What are Medical Coding Modifiers? Examples of CPT, HCPCS and Anesthesia Modifiers and When to Use Them

1. What are Medical Coding Modifiers?  Examples of CPT, HCPCS and Anesthesia Modifiers and When to Use Them www.outsourcestrategies.com

2. Using CPT, HCPCS and anesthesiamodifiers correctly is critical to communicate details regarding the performance of a medical procedure or service to payers. Modifiers are two-character codes that provide more meaning to the procedure code’s original definition. By using modifiers correctly and communicating specific information to the insurance carriers, medical billing and coding companies ensure that physicians get paid appropriately for services rendered • Features of Modifier Codes • Modifier codes can be two digit numbers, two character • modifiers, or alpha-numeric indicators • They are a tool to provide more detail to the performance of • a medical procedure or service • They are always placed at the end of a CPT code, separated • with a hyphen • Up to 4 modifiers may be stated on a claim • Functional modifiers affect reimbursement and informational • modifiers provide information about the procedure  • HCPCS Level II modifiers are used to provide additional • information about services provided to patients covered by • a payer that accepts HCPCS Level II codes. www.outsourcestrategies.com

3. Code Modifiers Clarifythe Following • Whether a service or procedure has a professional component or a technical • component • If multiple procedures were performed or only part of a service was performed • Why a procedure was necessary • The location on the body where the procedure was performed • Whether the service or procedure was performed by more than • one physician • Whether a service or procedure was provided more than once • Unusual events occurred • An add-on or additional service was performed • Other information that may be vital to a claim’s • specific reimbursement status www.outsourcestrategies.com

4. Commonly Used CPT and HCPCS Modifiers CPT Modifiers 22 Unusual procedural services 23 Unusual anesthesia 24 Unrelated evaluation and management service by the same physician during a postoperative period 25 Significant, separately identifiable E&M service by the same physician on the same day of the procedure or service 26 Professional component 27 Multiple outpatient hospital E&M encounters on the same date 32 Mandated services 47 Anesthesia by surgeons 50 Bilateral procedure 51 Multiple procedures Indicates that multiple procedures (other than E/M services) 52 Reduced services 53 Discontinued procedure 54 Surgical care only www.outsourcestrategies.com

5. 57 Decision for Surgery - Indicates an E/M service that resulted in • the initial decision to perform a surgery • 58 Staged or related procedure or service by the same physician • during the postoperative period • 59 Distinct Procedural Service - Indicates that a non-E/M procedure • or service was distinct or independent from other non-E/M • services performed on the same day: • XE-Separate Encounter • XP-Separate Practitioner • XS-Separate Organ/Structure • XU- Unusual Non-overlapping Service • 76 Repeat procedure or service by same physician or other qualified • healthcare professional • 77 Repeat procedure by another physician or other qualified • healthcare professional • 95 Synchronous telemedicine service rendered via real-time • interactive audio and video telecommunications system www.outsourcestrategies.com

6. HCPCS Modifiers • Anatomical Modifiers: Anatomical modifiers indicate the area or part of the body on which the procedure is performed on different sites during the same session. Examples: • E1–E4 Eyelids • FA–F9 Fingers • TA–T9 Toes • RT Right • LT Left • LC Left circumflex, coronary artery • LD Left anterior descending coronary artery • LM Left main coronary artery • RIRamusintermedius • RC Right coronary artery www.outsourcestrategies.com

7. Modifiers for Anesthesia Claims Correct use of anesthesia modifiers is necessary for proper claims payment. AAAnesthesia services performed personally by anesthesiologist – informs the payer that the anesthesiologist provided care to the patient alone, and not alongside a certified registered nurse anesthetist (CRNA). AD Medical supervision by a physician; more than four concurrent anesthesia procedures QZ CRNA service: without medical direction by a physician QYMedical direction of one certified registered nurse anesthetist by an anesthesiologist QK Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals QX CRNA service: with medical direction by a physician QS Monitored anesthesia care (MAC) provided by an anesthesiologist P1–P6 Anesthesia Physical Status Modifiers www.outsourcestrategies.com

8. Use of Modifiers - Key Points to Note • There are strict rules and regulations to using modifiers that must be followed • at all times • When two or more modifiers are used, the functional modifier should be listed • first, followed by all the other modifiers • The documentation within the medical record to support the use of each • modifier should be clear • While some modifiers can be used only with Evaluation and Management • (E&M) codes, there are several modifiers that are not compatible with • E&M codes • Incorrect use of modifiers prevents the provider from receiving the • full reimbursement for the services performed and vice versa • Repeated misuse of modifiers will attract scrutiny and trigger • audits www.outsourcestrategies.com

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