in stable condition. The patient tolerated the procedure well.
Modifier 59?
3C – Complications of Modifiers
Increased Procedural service
Used to indicate the service provided required
substantially greater work than typically required for
a service of the same type.
Modifier 22
3C – Complications of Modifiers
Examples:
• Excessive blood loss during the particular procedure
• Excessively large surgical specimen
• Trauma extensive enough to complicate the particular
procedure and not billed as additional procedure codes
• Other pathologies, tumors, malformations (genetic,
traumatic, surgical) that interfere directly with the procedure
but are not billed separately.
Modifier 22
16
3C – Complications of Modifiers
WPS Medicare - Reimbursement will required review of documentation including:
– The unusual circumstances of the procedure
“The ease or difficulty of a procedure generally falls within a bell curve with the lowest 2.5% of cases being extremely easy and the highest 2.5% of cases being substantially more difficult.”
– How the procedure differs from the “typical” service normally provided.
Modifier 22
Source: http://wpsmedicare.com/j5macpartb/resources/modifiers/clarification-use_modifier22.shtml
3C – Complications of Modifiers
WPS Medicare
• When the modifier 22 is used, two separate documents will
be required to support the claim.
– An operative report and
– A separate statement indicating how the service differs from the
usual
• Please note - on April 28, 2012, if a separate statement
describing the very unusual difficulty is not with the operative
report, the 22 modifier will not be considered.
Modifier 22
47 Source: http://wpsmedicare.com/j5macpartb/resources/modifiers/modifier22-billing-documentation.shtml
3C – Complications of Modifiers
WPS Medicare
“When developing a separate statement avoid using a
generalized statement. Comments like "patient was obese"
or "surgery took longer than usual" or "multiple adhesions"
lack specific details which identify why the procedure was
beyond the normal difficulties that could be encountered with
the procedure. Further, it is important that your operative
note supports the statement on why the surgical procedure
was beyond the ordinary range of difficulty.”
Modifier 22
48 Source: http://wpsmedicare.com/j5macpartb/resources/modifiers/modifier22-billing-documentation.shtml
17
3C – Complications of Modifiers 49
3C – Complications of Modifiers
NCCI
• Occasionally a provider may perform two procedures that should not be reported together based on an NCCI edit. If the edit allows use of NCCI-associated modifiers to bypass it and the clinical circumstances justify use of one of these modifiers, both services may be reported with the NCCI-associated modifier. However, if the NCCI edit does not allow use of NCCI-associated modifiers to bypass it and the procedure qualifies as an unusual procedural service, the physician may report the column one HCPCS/CPT code of the NCCI edit with modifier 22. The Carrier (A/B MAC processing practitioner service claims) may then evaluate the unusual procedural service to determine whether additional payment is justified.
Modifier 22
3C – Complications of Modifiers
Regence BCBS:
“In order to be considered for increased
reimbursement, documentation from the patient’s
record that will support the significantly greater effort
performed must be submitted with the claim. It is not
sufficient to simply document the extent of the
patient’s illness or comorbid conditions that caused
additional work. The documentation must describe
additional work performed. “
Modifier 22
51 Source: http://www.or.regence.com/provider/library/policies/reimbursement-policies/modifiers/modifier22-increased-procedural-services.html
18
3C – Complications of Modifiers
Procedure:
Gastrostomy revision.
T-tube change.
History: This is 7-year-old male who is admitted to the GI service. Patient has a prolapse of what appears to be large amount of gastric mucosa out of G-tube site. Because of this, changing of his G-tube was felt indicated. He currently has a Foley in place.
Procedure: The patient was taken to the operating room, laid in supine position while general anesthesia was induced. The Foley was used to measure the tract length and the tract length was felt to be about 3.5 cm. A Foley was removed and abdomen was prepped and draped in usual sterile fashion. A large mass on the superior portion of the G-tube was excised along with a large amount of scar tissue. This was followed down to the gastric mucosa and the mucosa was sutured in a 180 degree fashion on the superior side to the skin. This made a nice gastrostomy tract. 8 ML 25% Marcaine was injected as a local block. Next, a 16 X 4.0 Boston Scientific G-tube was placed and the balloon filled. This seemed to fit fairly well. Antibiotic was placed on the wound. Patient tolerated procedure well, awoke in the recovery room in stable condition.
Modifier 22?
3C – Complications of Modifiers
Procedure:
The patient was brought to the Operating Room and placed on the operating table in the supine position. General anesthesia was induced and she was prepped and draped in sterile fashion. Her ileal conduit was instrumented with silicone 14-Frech Foley catheter with return of yellow urine. The abdomen was then prepped with Betadine and latex allergy precautions were maintained throughout the procedure. Initial 3-cm incision was made superior to her previous lower midline scar and blunt dissection and Bovie electrocautery was down to the level of the anterior rectus fascia in the midline. Once this was identified, there was an obvious hernia, and this was incised. Two hours were spent in lysis of adhesions and to identify the point of obstruction, and the limits of the hernia. After the hernia defect had been identified in its entirety, there was no gross evidence of ischemic bowel, however, there was obvious obstruction, which went beyond on what was visible. Her incision was opened both inferiorly and superiorly and the lysis of adhesions continued. Pneumatosis was identified in several locations in the mid small bowel and along with copious adhesions…..
Modifier 22?
3C – Complications of Modifiers
Reduced services – Used to indicate a procedure was partially
reduced or eliminated at the discretion of the provider.
• Do not use for procedures that are terminated
• Do not use on time based codes
• Do not use to reduce the fee for the service
• Fee should be calculated by the percentage of the procedure
performed
Example: When a bilateral procedure is performed on one side
only. If the code description includes “unilateral or bilateral”
do not append modifier 52.
Modifier 52
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3C – Complications of Modifiers
Railroad Medicare
• Radiology
– Used when the ‘supervision’ and ‘interpretation’
components are performed by different providers.
CPT should be submitted with modifier 26 followed by
modifier 52.
– Used when a bilateral code is performed unilaterally or
when the available code describes more than was
captured on the film.
Modifier 52
Source: http://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~Railroad%20Med
icare~Articles~Modifier%20Lookup~8HKT225577
3C – Complications of Modifiers
Railroad Medicare
• Documentation must include:
– A concise statement that explains the nature of the reduced service
along with any other supporting documentation that the provider
deems relevant
– The concise statement may appear on the operative report, but it
must be clearly identified. You may circle, underline, highlight or
write the concise statement on the operative report. Failure to
submit the appropriate information will result in a denial of the claim.
Modifier 52
56 Source: http://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~Railroad%20Med
icare~Articles~Modifier%20Lookup~8HKT225577
3C – Complications of Modifiers
PROCEDURE: Limited colonoscopy to 45 cm. It could not be done further because of poor bowel prep and stool proximal to this area.
DESCRIPTION OF PROCEDURE: The patient had bowel prep the day prior and was brought to the operating room with sedation. He was placed m the left lateral descubitus position. Rectal examination showed that the rectum was clear. The colonoscope was then advanced into the anal/rectal area and advanced slowly up to 45 cm, At 45 cm. I encountered a large amount of stool and a large amount of fluid. I removed some of the stool in this area but proximal to this there was a large amount of stool and I could not advance the colonoscope any further. Because of poor bowel prep and I could not see the colonoscope was then removed from 45 cm back to the anal verge. There were no tumors, polyps, cancers identified. It was normal to 46 cm, I will need a barium enema to complete his evaluation of his colon. I will schedule this at a later date. The patient was then transported to the recovery room In stable condition. The patient tolerated the procedure well.
Modifier 52?
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3C – Complications of Modifiers
I have discussed the risks, benefits and alternatives of the procedural sedation with the patient. She requests analgesia for the reduction. I have obtained pre procedural vital signs. I pre-oxygenated the patient utilizing a non-rebreather. I had airway equipment at bedside. I had the patient with constant cardiopulmonary monitoring during the procedure. Utilizing 100 mcg of fentanyl, I was able to with reasonable anesthetic effect reduce her ankle dislocation. However, the ankle dislocation was unstable- I am unable to stabilize it sufficiently, and it has re-dislocated. I have irrigated the area again under pressure with sterile saline. 1 have once again placed a sterile dressing soaked with sterile saline on it. I re-examined the pulses including DP and PT pulses and they are intact. Her nerve function is intact. I have watched her for approximately 45 minutes after the procedure, and she has recovered completely from the fentanyl. Her blood pressure did not drop. Her oxygenation did not drop. Her recheck vital signs are 151/78, pulse of 75, respiratory rate of 18, 98% on room air. I have also discussed the risks, benefits and alternatives of joint reduction with her, and these include neurovascular injury, worsening fracture among multiple others, but she agreed to pursue this. I have obtained written consent for both procedures. At this time, the patient is comfortable. Her lab studies are still pending at this time. Chest x-ray is pending at this time, and she will be admitted to Dr. P for emergency surgery for irrigation and debridement of her open wound.
Modifier 52?
3C – Complications of Modifiers
Discontinued procedure – Used to indicate that
circumstances existed that were a threat to the
patient’s well being and the procedure was
discounted.
• Do not use for an elective cancellation
• Fee determined by the percentage of the procedure
completed.
Modifier 53
3C – Complications of Modifiers
WPS Medicare
• Documentation should:
– Be available upon request
– State the procedure was started
– State why the procedure was discontinued
– State the percentage of the procedure that was performed
• Facts:
– 45378-53, G0105-53, and G0121-53 have their own fee schedule
amounts
Modifier 53
Source: http://wpsmedicare.com/j8macpartb/resources/modifiers/modifier-53.shtml
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3C – Complications of Modifiers
CT-GUIDED LIVER CORE BIOPSY
FINDINGS: Prior to the procedure I explained the procedure, benefits and risks to the patient and his wife via a translator. They expressed their understanding of this information and wished to proceed. A detailed written informed consent was obtained and witnessed. The patient was brought to the CAT scan suite and laid in the supine position. Limited CT images of the upper abdomen were performed. These were viewed for scouting purposes only. The appropriate site for liver core biopsy was chosen. The patient's skin was then marked with the computer coordinates. Patient's skin was then prepped and draped in the usual sterile fashion. 1% lidocaine was used for local anesthesia. At this point, repeat limited CT scans of the upper abdomen were performed. This demonstrates the needle in satisfactory position. Therefore it was elected to proceed with liver core biopsy. I then utilized 1% lidocaine to numb the liver capsule. Throughout this procedure the patient was given instructions for breathing. A small incision was then made. Then an 18-gauge core biopsy device was advanced into the appropriate site and a sample was obtained. The first pass had limited sample. Therefore I did a second pass. The sample was small. At that point in time, due to the patient's respiratory variability and inability to follow breathing instructions it was elected to proceed with this biopsy under ultrasound guidance. Followup CT images of the upper abdomen and lung were obtained in order to rule out pneumothorax. Followup chest x-rays were ordered as well. The patient was then transferred to the holding area for monitoring and if stable, to undergo an ultrasound-guided liver core biopsy. All of this information was discussed with Dr. at the time of attempted CT-guided liver core biopsy. This information was also translated to the patient via a translator .
Modifier 53?
3C – Complications of Modifiers
OPERATIVE PROCEDURE:
1. Transmastoid approach to middle and posterior fossa.
2. Definitive resection of middle and posterior fossa intra and extradural resection of mass off clivus.
3. Microsurgical resection of brain.
4. Frameless stereotactic-craniotomy.
CLINICAL HISTORY:
The patient is a 41-year-old female who presented with difficulty walking and a large petroclival hemangioma. She was scheduled for resection. The risks of the operation, including bleeding, infection, paralysis, coma and death were explained to the patient and family, and they wished to proceed with surgery.
OPERATION IN DETAIL:
The patient was brought to the operating room; induced anesthesia in a smooth fashion. A curvilinear incision was made behind the right ear. We had the frameless stereotactic set up. We then put in three burr holes and removed a 5 cm of bone flap. We went above and below the transverse sinus and went to the middle fossa, as well. The transverse sinus was identified. We then opened the dura and tacked it up with 4-0 Nurolon; then went to the posterior fossa first and a supracerebral infratentorial tumor appeared. This was an extremely vascular tumor. Under the microscope, we were able to get it debulked and it had torrential bleeding. We lost over a liter of blood. We decided to be more cautious. We used the frameless stereotactic to resect. More than 50% of the tumor had been debulked. There was persistent bleeding and the brain was getting swollen and I figured we did not want to cause any unnecessary morbidity. So, we decided we would stop the procedure and then consider a gamma knife. The dura was closed with continuous 4-0 Nurolon. Glue was put over the bone flaps to pat together plates. Interrupted Vicryls was used on muscle and fascia, and locked Nylon was put on the skin. A sterile dressing was applied. Patient tolerated the procedure well and was taken to the recovery room in a stable condition.
Modifier 53?
3C – Complications of Modifiers
• 58 – Staged or related procedure or service by the same physician during the postoperative period
• 78 – Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period.
Post-Operative Surgical Modifiers
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3C – Complications of Modifiers
• Staged or related procedure or service by the same
physician during the postoperative period.
• Used when:
– The service is planned or staged
– The service is more extensive than the original service
– Therapy following a surgical procedure
• Not used when:
– Reporting the treatment of a complication from the original
surgery
Modifier 58
3C – Complications of Modifiers
• A new postoperative period begins when the staged or related procedure is performed.
Example: A breast biopsy is performed on 3/2/13. The patient is diagnosed with breast cancer and the same physician performs a modified radical mastectomy on the right breast on 3/6/13. The modified radical mastectomy would be submitted with modifier 58.
Modifier 58
3C – Complications of Modifiers
NCCI
“If a diagnostic endoscopic procedure results in the decision to
perform an open procedure, both procedures may be
reported with modifier 58 appended to the HCPCS/CPT code
for the open procedure.
However, if the endoscopic procedure preceding an open
procedure is a “scout” procedure to assess anatomic
landmarks and/or extent of disease, it is not separately
reportable. “
Modifier 58
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3C – Complications of Modifiers
Indication: This 44-year-old female with history of status post left upper extremity hand decompressive fasciotomy due to compartment syndrome. The patient has been brought previously for left upper extremity wound debridement and surgical bed preparation and preparation for application of full thickness skin graft to expedite wound closure and to allow earlier physiotherapy and return of function. The patient was planned to have a wound closure either in delayed fashion or with split-thickness skin graft during this operative encounter. The procedure was explained in full to the patient. She understands the risks include, but not limited to bleeding, infection, failure of the skin graft, need for further reconstructive surgery, loss of function, possible loss of limn, Informed consent was obtained.
Modifier 58?
3C – Complications of Modifiers
• Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period.
• Failure to submit the procedure with modifier 78 will result in claim denial
• Example: Patient has a liver transplant on 3/2/13, on 3/3/13 the patient is returned to the OR and the physician re-opens the abdomen to control bleeding. Modifier 78 is appended to the procedure performed on 3/3/13.
Modifier 78
3C – Complications of Modifiers
OPERATIVE INDICATIONS: The patient is a 51 year old gentleman who yesterday I tried to revise his AV graft. I did a thrombectomy and balloon angioplasty and intraoperative arteriogram and it failed right away.
OPERATIVE PROCEDURE: The patient was placed in supine position, underwent uncomplicated general endotracheal anesthesia. I reopened his old incision, I then opened up the graftotomy and did a thrombectomy both sides, got good back bleeding, good inflow. I went ahead and shot an arteriogram. There was a small amount of what looked like pseudo-intima in the distal anastomosis of the venous that was causing a flow defect, I finally got that out with a Fogarty catheter and then I ballooned it up again with a 6 millimeter and a 7 millimeter Conquest balloon up to 30 atmospheres and then reshot the arteriogram in both directions. The arterial anastomosis looked fine as did the venous anastomosis except it was a little bit narrowed still but certainly much bigger than it was at the time of the first revision. I closed up the graftotomy with 5-0 Prolene, restored flow. There was a modest thrill but of course his blood pressure was only 90 so hopefully it will get better with time. We closed the wound with Vicryl and Dermabond and turned the patient over to anesthesia for wake up.
Modifier 78?
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3C – Complications of Modifiers
PROCEDURE: Exploratory laparotomy and removal of 2 liters of blood clots; ligation of omental bleeding vessel; removal of 6 lap pads and reapplication of wound VAC.
FINDINGS: Six lap pads that could be easily removed, large amount of hematoma and a small bleeding arterial in his omentum.
FLUIDS REPLACED: I5OO crystalloid. DRAINS: Wound VAC.
INDICATIONS FOR PROCEDURE: The above patient was admitted following a head-on motor vehicle crash. He sustained multiple interabdominal injuries including a liver laceration and multiple bowel injuries. He had small bowel resection and was left in discontinuity. The patient was on Coumadin preoperatively and had significant bleeding intraoperatively. Additionally, his gonadal vein was avulsed from his inferior vena cava. Postoperatively the patient required massive fluid resuscitations of crystalloid and blood products. He required pressure release of his wound VAC earlier in the day and earlier in the afternoon he partially eviscerated from the bottom portion of his wound along the pelvis. We could only see purplish material underneath; it was unclear whether it was blood clots or ischemic bowel.
DESCRIPTION OF PROCEDURE: We removed his wound VAC, sterilely prepped and draped him in the usual manner. We encountered a large amount of hematoma and evacuated approximately a total of 2 liters. The bowel was still protuberant but viable. We were able to identify at least one area that was in discontinuity. We removed 6 laparotomy pads from his bilateral pelvis; there was no bleeding in the area. We left the lap pads surrounding the liver. Additionally, there was one small artery in his omentum that had pulsatile bleeding and we ligated that with a vicryl tie. We then irrigated the abdomen and reapplied a fenestrated bowel bag taking care to have the bowel bag extend into the gutters. We also applied an open abdomen wound VAC device and attained a good seal. The patient was taken back to the trauma ICU in still critical but hemodynamically stable condition. He tolerated the procedure well. Counts were correct during the case. He still has retained laparotomy pads. I do not know the exact number that are retained. We did however take 6 laparotomy pads out of his abdomen. I was scrubbed and present during this procedure.
Modifier 78?
3C – Complications of Modifiers
• Intent of modifier
• Documentation
• Payer Guidelines
Wrap Up
3C – Complications of Modifiers
Questions?
Thank you!