Coding with Modifiers

1. Coding with Modifiers Presented by Barbara parker, CMA, CPC Slides Prepared by Lori Dafoe, CPC

2. Modifier Objectives At the conclusion of this session, you should be able to: • Explain what CPT modifiers are and their importance to receiving correct reimbursement • Identify when and how to use CPT modifiers.

3. Modifiers • In today’s regulatory environment, it can be a real challenge to obtain reimbursement for procedures and services rendered • Accurate coding is the most crucial step in the reimbursement process

4. Mastering Modifiers • Coders need to use all the “tools” at their disposal to facilitate the reimbursement process • Modifiers are overlooked tools

5. What is a modifier? • A Modifier provides the means by which the rendering physician may indicate that a service or procedure has been performed, or has been altered by some specific circumstances, but not changed in its definition of code • They are essential ingredients to effective communication between providers and payors

6. What is a modifier? • Just as “modifiers” in the English language provide additional information, CPT modifiers also answer questions such as: • which one • how many • what kind • when • what

7. What is a modifier? • Modifiers are essential tools in the coding process • They are used to enhance a code narrative to describe 1.) the circumstances of each procedure or service 2.) how it individually applies to the patient

8. Primary Functions • Show that a service has been modified but not changed in its identification or definition • Explain special circumstances or conditions of patient care • Indicate repeat or multiple procedures • Method to show cause for higher or lower costs while protecting charge history data

9. MODIFIERS • A complete listing of CPT modifier is found in Appendix A of CPT • Two or more modifiers may be used with one code to give the most accurate description possible for the service rendered

10. modifiers • Not all modifiers can be used in every section of CPT • Consult with carriers regarding the use of two-digit modifier

11. Step by step guidance • Review CPT (AMA) Guidelines • Review individual carrier guidelines • Reference the practitioner’s or facilities patient medial record and/or visit note prior to appending modifiers • Use only 2 digits when appending modifiers (unless instructed otherwise by an individual carrier)

12. Step by step guidance • Provide training for physicians, staff, clinicians, etc. and update training regularly • Take a proactive approach and find the errors in modifier application before the claim is submitted to the insurance carrier • Understand that the insurance carrier interpretations are not always the same as CMS or CPT • Review the National Correct Coding Initiative (NCCI) each quarter for correct usage for each CPT code that your organization uses

13. Modifier tips • Always have the most recent edition of the CPT book on hand • Have your billing staff regularly attend coding workshops • Remember that modifiers are often used differently for physician services and hospital outpatient services • Learn as much as you can about using coding modifiers so you can help your billing staff with coding questions

14. Modifier 21 – Prolonged evaluation and management (e/M) service • Only use with E&M codes. • Use when the service exceeds the highest level within a given category • Recommend sending a written report to the carrier

15. Modifier 22 – Unusual Procedural Services • Do not use this modifier on E&M codes • Use this modifier when the service provided is greater than that described by the procedure code • Specific examples of unusual circumstances include: • Increased risk • Severe respiratory distress • Excessive bleeding (more than 500 cc) • Friable tissue

16. Appropriate use of modifier -22 • Extensive trauma that requires additional work • Significant scaring requiring extra time and work • Extra work due to morbid obesity • Increased time due to extra work by the physician

17. Invalid Use • Modifier 22 is not valid when there is also a “re-operation” code used with the primary code. • Modifier 22 is not valid if the purpose of the complication is based on the surgeon’s choice of approach (e.g., open vs. laparoscopic) • Modifier 22 is not valid to describe an average amount of lysis or division of adhesions between organs and adjacent structures.

18. Considerations for modifier 22 • The additional time and work must be significant. • The surgeon’s documentation should be thorough! • The documentation should be submitted with the claim. • Any additional fees should be charged up front to payers, which are unlikely to raise fees on their own just because modifier 22 is appended.

19. Modifier 24 – Unrelated e/M service by the same physician during a postoperative period • Only use with E&M codes. • To use this modifier, the E&M service must be unrelated to the surgery, but provided within the global care postoperative period. • Use when patient care is by the same physician for surgery. • Medicare Carrier Manual (MCM 4822 and 4824) indicate that an evaluation and management service(s) submitted with modifier 24 must be sufficiently documented to establish that the visit was unrelated to the surgery. • In order for critical care services (CPT 99291 and/or 9292) to be paid for services furnished during the preoperative or postoperative period, with modifier -24, the documentation submitted must support that the critical care was unrelated to the specific anatomic injury or general surgical procedure performed.

20. Modifier 25 – Significant separately identifiable e/m service by the same physician on the same day of the procedure or other service • Only use with E&M codes. • Patient care is by the same physician for procedure and E&M service • Documentation should indicate that the patient’s condition required a significant separately identifiable E&M service on the day a procedure or service identified by a CPT code was performed above and beyond the other service provided • This modifier is not used to report E&M service that resulted in a decision to perform major surgery

21. Modifier 25: CMS Policy • Modifier 25 should be used only when a significant, separately identifiable E&M visit is rendered on the same day as a minor surgical procedure. Payment for preoperative and postoperative visits is included in the payment for the procedure. For minor procedures, where the decision to perform the minor procedure is typically made immediately before the service (e.g., whether sutures are needed to close a wound, whether to remove a mole or wart, etc.), the E/M visit is considered to be a routine preoperative service and should not be billed in addition to the minor procedure. • The policy applies only to minor surgeries and endoscopies for which a global period of 0-10 day applies.

22. Modifier 25: CMS Policy Guidance • If the patient’s clinical record documents that extra pre-op and/or post-op work beyond what is usually performed with the service was performed, then it is proper to use the 25 modifier to indicate that extra work. • The clinical record should clearly document the extra or unusual work performed. • The provider should determine if the E&M service for which he/she is billing is distinct from the procedure.

23. Modifier 25? • Medicare patient presents with complaints of left knee pain. The physician evaluated the knee and determines the patient would benefit from arthrocentesis. The patient declines the injection at this time, but calls back two days complaining of continued pain. • At the follow-up visit, the physician performs a cursory exam of the knee and proceeds to perform the large joint injection that was recommended at the previous visit. • 25 or not?

24. NOT! • In this example, it would not be appropriate to bill the E&M service. • Correct coding: CPT 20610 – Arthrocentesis, aspiration and/or injection; major joint or bursa (eg, shoulder, hip, knee joint, subacromial bursa)

25. Modifier 25? • An established Medicare patient visited her internist for a follow up for hypertension and diabetes. The patient also complains of several skin tags along her bra area that are painful, itching, and bleeding due to the location. The physician performs a problem-focused history and examination, evaluates the patient’s hypertension, and determines the blood pressure is higher than it should be and adjusts medications. The patient’s blood sugar is doing well and the diabetes is well controlled with the current insulin regimen. During the encounter, the physician also evaluates the 6 skin tags and determines the patient would benefit from removal. This is performed in the office suite. • 25 or not?

26. YES! • Correct coding: CPT 99212-25 – Office visit for an established patient level two, and CPT 11200 – Removal of skin tags, any area; up to and including 15 lesions.

27. Modifier 26 – Professional Component • Some procedures can be divided into a professional only component (performed by a physician) and a technical only component (technician’s portion). Modifier -26 is used to describe the portion of the service that is performed by a physician. • The technical component includes: • providing the equipment • supplies • technical personnel • costs attendant to the performance of the procedure, other than the professional services • The professional component includes: • the physician’s work in providing the services (e.g., reading films, interpreting diagnostic tests, etc) • interpretation and written report provided by the physician performing the service

28. Modifier 26 – Professional component • Some CPT codes are indicated to be the professional component only, or the technical component only. No modifiers would be appended to these codes. • A facility performs a 12 lead ELG and has an independent physician read the strip • 93005 Tracing only (facility) • 93010 Interpretation and report only (physician)

29. Modifier 26: Example • If the physician owns the x-ray machine, buys the supplies, and pays the personnel in addition to reading the x-ray, the modifier -26 would not be used. • A physician has x-ray equipment in his office and performs a PA and lateral chest x-ray. The physician also reviews the x-ray and dictates a report. • Correct Coding: CPT 71020

30. Modifier 32: Mandated Services • Many third party payors and professional review organizations require an independent evaluation of a patient prior to procedures being performed. This modifier describes the visit required by the payor or review organization. • This modifier is not for a consultation with another physician for patient comfort or reassurance. • This modifier is also not used when another physician evaluates a patient for medical clearance prior to a procedure.

31. Modifier 47: Anesthesia by surgeon • This modifier is to be used when the surgeon performs and administers regional or general anesthesia in addition to the surgical procedure. • Do not use this modifier for local anesthesia. • Do not use this modifier with anesthesia procedures 00100-01999. • Do not use this modifier if the surgeon is monitoring general anesthesia performed by an anesthesiologist, CRNA, resident or intern.

32. Modifier 50: Bilateral Procedures • Most of the bilateral procedures listed in the Surgery section have been deleted. • This modifier is to be used when surgeries are performed bilaterally during the same operative session. • Some carriers prefer a “two code listing”, (i.e. 64721, 64721-50). Others prefer it listed on one line, while others want –LT & -RT. • The bilateral surgery may be performed • Through the same incision • Separate body parts

33. Modifier 51: Multiple Procedures • This modifier is used to identify the secondary procedure or when multiple procedures are performed on the same date or during the same operative session by the same physician. • The procedures may be in the same operative incision or at a different anatomical site. • Always list the major procedure (highest dollar value) first and append the modifier to the subsequent procedures.

34. Modifier 51: Multiple Procedures • Some of the listed procedures in CPT are commonly carried out in “addition to” the primary procedure performed. • All add-on codes found in CPT are exempt from the multiple procedure concept.

35. Modifier 52: reduced services • Used to identify when a service or procedure is less extensive than the description given in CPT would indicate it to be. • To develop a reduced fee, try calculating the reduced service by time. • Calculate the amount (cost) per minute of the complete procedure; times the amount per minute by the time it took to do the reduces procedure. • Many carriers reduce the amount automatically, so the preferred method is to bill the carrier the full amount and let the insurance carrier determine the value of the service.

36. Modifier 53: Discontinued Procedure • This modifier describes procedures that have been discontinued due to extenuating circumstances. • Usually the patient’s well-being is threatened, thereby precipitating the physician’s decision to terminate the procedure. • This modifier should not be used if a surgical procedure is canceled prior to t the patient’s anesthesia induction and /or surgical preparation in the operating room.

37. Modifiers 54, 55, 56 CPT Global Surgical Package

38. Modifier 54: Surgical Care Only • Used when the surgeon provides the surgical care only without pre- or postoperative services. • Fees and reimbursement should be reduced to represent the surgical portion of the global service.

39. Modifier 56: Preoperative management only • To be used when the physician provides only the preoperative care. • May be used when the physician prepares the patient for surgery performed by another physician. • Fees and reimbursement should be adjusted accordingly.

40. Modifier 55: postoperative management only • Used when the physician provides only the follow-up care during the global period. • Surgery was performed by a different physician • The physician providing the follow- up care does not perform, nor assist with the surgical procedure. • Fees and reimbursement should be reduced to represent “postop- erative” management only.

41. Global split

42. Modifier 57: decision for surgery • This modifier is appended to the appropriate E&M service to denote the visit where the decision to perform major surgery (90 global days) was made. • Modifier is used when the decision for major surgery is made the day of or the day prior to performing the procedure. • Assists in recouping payment for this visit because many payors will reimburse the visit where surgery is decided, but will not pay for other preoperative visits.

43. Modifier 57: decision for surgery • Modifier indicates to the payor that additional time and effort was necessary and all necessary counseling, including risks and outcomes were discussed with the patient. • There is no increase in fee for use of this modifer.

44. Modifier 58: Staged or related • Physician may need to indicate that the performance of a procedure or service during a post-operative period was: • Planned prospectively at the same time as the original procedure (staged) • More extensive than the original procedure • For therapy following a diagnostic surgical procedure

45. Modifier 59: distinct procedural service • Under certain conditions the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day: • A different session or patient encounter • Different procedure or surgery • Different site or organ system • Separate incision/excision • Separate lesion • Separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician

46. CCI Guidance • The 59 modifier is often misused. The two codes in a code pair edit often by definition represent different procedures. The provider cannot use the 59 modifier for such an edit based on the two codes being different procedures. • However, if the two procedures are performed at separate sites or at separate patient encounters on the same date of service, the 59 modifier may be appended. • The 59 modifier cannot be used with E&M services (CPT codes 99201-99499) or radiation treatment management code 77427).

47. Modifier 62: two surgeons • Used when skill of two surgeons (usually of different skills) may be required in the management of a specific surgical procedure. • Surgeon each performs a separate portion of one procedure. • Each physician would bill same CPT code with 62 modifier. • If a co-surgeon acts as an assistant in the performance of additional procedure(s) during the same surgical session, those services may be reported using separate procedure code(s) with the modifier 80 or modifier 82 added, as appropriate.

48. Modifier 63: Procedures performed on infants less than 4kg • Procedures performed on neonates and infants up to a present body weight of 4 kg may involve significantly increased complexity and physician work commonly associated with these patients. • This circumstance may be reported by adding the modifier 63 to the procedure number. • Unless otherwise designated, this modifier may only be appended to procedures/services listed in the 20000-69999 series. Modifier 63 should not be appended to any CPT codes listed in the Evaluation and Management Services, Anesthesia, Radiology, Pathology/Laboratory, or Medicine Sections.

49. Modifier 63: Procedures performed on infants less than 4kg • Modifier 63 is appended only to invasive surgical procedures and reported only for neonates/infants up to a present body weight of 4kg, cut off. With this group of neonates/infants, there is a significant increase in work intensity specifically related to temperature control, obtaining IV access (which may be required upward of 45 minutes), and the operation itself, which is technically more difficult with regard to maintenance of homeostasis.

50. Modifier 66: surgical team • More than two surgeons. • Used for highly complex or intricate procedures, which require multiple concomitantly operating physicians. • Usually of different specialties. • May require assistance of specially trained ancillary personnel or specialized equipment. • Approved procedures for modifier 66 include most of your transplant codes (heart, lung, kidneys, including live donor procedures)