MODIFIERS

Kandy Morris CPC,CPMA,CPB, CEMC, CCS-P, CPO-C

What Are Modifiers?

Modifiers are two digit codes appended to a CPT codethat indicates that a service or procedure hasbeen altered by a specific circumstance, but

has not changed in its basic definition“Strictly alters the code definition”

Why do we use Modifiers?

Modifiers are used for a variety of reasons, including: Claims can be incomplete or inaccurate without a

modifier Coding to the highest level of specificity requires

modifier use Appropriate use of modifiers get services reimbursed

that might otherwise be denied Allows for proper reimbursement (increased or

decreased) based on the procedure/service circumstances

………….and to avoid hearing your physician saying……….

Why aren’t my claims getting paid……?

Where to find Modifiers

CPT Book - Appendix A

HCPCS Level II - Appendix 2

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 reduced or increased

Only part of a procedure was performed

A service or procedure was provided more than once

A bilateral procedure was performed

Unusual events occurred

Modifier Categories

Global Package ModifiersCCI or Bundling ModifiersEvaluation and Management Only

ModifiersNumber of Surgeon Modifiers“Other” Modifiers

Global Modifiers

What is the “Global” Period?

Also known as the global surgical package. CMS and AMA have the same definition. Per CPT Guidelines, the following services are always included in addition to the operation: Local or topical anesthesia Subsequent to the decision for surgery, one related E/M

encounter on the date immediately prior to or on the date of the procedure (including history and physical)

Immediate postoperative care Writing orders Evaluating the patient in the post-anesthesia recovery area Typical postoperative follow-up care

Examples of Services Included in the Global Period

A visit with a patient prior to surgery to answer last minute questions

Removal of staples 10 days after a surgical procedure

A post-operative visit in the office to check on wound healing

Modifier – 24 Unrelated E/M Service by Same Physician During a Postoperative Period:

(Appended to the E&M code only)

Used when a physician provides a surgical service related to one problem, and then during the postoperative period provides an E&M service that is unrelated to the surgery.

Diagnosis code selection is critical to indicate the reason for the additional E&M service

Modifier Category: E/M Only & Global Package

Modifier - 24

Example: Patient came in for a post-operative visit. He is 12 weeks s/p discectomy. During the exam the pt c/o severe headaches with visual changes, proceeded 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

Modifier – 25 Significant, Separately Identifiable E/M by the Same Physician on the Same Day of the Procedure or other service

(Append to E&M Code Only)

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 Category: E/M Only & Global Package

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: 9921X(25) & 20610

Modifier – 26 Professional Component(Appended to procedure code)

Certain procedures are a combination of a physician component and a technical component.

When the physician component is reported separately, add -26 to the CPT code to identify that the physician’s component ONLY is being billed.

Modifier – 26 Professional Component(Appended to procedure code)

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 - 26

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 – 54 Surgical Care Only(Appended to the surgical procedure codes only)

Physician service to the patient was only the intra-operative procedure. (The physician is paid a portion of the global package and another physician will perform the pre & post-operative care)

There should be 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 physician who performed the procedure

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, and performed the procedure. Follow-up care was provided by a local surgeon. The Neurosurgeon would report 61321-54

Modifier – 55 Post Operative Management Only(Appended to the surgical procedure codes only)

Modifier 55 is reported when one physician performed the postoperative management only; another physician performed the surgical procedure

Example: While on vacation in Vail, the patient had a skiing accident. A local Orthopedist in Vail did the pre-operative & intra-operative procedure. The patient’s physician at home provides all the post-op care and would bill by adding a -55 to the surgical

procedure code.

Modifier – 56 Pre Operative Management Only(Appended to the surgical procedure codes only)

Modifier 56 is reported when one physician performed the preoperative care and evaluation and another physician performed the surgical procedure

Example: Internist does pre-op work-up on a patient having a laparoscopic cholecystectomy by a general surgeon who travels to the area monthly. Internist would bill 47562-56

Modifier-57 Decision for Surgery(Appended to E&M code only)

The purpose of this modifier is to report an E&M service on the day before or on the day of a major surgery (90 day global period) which results in the initial decision to perform the surgery

Without using this modifier on the E&M code the E&M will be denied as “included in the Global period of the surgical procedure”.

Example: Patient comes to the emergency department with sudden onset of acute abdominal pain. GYN physician evaluates patient & determines that patient has a twisted ovarian cyst. Physician admits patient to OR for a right salpingo-oophorectomy. CPT codes report are 99223(57) &

58720.Modifier Category: E/M Only & Global Package

Modifier-58 Staged or Related Procedure by the Same Physician during the Postoperative Period

(Appended to surgical code)

The purpose of this modifier is to report the performance of a procedure or service during the postoperative period for one of the following circumstance's:

planned or stagedmore extensive than the original procedure

therapy following a surgical procedure

This modifier is used to report a staged or related procedure by the same physician during the postoperative period of the first procedure

Modifier -58 is used ONLY during the global surgical period for the original procedure

Modifier-58 Staged or Related Procedure by the Same Physician during the Postoperative Period

(Appended to surgical code)

The purpose of this modifier is to report the performance of a procedure or service during the postoperative period for one of the following circumstance's:

planned or stagedmore extensive than the original procedure

therapy following a surgical procedure

This modifier is used to report a staged or related procedure by the same physician during the postoperative period of the first procedure

Modifier -58 is used ONLY during the global surgical period for the original procedure

Modifier – 58 Clinical Examples

Example # 1: 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 # 2: 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 the muscle flap was planned at the time of the initial surgery

Modifier Category: Global Package

Modifier-62 Co-Surgeon

When two or more surgeons with different specialties submit claims for the same operative session for the same beneficiary and same date of service, all providers must use the co-surgeon modifier.

When two different providers bill the same CPT code, same patient and same date of service and one of the providers bills with modifier 62, the other provider must also bill with modifier 62. Note, however, that modifier 62 may only be used when

the co-surgeons are of different specialties and are working simultaneously.

Example # 1: A provider bills for CPT code 61548, Hypophysectomy or excision of pituitary tumor, and bills with modifier 62, for a patient on date of service March 8, 2014. A different provider bills for the same service for the same patient on the same date of service because he/she was the co-surgeon, yet did not bill with modifier 62. The second surgeon was overpaid for failing to properly apply modifier 62.

Example # 2: A provider bills for CPT code 49652, Laparoscopy, Surgical repair, ventral, umbilical, spigelian or epigastric hernia, and bills with modifier 62, for a patient on July 2, 2014. A different provider bills for the same service for the same patient on the same date of service because he/she was the co-surgeon, yet did not bill with modifier 62. The second surgeon was overpaid for failing to properly apply modifier 62.

Modifier-62 Clinical Examples

Modifier-76 Repeat Procedure by the Same Physician(Appended to procedure code)

Modifier -76 is used when it is necessary to report a repeat of the same procedure on the same day

Medicare considers two physicians, in the same group with the same specialty performing services on the same day as the same person

Appropriate Usage: On procedure codes that cannot be quantity billedReport each service on a separate line, using a quantity of one and append 76 to the subsequent procedures

The SAME physician performs the services

Inappropriate Usage: Appending to a surgical codeAppending to each line of service

Repeat services due to equipment or other technical failureFor services repeated for quality control purposes

Modifier - 76

Medicare considers two physicians, in the same group with the same specialty performing services on the same day as the same physician

For all procedure codes that cannot be quantity billed always use quantity of “1”

To avoid denials, bill all services performed on one day on the same claim

For repeat clinical diagnostic laboratory tests, use modifier 91 if the service can not be quantity billed

Modifier Category: Global Package

Modifier-77 Repeat Procedure by Another Physician(Appended to procedure code)

Repeat procedure by a different physician; use when it is necessary to report repeat procedure performed on the same day

Appropriate Usage: A different physician performs the repeat services

Inappropriate Usage: Appending to a surgical procedure codeAppending when the repeat procedure is performed by the same physician

Appending to E&M codes

Modifier Category: Global Package

Modifier – 77

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 77 modifier and provide documentation to support the need for a repeat CXR.

Modifier-78 Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the Postop Period

(Appended to procedure code)

The purpose of this modifier is to report a related procedure performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure) and requires use of the operating/procedure room

Modifier -78 should NOT be used if a complication does not require use of the operating/procedure room

Modifier -78 may be used to report procedure performed on the same day (usually in emergency situations)Modifier Category: Global Package

Modifier – 78

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)

“Complication” modifier

Modifier Category: Global Package

Modifier-79 Unrelated Procedure/Service by Same MD during the Post-op Period(Appended to procedure code)

The purpose of this modifier is to report services during the postoperative period that are unrelated to the original procedure

The procedure must be performed by the same physician, and modifier -79 is appended to the procedure code

Claim should be submitted with a different diagnosis and documentation should support the different diagnosis and medical necessityModifier Category: Global Package

Modifier - 79

Example: A cataract removal of the right eye(90 day global) is performed on Jan. 5th. On Feb. 12th, the same physician performs a cataract removal on the left eye.

Report: CPT Code 66984(79)

“Other” Modifiers

Modifier-22 Unusual Procedural Services(Appended 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%

Must be accompanied by an operative report with a letter explaining additional time required to support modifier -22 use

Modifier-22 Unusual Procedural Services(Appended to procedure code)

Operative/Procedure Note Key Terms:Increased risk; difficult; extended; complication; prolonged; unusual findings; unusual contamination controls; hemorrhage, blood loss over 600cc; etc

Additional physician work due to complications or medical emergencies may warrant use of -22

Documentation MUST support the substantial additional work and the reason for the additional work (i.e., increased intensity, time, technical difficulty of procedure, severity of patient’s condition, physical and mental effort required)

Overuse can trigger an audit, if you find yourself consistently using modifier -22, chances are you are using the wrong CPT

Use of Modifier - 22

Appropriate 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-50 Bilateral Procedure (Appended to procedure code)

Used to report bilateral procedures that are performed at the same operative session(bi = two, lateral = side; both sides)

Modifier -50 is used to report diagnostic, radiology and surgical procedures

Modifier -50 should only be applied to services and/or procedure performed on identical anatomic sites, aspects, or organs (arms, legs, eyes, breasts)

Modifier -50 is NOT applicable to:Procedures that are bilateral by definition

Procedures with descriptions including the terminology as “bilateral” or “unilateral”When removing a lesion on the right arm and one on the left arm (RT/LT should be used)

Modifier-50 Bilateral Procedure (Appended to procedure code)

Modifier -50 CAN be appended to codes with a bilateral indicator of “1” or “3” on the Medicare Physician Fee Schedule

https://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx

Some payers require the bilateral procedure to be report on a single line with -50; however some may require the procedure to be reported on two separate lines using RT/LT modifiers (check with the individual payer for their bilateral billing policy)

Modifier – 51 Multiple Procedures(Append to Procedure Code)

Used when multiple procedures, other than E/M services, performed at the same session by the same provider

Reimbursement is subject to 100% of the allowable charge for the primary code and 50% of the allowable charge for each additional procedure code

Example: Patient presents for removal of a malignant lesion on the face with a complex repair of the defect

Report: Line 1: 11641 Paid at 100% of Allowed

Line 2: 13152(51) Paid at 50% of Allowed

Modifier - 51

The surgical procedure with the highest allowable amount is considered the primary (first) procedure. Medicare uses the RVU for this determination, which can be found on the Physician Fee Schedule

Do NOT use -51 on the primary procedure, only on the secondary procedures (order procedures by RVU; highest to lowest)

Do NOT use -51 on procedures with a “+” or symbol indicated in the CPT Manual (See Appendix D and E)

These codes can also be identified on the Medicare Physician Fee Schedule with a Multiple Procedure Indicator of “3”

Modifier-52 Reduced Service (Appended to procedure code)

This modifier is used to report a service or procedure that is partially reduced or eliminated at the physician’s election

Modifier -52 is NOT used to report an elective cancellation of a procedure before surgical preparation in the operating suite

Modifier -52 should NOT be used if the procedure is discontinued after administration of anesthesia

The presence of modifier -52 will reduce the payment of the service. Depending upon the payer

Modifier-53 Discontinued Procedure (Appended to procedure code)

Used to indicate that a surgical or diagnostic procedure was started but discontinued due to extenuating circumstances that threaten the patient’s well-being

This modifier is used to report services or procedures when discontinued after anesthesia is administered to the patient

This modifier is NOT used to report an elective cancellation of a procedure or prior to the patient’s anesthesia induction and/or surgical preparation in the operating suite; including situations where cancellation is due to patient instability

Modifier -53 should NOT be used when a laparoscopic or endoscopic procedure is converted to an open procedure

Modifier -53 should NOT be appended to E/M codes

CCI or Bundling Modifiers

What is CCI or NCCI?CMS developed the National Correct Coding Initiative (NCCI) to promote national correct coding methodologies and to control improper coding leading to inappropriate payment in Part B claims. The CMS developed its coding policies based on coding conventions defined by the American Medical Association’s CPT manual, national and local policies and edits, coding guidelines developed by national societies, analysis of standard medical and surgical practices, and a review of current coding practices

NCCI (National Correct Coding Initiative ) edits, which are released by CMS quarterly, define when two procedures HCPCS/CPT codes may not be reported together except under special circumstances. If an edit allows use of NCCI associated modifiers, the two procedure codes may be reported together if the two procedures are performed at different anatomic sites or different patient encounters

Edits can be viewed @:

https://www.cms.gov/NationalCorrectCodInitEd/01_overview.asp

•

Modifier-59 Distinct Procedural Service (Appended to procedure code)

The purpose of this modifier is to identify procedures or services that are not usually reported together but appropriate under the circumstance. This may represent the following:A different session or patient encounter

A different procedure or surgeryA different site or organ systemA separate incision or excision

A separate lesionA separate injury (or area of injury in extensive injuries)

Modifier -59 should only be used if no other modifier more appropriately describes the relationships of the two or more procedure codes (i.e. RT/LT, T1-T10, etc.)

Modifier 59 should NOT be appended to an E/M code

CMS is establishing the following four new HCPCS modifiers (referred to collectively as -X{EPSU} modifiers) to define specific subsets of the -59 modifier:

-XE Separate Encounter: A Service That Is Distinct Because It Occurred During A Separate Encounter.Separate surgical operative session on the same date of service (e.g. 8 AM surgery with one procedure, 4 PM surgery with second procedure code). If a patient came in for an outpatient EKG, then comes back later in the day for blood work, the blood work would require an XE modifier.Patient comes to the facility for an x-ray of their hip as a result of an injury. The results are sent to the physician’s office who calls the patient and has them return to the radiology department for a CT of their hip due to possibility of a hairline fracture all on the same day.

-XS Separate Structure: A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure. From an NCCI perspective, the definition of different anatomic sites includes different organs or different lesions in the same organ. However, it does not include treatment of contiguous structures of the same organ. Injection into tendon sheath, right ankle (20550) and injection into tendon sheath, left ankle (20550-XS). Right pectoralis major muscle flap (15734) and right rectus abdominis muscle flap (15734-XS)

-XP Separate Practitioner: A Service That Is Distinct Because It Was Performed By A Different Practitioner.

The patient is seen in the office by a family practice physician, who in the course of the visit encounters a problem outside their scope of ability so calls in (or arranges an immediate transfer to) a specialist physician at the same claim to perform the needed service. -XP modifier still unclear, but probable scenario: The patient is seen by one provider who in the course of treating a patient encounters a problem outside his scope of ability so calls in another doctor to perform the service.Patient goes to their family physician due to a cold, after being seen by their physician the are sent to their respiratory physician for breathing treatments, all on the same day.

-XU Unusual Non-Overlapping Service: The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service.

A diagnostic procedure is performed. Due to the findings, a decision is then made to perform a therapeutic/surgical procedure. (This may or may not occur in the same procedure room during the same session/encounter.) For example, diagnostic cardiac angiography leads to therapeutic angioplasty. Patient is seen in the OR for an EGD procedure in the recovery room the patient is noted to be short of breath and a fever, patient receives a chest x-ray to rule out pneumonia.Excision of two non-contiguous lesions on the same structure or body area that might typically be bundled together can be separated by this modifier.

CMS will continue to recognize the -59 modifier, but notes that Current Procedural Terminology (CPT) instructions state that the -59 modifier should not be used when a more descriptive modifier is available. While CMS will continue to recognize the -59 modifier in many instances, it may selectively require a more specific - X{EPSU} modifier for billing certain codes at high risk for incorrect billing. For example, a particular NCCI PTP code pair may be identified as payable only with the -XE separate encounter modifier but not the -59 or other -X{EPSU} modifiers. The -X{EPSU} modifiers are more selective versions of the -59 modifier so it would be incorrect to include both modifiers on the same line.

The combination of alternative specific modifiers with a general less specific modifier creates additional discrimination in both reporting and editing. As a default, at this time CMS will initially accept either a -59 modifier or a more selective - X{EPSU} modifier as correct coding, although the rapid migration of providers to the more selective modifiers is encouraged. However, please note that these modifiers are valid even before national edits are in place. MACs are not prohibited from requiring the use of selective modifiers in lieu of the general -59 modifier, when necessitated by local program integrity and compliance needs.

Modifier-59 Distinct Procedural Service (Appended to procedure code)

Modifier -59 is an important NCCI associated modifier that is often used incorrectly. For the NCCI it’s primary purpose is to indicate that two or more procedures are performed at different anatomic sites

From an NCCI perspective, the definition of different sites includes different organs or different lesions in the same organ. However, it does not include treatment of contiguous structures of the same organ. For example, treatment of the nail, nail bed, and adjacent soft tissue constitutes a single anatomic site. Treatment of posterior segment structures in the eye constitute a single anatomic site.

Use of modifier -59 to indicate different procedures or surgeries does not require a different diagnosis for each HCPCS/CPT coded procedure/surgery

Number of Surgeons Modifiers

How to Determine if Multiple Surgeons Are Allowed

To determine whether the services of more than one surgeon may be submitted to Medicare with CPT Modifiers 62, 66, 80, 81, 82 or AS, refer to the Medicare Physician Fee Schedule database (MPFSDB):

Access the database directly from the CMS Web Site at

www.cms.gov/apps/physician-fee-schedule/overview.aspx/

Select Physician Fee Schedule Search from the left area of the Web page

Refer to the column headings applicable:

‘Co Surg’, ‘Team Surg’, or Asst Surg’

0 = Co-surgeons not permitted for this procedure

1 = Co-surgeons may be paid if supporting documentation is supplied to establish medical necessity

2 = Co-surgeons permitted. No documentation is required if two- speciality requirement in met

Modifier – 62 Two Surgeons(Append to Surgical Procedure)

Two surgeons (each in a different specialty) work together to perform a specific procedure

If two surgeons (each in a different specialty) are required to perform a specific procedure, each surgeon bills for the procedure, and both surgeons need to report the same surgery code with the modifier 62.

Example: Thansphenoidal Hypophesectomy, Neurosurgeon and ENT both

report 61548(62)

Warning: If one surgeon bills with a modifier “-62” and one surgeon bills with no modifier, the payer may deny or suspend the claim with the modifier for review. Coordination of billing is key to proper reimbursement for each surgeon!

Modifier – 80 Assistant Surgeon (for MD’s, DO’s)

Modifier – 81 Minimal Assistant Surgeon Modifier – 82 Assistant surgeon (when

qualified resident surgeon not available)

Modifier – AS Physician assistant, nurse practitioner, or

clinical nurse specialist services for assistant at surgery

HCPCS Level II Modifiers

Alpha or alphanumericProvide additional information just

like CPT modifiersFound in HCPCS ManualCan be used on Level I CPT codes

and/or Level II HCPCS codes

Examples of HCPCS Modifiers

LT: Left side RT: Right side GA: Waiver of liability statement on file RR: Rental (for DME) F1: Left hand, 2nd digit F6: Right hand, 2nd digit GP: Services delivered under an outpatient

physical therapy plan of care

Modifiers – Work Comp/Colorado

Modifier – 00 All providers should indicate whether they are billing for the total component for a radiology service

Questions????? Feel free to email me directly at mzkandyd@gmail.com

Kandy Morris CPC, CPMA, CPB, CEMC, CCS-P, CPO-C

2015 Las Vegas Chapter Vice President

Physicians Choice, LLC

2657 Windmill Pkwy, Suite# 590

Henderson, NV 89074

Phone: 702.550.8769/Fax: 702.543.7095