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NYU School of MedicineCoding and Reimbursement Seminar Series
MODIFIERS - The Key to Proper Reimbursement
Presented by the Office of Reimbursement Compliance
Gretchen L. Segado, MS, CPCDirector of Reimbursement Compliance
(212) 263-2446(212) 263-6445 fax
Today’s Agenda
What are modifiers?How are they used?Why do I care?
What are modifiers? Modifiers are two digit codes appended to a
CPT code that indicate that a service or procedure has been altered by a specific circumstance, but has not changed in its basic definition
Three Levels of HCPCS Codes(Healthcare Common Procedural Coding System) Level 1-CPT, Physician’s Current Procedural
Terminology
Level 2-HCPCS National Codes
Level 3-Local Codes assigned and maintained by individual state Medicare Carriers Eliminated by HIPAA as of Dec 31, 2003
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 increased or
reduced Only part of a service was performed A service or procedure was provided more
than once A bilateral procedure was performed Unusual events occurred
Examples:
31237-50 (procedure done bilaterally)
99214-25 (office visit and procedure on same day)
33208-62 )two surgeons of differing specialties doing same procedure together)
Two Ways to Report Modifiers on a Claim Form
1. Modifier appended to the CPT code 49500-50
2. Reported by using separate five-digit code along with the procedure code.
Example 49500 plus
09950
Method #1 is the most common usage
Why aren’t my claims getting paid?
Why aren’t my claims getting paid?
Appropriate use of modifiers get services reimbursed that might otherwise be denied!!!
Claims can be incomplete or inaccurate without a modifier
Coding to the highest level of specificity requires modifier use
What is the “Global” Period?
Also known as the global surgical package No one standard definition Per CPT guidelines,
The following services are always included in addition to the operation per se:
local infiltration, metacarpal/metatarsal/digital block or topical anesthesia;
What is in the Global Period? subsequent to the decision for surgery, one related
E/M encounter on the date immediately prior to or on the date of procedure (including history and
physical); immediate postoperative care, including dictating
operative notes, talking with the family and other physicians;
writing orders; evaluating the patient in the post-anesthesia
recovery area; typical postoperative follow-up care.
Examples of Services Included in the Global Period Removal of staples 10 days after a surgical
procedure A visit with a patient prior to surgery to
answer any last minute questions A post-operative visit in the office to check
on wound healing
Examples of Services NOT Included in the Global Package
The visit where the decision to perform a procedure or surgery was made, even if on the same day as the procedure
A visit during the post-op period for a problem unrelated to the surgery
Without a modifier, these service will not get paid!!!!!!!
Modifier -21Prolonged E/M ServicesAppend to E&M code
When face-to-face or floor/unit service provided is prolonged or otherwise greater than that usually required for the highest level of E&M code
Unfortunately, the modifier rarely affects payment
May only be used with the highest level of E/M service
NOT a time based modifier
Modifier -22Unusual Procedural ServicesAppend 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%
Key terms:
Increased risk; difficult; extended; complications; prolonged; unusual findings; unusual contamination controls; hemorrhage, blood loss over 600cc, unusual findings, etc.
Additional physician work due to complications or medical emergencies may warrant use of -22
Appropriate Use of Modifier -22Appropriate 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)
Inappropriate Use:
Partial colectomy with accidental laceration of vessel resulting in additional time for repair
Modifier -23 Unusual AnesthesiaAppend to Procedure Code
Occasionally, a procedure requiring local or no anesthesia must be done under general anesthesia due to unusual circumstances.
Example: Child or adult unable to cooperate with procedure - requires anesthesia i.e. CT, MRI, XRT
-23 Unusual Anesthesia Use the code once on the basic service procedure code
Claim must be accompanied by documentation and cover letter by physician explaining the need for general anesthesia
Not for use by the anesthesiologist
Do not use for local anesthesia
Modifier -24 Unrelated E/M Service by Same Physician during a Postoperative Period Append to E&M code
Used when a physician provides a surgical service related to one problem and then during the postoperative period provides an E&M service unrelated to the problem requiring the surgery. Diagnosis code selection is critical to indicate the reason for the additional E&M service.
Modifier -24 Example: Patient came in for post-operative visit. He is
12 weeks s/p diskectomy. During the exam, pt c/o severe headaches with visual changes, preceded 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
Services Not Included in Global Package: Initial consultation or evaluation by the surgeon to
determine the need for surgery Services of other physicians unless a transfer of
care has been arranged Visits unrelated to patient’s surgical diagnosis Treatment for the underlying condition or an
added course of treatment that is not part of normal recovery from surgery
Services Not Included in Global Package:
Diagnostic tests and procedures Staged or clearly distinct surgical
procedures during the post-op period Treatment for post-op complications
requiring a return to the OR A more extensive procedure when a less
extensive procedure fails
Services Not Included in Global Package: Supplies, such a surgical trays, splints and
casting materials when certain surgical services are performed in the physician’s office
Immunosuppresive therapy for organ transplants Critical Care services unrelated to the surgery for
a critically injured patient Pre-op evaluations outside of the global surgical
period
"Let's hope there‘re no post-op problems-it complicates the billing."
Clinical Examples for Modifier -24Appropriate Use: Patient 80 - days s/p TURP.
Reports to the office of the surgeon who performed the procedure complaining of right flank pain and abdominal pain. Diagnostic work-up reveals a kidney stone.
Report 992XX-24 with diagnosis code for the kidney stone
Inappropriate Use: Patient returns for
complaining of fever and wound tenderness in the global period of her C-Setion
Report 99024 post-op visit
Modifier -25Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service
Append to E&M Code
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 -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:
CPT Codes 9921X-25 & 20610
Clinical ExampleAppropriate Use:Procedure: Excision, rt. arm lesion Visit- Established Pt concerned about
changes to a lesion on right arm. History taken, examination of arm and additional body areas for new and suspicious lesions performed. Physician decides to remove lesion.
Clinical Example Inappropriate Use: Patient presents for scheduled removal of
lesion on right arm. Exam of arm to determine status of lesion performed and a general determination of the patient’s status prior to excision.
Modifier -26Professional ComponentAppend to procedure code
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 2D echocardiography using the hospital equipment. The physician provides the written interpretation.
REPORT: CPT Codes: 93307-26
Modifier -26 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 -32Mandated ServicesAppend to E&M Code
Attach modifier 32 to mandated consultation &/or other services.
Usually mandated by courts, government agencies or an insurance entity
Modifier -47Anesthesia by SurgeonAppend to Procedure Code
Regional or general anesthesia provided by surgeon may be reported by adding -47. Not to be used with local anesthesia
This service is not covered by Medicare or Medicaid
Do not use this modifier with anesthesia codes
Modifier -50Bilateral ProcedureAppend to procedure code
Used to report bilateral procedures that are performed at the same operative session. Used only to services/procedures performed on identical anatomic sites, aspects or origins (arms, legs, eyes, breasts)
Example: Physician removes a foreign body from each of a patient’s ears without anesthesia.
CPT Code 69200-50
Modifier -51Multiple ProceduresAppend to Procedure Code
Multiple and related surgical procedures, other than E/M services, performed at the same session by the same provider.
EXAMPLE: Patient presents for removal of a malignant lesion
on the face with complex repair of the defect
REPORT: CPT Codes 11641 & 13152-51
Modifier -51 Do not use -51 on procedures that are
components of another procedure Do not use the -51 on the primary
procedure, only on the secondary procedures (order procedures by RVU)
Do not use -51 on procedures with a “+” sign indicated in the CPT Manual
Modifier -52Reduced Services
Used to identify a procedure or a service that is partially reduced or eliminated at the physician’ s discretion.
EXAMPLE: A 50 year old woman presents to have 20 skin tags removed.
REPORT: CPT Codes: 11200 - removal of skin tags; up to and
including 15 lesions.11201-52 - each additional 10 lesions
Modifier -53Discontinued ProcedureAppend to Procedure Code
Used to indicate that a surgical or diagnostic procedure was started but discontinued, usually because of extenuating circumstances or those that threaten the patient’s well-being.
Most often used when a physician elects to terminate a surgical or diagnostic procedure
Usually used after the induction of anesthesia
Modifier -53 Differs from modifier -52 because in that a life-
threatening condition precipitates the terminated procedure.
Not used to report elective cancellation prior to induction of anesthesia or surgical prep, including situations where cancellation is due to patient instability
Modifier 53Discontinued Procedure cont.
EXAMPLE: A 50 year old woman complaining of acute rectal bleeding. She was given a bowel prep, administered at home, and returned for a total diagnostic colonscopy. The procedure proceeds in the normal fashion, however the patient suddenly develops an erratic heart beat and the physician elects to discontinue the procedure.
REPORT: CPT CODE: 45378 - 53
Modifier -54Surgical Care OnlyAppend to Procedure Code
Physician service to the patient was only the intra-operative procedure. Another physician(s) will perform the Pre-operative and Post operative care.
There should be an 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 surgeon who performed the procedure
Clinical 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 surgery, and performed the procedure. Follow-up care was performed by a local surgeon.
The neurosurgeon would report 61321-54
Modifier -55 Postoperative Management Only
While on vacation in Vail, Anna had a skiing accident. A local Orthopedist in Vail did the Pre operative and Intra-operative procedure and the patient went home.
NYU physician provides all post-op care, and bills by adding a -55 to the surgical procedure code.
Modifier -56Preoperative Management OnlyAppend to Procedure Code
Pre operative evaluation was performed and decision was made to have the intra-operative procedure and post operative care done else where.
Internist does pre-op work-up on a patient having a laporoscopic cholecystectomy by a general surgeon who travels to the area monthly. Internist would bill 47562-56
MODIFIER -57DECISION FOR SURGERY
•E/M service on the day before or on the day of major surgery (90 day global period) which results in the initial decision to perform the surgery is not included in the global surgery payment.
EXAMPLE: Patient comes to the emergency department with sudden onset of acute abdominal pain. Gyn physician evaluates patient & determines that patient has twisted ovarian cyst. Physician admits patient to OR for right salpingo oophorectomy.REPORT: CPT Code 99223-57 & 58720
Modifier –58Staged or Related Procedure by the Same Physician during the Postoperative PeriodAppend to Procedure Code
Indicates that the procedure or service during the post-op period was either planned prospectively at the time of the original
procedure More extensive than the original procedure For therapy following a diagnostic surgical procedure
Without the modifier, the third-party payer could reject the claim because the surgery occurred during the post-op period
Modifier -58 Example: 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: 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
muscle flap planned at time of initial
surgery
Modifier -59Distinct Procedural ServiceAppend to Procedure Code
Indicates that a procedure or service was distinct or separate from other services performed on the same day. May represent a different session or patient encounter, different incisional site, separate lesion, or separate injury.
Example: An arthroscopic synovectomy was performed on the right knee for localized synovitis and a diagnostic arthroscopy was performed on the left knee for chronic pain syndrome.
Report: CPT Codes 29875 & 29870 - 59
Modifier -62 Two surgeonsAppend to Procedure Code
2 surgeons work together as primary surgeons
performing distinct parts of a single procedure
Each surgeon reports his/her distinct operative work by
adding the -62 modifier to the procedure code and related
add-on codes
Example: Transphenoidal Hypophesectomy
Neurosurgeon and ENT both report 61548-62
Modifier -62 Appropriate Use:Arthrodesis using anterior
interbody technique, thoracic level.
Thoracic surgeon performs a thoracotomy, exposes and later closes the site
Orthopaedic surgeon performs the arthrodesis
Both surgeons use CPT Code
22556-62
Inappropriate Use:Oncology surgeon performs a radical mastectomy. At same operative session the plastic surgeon then performs breast reconstruction. In this case, the surgeons are performing 2 distinct services and each uses separate CPT codes and -62 is not required
Modifier -63 Procedure Performed on Infants less than 4kgAppend to Procedure Code
Procedures performed on neonates and infants up to a present body weight of 4kg may involve significantly increased complexity and physician work
Unless otherwise designated, should only be appended to services in 2000-69999 code series. Should not be appended to E&M, Anesthesia, Radiology, Path/Lab, Medicine sections
Modifier -66Surgical Team Highly complex
procedures requiring concomitant services of several physicians, often of different specialties plus other highly skilled, specially trained personnel, various types of complex equipment
Transplants Separation of
conjoined twins Each participating
physicians uses the modifier
Modifier -76 Repeat Procedure by same physician Append to Procedure Code
Example: Pt. was brought by an ambulance to the ER with
multiple trauma. Pt. was intubated and chest X-ray was
taken. Results showed tube was not in position, pulled and
re-inserted.
Report: CPT Codes 31500
31500 [76]
Modifier -77Repeat Procedure by Another Physician Append to Procedure Code
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 and provide documentation to support the need for a repeat CXR.
Modifier 78 Return to OR for a related procedure during post-operative period Append to Procedure Code
Example: Pt. brought to recovery room S/P abdominal
surgery. Dressings became saturated, vital signs were
unstable. Pt. brought back to OR for exploration post-op
hemorrhage.
Report: CPT Codes 35840 [78]
Modifier 79 Unrelated Procedure/Service by same MD during the post-op period Append to Procedure Code
Example:
A repair of femoral hernia [49550 (90 day global)] is
performed on Jan. 5. On Feb. 12, the same physician
performs an appendectomy.
Report:
CPT Code 44950 [79]
HCPCS Modifiers Alpha or alphanumeric Provide additional information just like CPT
modifiers
Examples AH- services by Clinical Psychologist F1-Left hand, second digit FP-service provided as part of Medicaid
Family Planning Program GG-performance and payment of a
screening mammogram and diagnostic mammogram on the same patient, same day
GC ModifierAppend to both E&M and Procedure Codes
Used to indicate when a service has been performed in part by a resident under the direction of a teaching physician.
Also applies to “assistant surgeon” on operative reports.
GE Modifier Append to both E&M and Procedure Codes
Service performed by a resident without the presence of a teaching physician under the primary care exception
A Quick Self-Test for Compliance Practices in Your Office
Does your office review all pertinent documentation prior to appending a modifier?
Do you monitor the activities of your billing office or service with respect to modifier usage?
Do you randomly cross-check all billings performed by your office or service to be certain that claims submitted with modifiers are accurate and appropriate?
Compliance Test con’t. Do you make sure the staff is educated
and updated on Medicare and Medicaid program changes?
Are services billed to Medicare and Medicaid thoroughly documented?
Are new billing employees and new physicians oriented on modifier reporting policies?
The Answer to all those questions should be YES.
A Quick Self-Test for Complaint Practices in Your Office Do you allow your billing office or service to
assign modifiers and subsequently report services on claims without conducting an intermittent review of claims?
Does your billing office or service have carte blanche permission to correct and/or change codes for services that you have performed?
Is there evidence of inappropriate overpayment by the payer when a modifier is used?
Does your billing office or service answer all Medicare and Medicaid inquiries regarding your services and claims on your behalf without your knowledge?
The Answer to These Questions Should be NO!!!!!!!!
Remember, Modifiers mean real money for your practice!!!
