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Modifiers your key to reimbursement 2018

Discussing the HCPCS Modifier 59 Subsets and their impact<br>Tools to make the 22 modifiers work for you<br>How to make the 25 modifiers your financial friend<br>The benefit of information modifiers vs payment modifiers<br>Clarification on the professional 26 modifier<br>Direction on the -24 and how it impacts reimbursement.<br><br>E-mail us at cs@onlineaudiotraining.com or Call 1-800-935-3714 to buy full webinar.

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Modifiers your key to reimbursement 2018

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  1. “Modifiers: Coding,Billing,Challenges&Money!” OnlineAudioTraining Presents: Webinar Education Prepared and Presentedby: TerryA.Fletcher BS, CPC,CCC,CEMC,CCS,CCS-P,CMSCS,CMCS,CMC,ACS-CA, SCP- CA www.onlineaudiotraining.com 1

  2. TheWordSearch-Codingis apuzzle:Doesitfit? I'veworkedin codingeducation nowforabout 30years. In that time I'vebeen askedto work onalot ofdifferent projects related to coding education andauditing. In addition to training coders, I'vebeenaskedto evaluate peopleto seeif they would makegoodcoders.AndI alwaysstartwith thewordsearchtest.Doyoulike wordsearches? If not, youmight want to consider adifferent career.Because coding is onebig wordsearch. Youhaveto decipher themedical record (or operative report)anddecidewhich words/proceduresare importantandwhich onesyoucanditch.Also, whenlooking at detailsit is out job to decideif thecodefully supports theCPTcodeto bebilled,or canwefind language detailsin thereport that allow usto chooseamodifier to help descript,increase,or enhanceacode. SORETHRO AT NU EZ C CVTSUNBURNEGXPRSANGI OGR APHYPQWSA 2 2

  3. Deciphering theOperativeReportforModifiers I amoftenaskedto explain howto decipheranoperative report.Well,it dependsonthe procedure,really. Andif youare anew coderandyouever havethe opportunityto goto aseminarwhere they will presentcasestudies,this is the bestwayto learn. I've taught hundreds of classesandnothing driveshome mypoint more than walking through the cases andcoding them.But I will give yousomebasic elementshere to get youstarted. Whilethese rules don't apply to all specialties (e.g., interventional radiology has "special" rules that drive the eventhe mostexperienced coders -that would beme- batty!), this should get you startedonsomeof those basic surgicalreports. I want to walk you through the process to findthe modifier(s) you mayneedfor successfulcoding andbilling……. 3 3

  4. Rule1-JustLikeRagu,It's ProbablyinThere:In coding classweheartermslike"it's bundled" or "separate procedure" but  whatdoesthat really mean?Well,it meansit's integral to themainprocedureanddon'tcodeit outseparately.What'sincluded? Well,pretty much anything that hasto bedoneinorder to accomplishthemainprocedure.Takingoutanappendix? Well,then theincision(or creation ofports for laparascopic instruments)is included. Performing adiagnosticcardiaccatheterization,byradial or femoral approach? Theaccessis included, per CPT.Sois theclosure at the endofanyprocedure.I don'tknowaboutyou, but if I havemyappendixtaken outI sure hopethephysicianremembers to suture meclosed at the end.All those things are likeregular ingredients in Ragupastasauce-tomatoes, oregano,garlic.It's inthere!Sodon't codeeachcomponent out separately.Now,hadthey decidedto doaliver biopsy while inthere,that's different. That'slikethrowing abananainthe pastasauce.Soit gets codedseparately. Example: Left HeartCatheterization, left ventricularinjection, rightandleft coronary injections, andanabdominal aortogramwith runoff. CPTCodes:93458(26),75630.26.59 Rationale:Thecardiaccath performedby thephysicianis theprofessionalcomponent–viathe 26modifier,andthe presenting indicationswerechest pain andabnormal EKG.Thenweseetheabdominal aortogramwith runoff, andthat hasnothing to dowith the heart.This wasperformedfor uncontrolledhypertension and lower extremity edema.Byjust realizingthat oneprocedure, evenif it is performedat the sameencounteras another,doesn’tmeanthey are related inanywayandamodifier could beneeded to getpaymentforboth or all services. CheckMedicare CCIedits first, andthen askyourself, “Is this agoodindicationthat amodifier to “protect” the unrelated service?”, or asCPTsays, “Distinct Procedural Service”the 59maybeappropriate?”It’s all about knowing andlooking fordetails, andunderstanding anatomical differences whencoding. ICD-10-CM Codes:R94.31(abnormal EKG–linked toCath),I10andR60.9(Essential Hypertension &Edema, unspecified-linked toAIFF) 4 4

  5. Rule 2 – Modifiers are Interpretive:Practice, Practice, Practice! AndKNOW your payers! CLINICAL PROFILE: A52-year-old white female with diabetes mellitus, dyslipidemia, cigarette smoking andacuteinferior ST-elevationmyocardial infarction. Shehada history of coronarystenting. PROCEDURESDONE:Emergent diagnostic left heart catheterization, left ventriculography, selective coronary arteriography, right commonfemoral arteriography followed by complex, mid left circumflex coronary balloon and stent angioplastyas well as Perclose for hemostasis of the right femoral artery. ICD-10-CM: I21.19 STelevation (STEMI) myocardial infarction, involving other coronary artery of inferior wall. E11.9 Type2Diabetes without mention of complication. (not allowed for admitting dx under the DRGinpatient) Z95.5 CADwith presence ofstent F17.210 Nicotine dependence, cigarettes, uncomplicated CPTCODES: 92941-LC (I21.19) 93458.26.59(UseXUif Medicare patient)(1-4) 5 5

  6. Rule 3: Know what CMS Says! :Medicare TransmittalsGOLD TAVI-CMSTransmittalinfo: 290.4 -ClaimsProcessing Requirementsfor TAVRServices for MedicareAdvantage (MA) Plan Participants (Rev.2628, Issued 01-07-13; Effective:01- 01-13, Implementation: 04-01-13) MAplans are responsible for payment ofTAVRservicesforMAplan participants.Medicare coverage for TAVRisincluded under section 310.1 of the NCDManual (RoutineCosts in ClinicalTrials). Whenreporting these services toMedicare, you mayneed toinclude themodifier –Q1 (Routine clinical service provided in a clinical research study that isin an approved clinical research study) when these are approved. Example:Transcatheter, Aortic Valve Replacement CPTCodes: 33361-62-Q0 (-Q1 if routine in that approved facility) ICD-10-CM: I35.0-(AorticValve Stenosis), Z00.6 (Examination ofapatient inaclinicaltrial) TAVRandClinicalTrials WhenTAVRisperformedfor indications that are not approved by the FDA, patients mustbeenrolledin qualifying clinicalstudiesin order for Medicare to cover the service.The clinicalstudy must addresspre-specifiedresearch questions,adhere to standards of scientificintegrity, andbeapproved by CMS.Approved studieswill bepostedonthe CMS website. The processfor submittingaclinicalresearch study to Medicareisoutlined in theNCD. Effectivefordates of serviceonor afterJanuary 1, 2013,report claims forTAVRthat are part of aqualifying clinicaltrial using the appropriateCPTcode (33361, 33362, 33363,33364,33365,or 33366) with HCPCSmodifierQ0(this is the letter Qwith anumeric 0Investigational ClinicalTrials). 6

  7. TAVRREPORTLINKING Knowwhatis INCLUDEDinwithinthe CPTCODE!!! 7

  8. CPT MODIFIERS: Alwayshave a current year CPT book Please refer to Appendix A of your CPT book for a complete listing of modifiers. List regular fees and let carrier make contractual adjustments. Do not adjust fees before submitting your claim… most insurance carriers will adjust it again for you just in case… Modifiers are used to report a service or procedure that was significantly altered from the CPT description. Modifiers are used to enhance the meaning of a code, not to change it. CPT added a Narrative update to many of the modifiers to include "or other qualified health care professional.." Modifiers’ impact on reimbursement can vary from payor to payor. CMS and AMA/CPT guidelines will be addressed below. (Modifiers are copyrighted under the AMA CPT® 2017 all rights reserved) 8

  9. Modifiers: Descriptors Modifiers Modifiers are two-digit adjectives that give additional information that is not part of the CPT code description. By identifying special circumstances to payers, use of modifiers can improve reimbursement in some cases, and reduce audit exposure in others. The use of the–22modifier may require documentation to be submitted at the time the claim is submitted. There are other documentation requirements for other modifiers, but this documentation need only be present in the patient’s medical record should the payer request supporting documentation. According to the November 1998 CPT Assistant, Modifiers will only be listed in appendix A, to allay confusion of the use of modifiers with any particular subsection of CPT. The following are the guidelines and appropriate use of the CPT modifiers. 9

  10. Modifier22: IncreasedProceduralService 10

  11. Modifier-22: TricksoftheTrade InsuranceCompany Address, City StateZip Re:Patient: Attached Claim# DearInsurance Companyrep: Please find enclosed acopy of our claimdated _ thisclaim wasan “increasedprocedural service”. (2018 CPTBookAppendixA). . Wewerepaid our contract rateof $ .After further internal review,wehave determined that This procedure was scheduled for time and increased mentalefforton behalfof the physician.The attached report outlines these issues in the highlighted section. I have alsoincludedthe 2018CPTBookcopyof the Appendix A, Modifier’s sectionto descript the -22 modifierin thiscircumstance. Weare respectfully requesting additional reimbursementof $_, to reflectthe moreappropriatereimbursement for thisservice. Pleaseletus know if you have any questions.I can bereached directlyat (800) 555-1212.Welookforward tohearing fromyou and receivingadditional paymentas requested. Thankyou for your considerationin thematter. Sincerely, SusanBusinessManager Cc:attached CPT2018–22modifier section, OPreport,Claim,EOB,Cover of CPTBook hours, but actuallytook_ hours.The technicaldifficulty of this procedure wassuch that it requiredincreased intensity, 11

  12. Modifier -24: UnrelatedE/MServicebythesamephysicianintheP/Operiod. 12

  13. Modifier-24Example:Orthopedics 13

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