Modifiers - AAPCstatic.aapc.com/3b7310d0-2751-4c51-8dd2-4cc34d8103...Modifiers The Rest of the Story...

ModifiersThe Rest of the Story

2011

Sponsored by:AAPC2480 South 3850 West, Suite BSalt Lake City, Utah 84120800-626-CODE (2633), Fax 801-236-2258www.aapc.com

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Modifiers—The Rest of the Story

Written by: Jennifer Swindle

RHIT, CPC, CPMA, CEMC, CFPC, CCS-P, CCP

Modifiers–The Rest of the Story

ii AAPC 1-800-626-CODE(2633)

DisclaimerThis course was current at the time it was written. The materials are offered as a tool to assist the participant in under-standing how to ensure that code selection decisions are accurate and defensible 100% of the time as a means of improving reimbursement and avoiding post payment risk. Every reasonable effort has been made to assure the accuracy of the infor-mation within these pages. Proper coding may require analysis of statutes, regulations or carrier policies and as a result, the proper code result may vary from one payer to another. As such, rather than attempt to provide the instructions for each, this course is designed to educate you on how to find, interpret and apply the guidance available in each and in circum-stances where such guidance is not provided, how to evaluate the quality and applicability of persuasive guidance.

This program is not intended to be legal advice and your attendance should not be construed as a legal opinion of the program developer or as establishing an attorney client relationship with the developer of this program. AAPC employees, agents, and staff make no representation, warranty, or guarantee that this compilation of information is error-free, and will bear no responsibility or liability for the results or consequences of the use of this course.

USGovernmentRightsThis product includes CPT® which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable, which was developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015(b)(2) (November 1995), as applicable, for U.S. Department of Defense procurements and the limited rights restrictions of FAR 52.227-14 (June 1987) and/or subject to the restricted rights provision of FAR 52.227-14 (June 1987) and FAR 52.227-19 (June 1987), as applicable, and any applicable agency FAR Supplements, for non-Department of Defense Federal procurements.

NoticesCPT® copyright 2010 American Medical Association. All rights reserved. Fee schedules, relative value units, conversion fac-tors and/or related components are not assigned by the AMA, are not part of CPT®, and the AMA is not recommendation their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

All Rights Reserved. CPT® is a registered trademark of the American Medical Association (AMA).

CPC®, CPC-H®, CPC-P®, CIRCC® CPCOTM and CPMA® are trademarks of the AAPC

Written by Jennifer Swindle RHIT, CPC, CPMA, CEMC, CFPC, CCS-P, CCP

© 2011 AAPC2480 South 3850 West, Suite B, Salt Lake City, Utah 84120800-626-CODE (2633), Fax 801-236-2258, www.aapc.com

All rights reserved.ISBN 978-937348-01-4


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Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

AnatomicalModifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

EvaluationAndManagementModifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

Modifier25 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Modifier24 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Modifier57 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

RepeatProcedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

Modifier76and77 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

Modifier91 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

ProceduresInTheGlobalPeriod . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

Modifier58 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Modifier78 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Modifier79 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Pre,Post,orSurgicalOnly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

Modifier54 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Modifier55 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Modifier56 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

DiscontinuedorReduced . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

Modifier53 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Modifier52 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

Bilateral . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

Modifier50 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

MultipleProcedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

Modifier51 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

AssistantatSurgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

DistinctandSeparate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

Modifier59 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

IncreasedProceduralService . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8

Modifier22 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9


iv AAPC 1-800-626-CODE(2633)

PhysicalStatus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Modifier23 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

ModifierAA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

AdvancedBeneficiaryNoticeorStatutorilyExcluded . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10

ModifierGA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

ModifierGZ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

ModifierGY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

ModifiersUsedinthePQRSInitiatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

ModifiersIdentifyParticularTypesofProviders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

PhysicianofRecord . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

ModifierAI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

OtherMiscellaneousModifiers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

ModifierGG . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

ModifierGH . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

ModifierQW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

ModifierQ6 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

Hands-onExercises . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

SummaryofModifiersAddressed: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

SlidePresentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21


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IntroductionWhile coding always acts as a translation from the physi-cian’s documentation to a numeric value identifying the diagnostic codes and services and supplies provided, it is not always enough to give a clear and accurate picture.

Status, decisions, distinct, significant-is it supported? Nec-essary, must use, can’t abuse…when and how? A patient has a screening mammogram and a diagnostic mammo-gram on the same day, can both be billed? Primary care and specialist both see a patient on the date of admission and both report an initial hospital service to the Centers for Medicare & Medicaid Services (CMS), what critical distinction is needed? A patient receives a joint injection in the orthopedic office; is a visit also reportable? The correct answer is yes, no, maybe-when, why, what is needed? This can be very confusing and frustrating.

CPT®, HCPCS Level II, and ICD-9-CM tell most of the story. Modifiers help tell the rest of the story. Modi-fiers often must be utilized to further clarify, identify, or explain more detail about what transpired during the patient’s encounter.

Modifiers are necessary to achieve the appropriate reim-bursement in many instances, but modifiers also can be misused, overused, or abused and can put a physician or an organization at risk.

Modifiers also often are frustrating, as not all payers follow the same or standard rules and not all payers recognize all modifiers available. All coders, physicians, and facilities must know their unique payers and how modifiers can impact their billing. Staff involved in working the denial process must also be extremely adept at modifier usage, as often denials indicate that a modifier is needed; however, this does not mean a modifier can be blindly attached and the claim resubmitted. What this type of denial is actu-ally stating is that if appropriate for this particular patient, under the particular circumstance, on the particular day, and if supported by documentation a modifier should have been used. Then it should be attached and reprocessed.

There are concerns with electronic health records (EHRs) “auto attaching” modifiers based on code selection. If the EHR does not have a mechanism to verify the documenta-tion supports the use and need of a modifier, it should not be appended. For example, if an EHR attaches modifier 25 to the evaluation and management (E/M) service any time a minor procedure is captured on the same day, from a

technical standpoint, this is correct. However, there should be coding oversight and review to determine that the docu-mentation supports both services and that the E/M service meets the needs of “separate and significant,” which is required to report both services.

It is certainly recommended that as part of the organiza-tion’s internal audit program for compliance, modifier use is a component that is reviewed. Look at the frequency by which modifiers are utilized; review a random sample for the accuracy of modifiers utilized. Track denials for modifier-related reasons by payer, modifier, and type, and determine how and which payers are identifying issues based on modifiers.

While modifiers tell payers the rest of the story, they should tell the right story. Coding does allow organizations to obtain reimbursement and they are deserving of the cor-rect reimbursement; coding truly captures the condition, the severity and the status of the unique patient, and the quality of care provided.

The content of this presentation is based on the expected and intended usage of all modifiers; however, all organiza-tions, physicians’ offices, and coders need to know their payers and if payers do not recognize a specific modifier or instruct a different means of reporting, this should be obtained from the payer in writing and followed. If you have a contract with a specific payer, look to see if the contract identifies modifier usage. If not, utilize payers’ manuals or on-line payment policies. Get familiar and know how to find your payer policy regarding modifiers. For example, Horizon of New Jersey, said in a decision published in February, 2010 indicated: “the evaluation and management (E/M) services that are appropriately appended with modifier 25 will pay at 50 percent of the applicable Horizon BCBSNJ fee schedule amount.”

http://codingnews.inhealth care.com/tag/payers/

Network Health has published that when utilizing modi-fier 62, they will reimburse each physician at a rate of 57.50 percent.

www.network-health.org/uploadedFiles/pdfs/payment_policies/pay_policy_modifier_62.pdf

Blue Cross Blue Shield of Mississippi published a modifier usage guide for their payment policies.

www.healthymississippi.com/assets/docs/Modifier_Usage_Guide.pdf

Modifiers—TheRestoftheStory


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AnatomicalModifiersThese modifiers are utilized to capture that either a partic-ular side of the body or appendage is involved or a specific location of the body. These are Level II modifiers, which are found in the HCPCS Level II book.

These modifiers are informational only and do not impact payment of the specific service.

Some examples of anatomical modifiers are the RT and LT to identify whether it is the right (RT) or left (LT) side or appendage or body part. Other very specific anatomical modifiers include the TA-T9 modifiers to identify specific toes and the FA-F9 modifiers to identify specific fingers. The table below identifies the digit modifiers:

Modifier Description

TA Leftgreattoe

T1 Leftseconddigitfoot

T2 Leftthirddigitfoot

T3 Leftfourthdigitfoot

T4 Leftfifthdigitfoot

T5 Rightgreattoe

T6 Rightseconddigitfoot

T7 Rightthirddigitfoot

T8 Rightfourthdigitfoot

T9 Rightfifthdigitfoot

FA Leftthumb

F1 Leftseconddigithand

F2 Leftthirddigithand

F3 Leftfourthdigithand

F4 Leftfifthdigithand

F5 RightThumb

F6 Rightseconddigithand

F7 Rightthirddigithand

F8 Rightfourthdigithand

F9 Rightfifthdigithand

Eyelids also have anatomic modifiers, E1-E4, to identify which eyelid is involved in a particular procedure.


E1 Upperlefteyelid

E2 Lowerlefteyelid

E3 Upperrighteyelid

E4 Lowerrighteyelid

Anatomic modifiers can be critical, particularly if the same service or procedure is performed on more than one area, these modifiers identify that the services were not a dupli-cate or were distinct and separate.

For example, if a blepharoplasty is performed on both the right and left lower lid, the same procedure code is needed to report the services; however, the appropriate eyelid modifier with E2 being captured for the left lower lid and E4 to capture the right lower lid should be attached. This will identify that the procedures were distinct and separate as they are performed at separate locations.

Anatomical modifiers should only be utilized on proce-dures or supply codes. They should not be attached to E/M services, even if the chief complaint is specific to one side. These modifiers also should never be attached to a diag-nostic code.

A patient presents with right elbow pain and after evalu-ation has a three-view radiograph done of the elbow, receives a joint injection in the right elbow and is given a splint for the right elbow. In this instance, the RT modifier to identify “right” should be used on three services:

yy Theythree-viewyradiographyshouldyhaveytheyRTyappendedytoyshowytheyrightyelbowywasyX-rayed.

yy TheyinjectionygivenyinytheyjointyshouldyhaveytheyRTyappendedytoyshowytheyinjectionywasygivenyinyayrightyjoint.

yy TheysplintyshouldyhaveyanyRTyattachedytoyshowytheysplintyisyforytheyrightyarm.

Clearly and quickly the appending of the modifiers to the codes paint a clearer picture of the problem of the patient, the service that was provided, and links the ser-vices together to help support the medical necessity of all services provided.

EvaluationandManagementModifiersThere are only three CPT® modifiers appropriate for E/M. These modifiers are very specific in their use and allow for payment for E/M services that might otherwise be denied as included in some other service.

Modifier25Significant, separately identifiable evaluation and man-agement service by the same physician on the same day of the procedure or other service—This modifier is a high risk modifier as it is sometimes perceived to be overutilized. Modifier 25 should be used any time an E/M service is separate and significant from another service provided on


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the same day that has a global period of 0 or 10 days. This modifier should also be captured when an E/M service is provided with services that have an XXX as the global period, per the National Correct Coding Initiative (NCCI) policy. This modifier is not necessary on E/M codes billed with services having a ZZZ as a status to identify the global period.

The key to proper utilization of modifier 25 is that the service is separate and significant. There is a component of E/M included in every procedure and there are occasions when just a procedure should be reported. Documentation for the E/M service must still support the documentation guidelines, must be separate and significant and medically necessary, and the documentation for the other service cannot be utilized to support the E/M service, as that doc-umentation must support the other service reported.

For example: A patient presents to the office for wheez-ing and shortness of breath. During the course of the examination, the physician notices a suspicious lesion on the patient’s back. The E/M service was completed and is separate and significant, but the patient opts to have the lesion biopsied while in the office. A procedure note for the biopsy is also documented. In this instance, modifier 25 should be reported on the E/M code.

To change this scenario, the same visit occurred for the same reason, but the patient scheduled a follow-up visit to have the biopsy performed. On the follow-up visit a cur-sory visit was done just to update the patient’s status; but, the reason for the visit was for biopsy, which was known prior to the visit and the only service provided. The brief exam involved inspection of the lesion location only and was not separate and significant. In this instance, a sepa-rate visit would not be reported, and modifier 25 would not be appropriate.

Modifier24Unrelated evaluation and management service by the same physician during a postoperative period —This modifier identifies a separate and significant office visit in the post-operative period of a major procedure with a 90 day global period when the visit is unrelated to the surgery.

Major procedures with a 90 day global period include all the normal and expected routine follow-up visits during this period.

However, there are times when a patient presents to the operating surgeon during the post-op period and the service is for an unrelated reason. In this instance, failure to utilize modifier 24 will result in non-payment for the visit, as it will

be denied as being included in the post-operative period. This modifier must be used to receive proper payment.

For example: A patient has gallbladder surgery by the general surgeon and is in the post-op period. During the global period, the patient’s primary care physician identi-fies a breast mass and refers the patient back to the general surgeon for evaluation. Since the patient is in the global period from the gallbladder surgery and the breast concern is unrelated, modifier 24 must be reported on the visit code for the surgeon.

Modifier57Decision for surgery—This modifier identifies when the decision to perform major surgery is made and surgery is going to be the same or next day. The global surgical pack-age includes the admission to the hospital for surgery or the cursory visit right before surgery to determine that the patient is cleared and healthy enough to have the surgery. This visit would not be payable separately and is part of the global package.

There are instances in which the surgeon sees the patient—usually in an emergent situation—and performs a com-plete E/M service, determines at the visit that surgery is necessary, and decides to perform surgery within the next 24 hour period. This visit is not included in the global surgical package since the decision to perform immediate surgery was initially made. When this occurs, modifier 57 must be reported on the E/M code to allow the visit to be paid outside of the global period.

This modifier can be utilized on any type of E/M code such as: office visit, hospital admission, observation admis-sion or emergency department visit. This modifier would be appropriate, for example, if a patient presented to the emergency department with abdominal pain. The emer-gency department physician transferred the care to the general surgeon on call. After monitoring and a complete E/M service, it was determined that the patient had appen-dicitis and the appendix should be removed. The patient was taken to surgery on the same date. The surgeon would append modifier 57 to his E/M service performed on the day of the appendectomy.

Modifiers 24, 25, and 57 all should be utilized when appropriate; however, they should not be routinely added based on denials without review to determine that the documentation supports the use of the modifier. While these modifiers will not change the amount of payment for the evaluation and management service, they do allow for payment of this type of service that might otherwise be inclusive in other services provided. Remember, you are


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telling a unique patient’s story and when modifiers are cor-rectly utilized, they provide significant additional informa-tion related to the services billed.

RepeatProceduresThere are instances that for quality patient care the same service must occur more than one time on a specific day. This may be a lab service, a diagnostic service, or a proce-dure. It may be completed by the same physician or a dif-ferent physician.

The risk when this occurs is that the claim will be denied inappropriately because it is thought to be a duplicate procedure. A modifier must be utilized to identify that it is not a duplicate but was actually a medically necessary repeated procedure.

Modifier76and77Modifier 76 and 77 are similar modifiers. Modifier 76 identifies when a repeat procedure is performed by the same physician, same patient, same day. Modifier 77 identifies when a repeat procedure is performed by differ-ent physicians, but on the same patient and the same day. Modifier 76 and 77 are necessary anytime a repeat pro-cedure is performed on a patient to identify that it is not a duplicate, but that the actual procedure was performed more than one time. Choosing between the two modifiers is dependent upon whether it was the same or a different physician. When these modifiers are not used, the claim will often be interpreted as a duplicate and inappropriately denied.

One example: A patient in the office has a very low pulse oxygen level and her asthma is exacerbated and a nebulizer treatment is performed. The oxygen saturation is again measured and while better is still lower than the physician would like to see, so a second treatment is given. When this occurs, modifier 76 is necessary on the second nebu-lizer treatment to show it was not a duplicate, but a repeat procedure. Chart documentation must support that it was medically necessary and support that the service was per-formed twice during the visit.

Another instance where these modifiers would be neces-sary is in the case of a patient who is in the emergency department and has an abnormal electrocardiogram (EKG) performed at 10 a.m. He has a repeat EKG a few hours later in the day to compare the results to try to confirm an abnormality and, possibly, an occurring acute myocar-dial infarction. The EKG in the morning was interpreted by Dr. Smith, and Dr. Jones interpreted the EKG in the

afternoon. These two physicians are partners in the same cardiology practice. In this instance, modifier 77 would have to be utilized on the interpretation of Dr. Jones to capture that it was a repeat procedure performed by a dif-ferent physician.

Modifier91Repeat clinical diagnostic laboratory test—This modifier identifies a repeated laboratory service. One risk of utiliz-ing this modifier is using it when an incomplete sample is obtained. This modifier identifies that the same test was done more than once in the same day and was medically necessary and most frequently occurs when a physician wants to have comparative results. When this occurs, mod-ifier 91 must be attached to the additional services.

For example: A patient has an unusually high glucose in the morning and a repeat test is performed later in the day to insure that the level is lower. Modifier 91 would be attached to the second glucose.

ProceduresintheGlobalPeriodMajor procedures have a 90 day global period. What this really identifies is that nearly all services provided by the surgeon in the 90 day global period are included in the global surgical package and are not paid separately. All of the following services are included in the global surgical package, per CMS:

y Preoperative Visits—Afterytheydecisionytoyperformysurgeryyhasyalreadyybeenymade.yThisybeginsywithytheydayybeforeymajorysurgery.

y Intraoperative services—Servicesythatyareyayusualyandynecessaryypartyofyaysurgicalyprocedure.

y Complications following surgery—Thoseywhichydoynotyrequireyayreturnytripytoytheyoperatingyroom.

y Postoperative visits—Follow-upyvisitsythatyareyrelatedytoynormalysurgicalyrecovery.

y Postsurgical pain management—Painymanagementypro-videdybyytheysurgeon.

y Miscellaneous services—Theseyincludeysupplies,ydress-ingychanges,yincisionalycare,yremovalyofypacking,yremovalyofysuturesyorystaples,yremovalyofylines,ywires,ytubes,ydrains,ycastsyandysplints,yinsertion,yirrigationyandyremovalyofyurinaryycatheters,yroutineyperipheralyIVylines,ynasogastricyandyrectalytubes,yandychangesyoryremovalyofytracheostomyytubes

When services other than those included in the global package are performed, and claims are electronically adjudicated, the payers’ systems usually treat all services


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reported by the surgeon as “included in the global pack-age.” Again, modifiers are needed to clarify the story and to identify when services and items are not included in the global surgery package.

Modifier58Staged or related procedure or service by the same physi-cian during the postoperative period—This modifier identifies when a staged or related procedure is performed on a patient that is still in a global period from an initial service. It should be utilized when there is a planned or staged procedure that is related to the first but done at a separate later encounter or used when a related procedure, usually of a more extensive nature, is performed during the global period.

For example, a patient has been diagnosed with breast cancer and has a lumpectomy performed and lymph nodes are taken. After pathology, the nodes come back positive for malignancy, so the patient is returned to surgery and a more extensive total mastectomy is performed. The patient is still within the global period from the lumpectomy, so modifier 58 would be attached to show the mastectomy is a related procedure in the post-operative period. One criti-cal thing to remember is when this occurs, a new 90 day global period begins and the clock starts again from the date of the second procedure.

Modifier78Unplanned return to the operating/procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period—This modifier identifies a related procedure that requires a return to the operating room performed by the same physician within the post-operative period. This modifier and modifier 58 are often confusing as they have very similar features. One key to correct use of modifier 78 is to append it when there is an unexpected return to the operating room and, while related, it is not an extension of the initial procedure. This is used most fre-quently when a complication arises and causes the patient to return to the operating room to handle and treat the complication by means of an additional procedure.

This modifier would be appropriate in a scenario in which the patient had open heart surgery. The following day there is still bleeding and seepage around the incision site and the patient is returned to the operative suite to per-form a procedure for bleeding control. It was not staged and expected, it wasn’t more extensive, but it did require a return to the operating room. Modifier 78 should be utilized. One key difference is that when utilizing the 78

modifier, the global period does not change and the 90 day global period remains from the date of the first procedure.

It also should be noted that a slight change in the word-ing does allow for modifier 78 to be utilized if there is no return to a formal operative suite, but any dedicated proce-dure room or an ASC.

Modifier79Unrelated procedure or service by the same physician during the postoperative period—Unrelated procedure requiring a return to the operating/procedure room by the same physician in the global period is identified by modi-fier 79 and should be utilized when a patient has a second surgery within the 90 day global period, but it is for an unrelated event.

For example: A patient has an excision of her gallblad-der due to gallstones. During the 90 day post operative period, the primary care physician identifies a breast mass and sends the patient to the surgeon for evaluation. The surgeon performs a biopsy of the breast mass and a modi-fier 79 must be attached to the biopsy to identify that it is in the 90 day global period, but unrelated to the previous surgery.

Pre,Post,orSurgicalOnlyWhile the global surgical package includes the pre-operative, surgical, and routine post-operative care, there are times when this service must be split apart and when a physician performs only a portion of the global surgical package. When that occurs, modifiers must be utilized to capture the appropriate service. Each service is reported with the actual surgical code of the procedure performed, with the appropriate modifier to identify which component of the global surgical package was provided.

The allowable amount of the procedure is divided between the physicians providing the individual component parts of the surgical package. The surgical component only reimburses at 70 percent of the allowable, the pre-operative management is reimbursed at 10 percent of the allowable and the post-operative management care is reimbursed at 20 percent of the allowable.

Modifier54This modifier identifies the surgical care only and when reported identifies that the pre-operative and post-operative work are not included.


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Modifier55Post-Operative management only—This modifier should be used when a patient has had a major surgery performed, but the physician who performed the surgery is not provid-ing the post-operative management.

Modifier56Pre-operative management only—For example, an ortho-pedic surgeon is called into the Emergency Department on the weekend and does an emergent surgery to repair a comminuted fracture of the distal radius. The orthopedic surgeon does the pre-operative management and also per-forms the surgery, but is leaving on vacation the following day and the follow-up care will be assigned to a different orthopedic surgeon.The initial physician would report the procedure with a modifier 56 to capture the pre-operative management and the same procedure code with a modifier 54 to capture the surgical component only.

The physician whom the care is transferred to would then report the same procedure code, date of the original surgery and attach a modifier 56 to identify that the post-operative management is being provided separately and should be reimbursed separately.

DiscontinuedorReducedModifier53Discontinued procedure—Modifier 53 is appended to the CPT® code for a procedure that is started but can’t be com-pleted due to the patient’s condition. The service still needs to be reported - work was done - but the procedure wasn’t completed and the patient may very well have to have the same procedure at a later date. In this instance, modifier 53 should be reported to identify that it was discontinued and that it was discontinued due to the condition of the patient. Documentation in the medical record should clearly identify why the service had to be discontinued. It should also include a description of the portions of the service that were completed before it was discontinued. If a colonoscopy was planned and started; and, due to a tortu-ous colon, the physician could not pass the scope because of the splenic flexure, the colonoscopy (45378) would be reported with a modifier 53 to show the service was dis-continued. When modifier 53 is utilized, most payers will require that documentation be submitted to help them determine the extent of the procedure that was performed.

Modifier52Reduced services—This modifier differs from modifier 53 in that a service was not discontinued, it was a reduced from the total description of the procedure. When modi-fier 52 is utilized, payers will often request documentation to determine what portion of the service was reduced. If significant, they may reduce the allowable payment. One example would be when a service that is clearly defined or intended to be a bilateral service is performed unilater-ally. If a pure tone audiometry, air, (92552) is performed only on the left ear, modifier 52 should be appended (92552-52). This procedure is a bilateral procedure and was reduced as it was only completed on one ear. Some services are identified by CPT® to be a unilateral or a bilat-eral procedure, such as 92227 Remote imaging for detection of retinal disease with analysis and report under physician supervision, unilateral or bilateral. Since by definition of the code, it can be a unilateral procedure, if it is only per-formed on one eye, a modifier 52 would not be necessary or appropriate.

BilateralModifier50Bilateral procedure—This modifier identifies a service that is performed bilaterally. It is only utilized if the exact procedure is performed on two body areas that come in pairs (example, ears, legs, hands, etc.). To accurately report modifier 50, the service should be reported on one line item with one unit of service. The claim should have the fee doubled to capture both procedures. Expected reim-bursement would be at 150 percent of the allowable, which is based on 100 percent for the first procedure and 50 per-cent for the second procedure, following normal multiple procedure reduction rules.

This modifier is not always accepted by all payers and some payers would rather you identify two line items utilizing an RT modifier on one and an LT modifier on the other. This does identify the exact same information. Again, you must know your payers to determine how they want bilateral services reported. For example, if a joint injection was performed in both the right and the left knee, it could be reported as:

20610-50 or on two separate line items with 20610-RT and 20610-LT


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MultipleProceduresModifier51Multiple procedures—Modifier 51 is used anytime there are multiple procedures identified in the same surgical ses-sion. It should never be appended on an add-on code where another code must be reported with the primary procedure (example, +11101), and it is not appended on codes identi-fied as modifier 51 exempt (example, 31500). For all other procedure codes, if more than one procedure is performed, it is appropriate on all procedures but the primary. If a patient has been injured and has fractures of both the clavicle and the sternum and both are treated with a closed reduction, modifier 51 should be added to the second pro-cedure.

23500 Closedtreatmentofaclavicularfracture,withoutmanipulation

21820-51Closedtreatmentofsternumfracture

Modifier 51 is attached to the procedure of ‘lesser value’ based on the relative value units, and on multiple proce-dure reduction rules. Payment will be 100 percent of the first procedure and 50 percent of each additional proce-dure. Be sure to indicate the procedure of the lesser value to be the one in which payment is reduced.

Critical to Note: Many payers no longer require this modifier, including the CMS. Some payers will even deny claims if the modifier is utilized. If your payers deny pay-ment or do not want this modifier reported, it should not be submitted. For example: Palmetto GBA strongly recom-mends that this modifier not be reported.

www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~Jurisdiction percent201 percent20Part percent20B~Articles~Modifier percent20Lookup~7REK2L5824?open&navmenu=||

Most Medicare Administrative Contractors (MACs) do not want providers to use modifier 51 as their claims adjudi-cation software prices multiple procedures automatically. There have been instances in which the Recovery Audit Contractors (RACs) have interpreted this modifier differ-ently than noted from CMS, so make certain you know what your carriers and RACs require.

AssistantatSurgeryThere are many modifiers that involve an assistant at sur-gery. You must know who is assisting, the circumstance, and the extent to which the assistant is utilized.

80 AssistantSurgeon

81 MinimumAssistantSurgeon

82 AssistantSurgeon(Whenqualifiedresidentsurgeonnotavailable)Theunavailabilityofaqualifiedresidentsurgeonisaprerequisiteforuseofmodifier82appendedtotheusualprocedurecodes .

AS Assistantatsurgeryperformedbyamid-levelprovider(PA,CNS,NP)

Clearly the first thing to identify is who the assistant is. A physician providing the service vs. a mid-level provider will definitively influence the choice of the appropriate modi-fier. Also, in a teaching setting it is expected that qualified residents will be utilized to perform surgical assists, and their services are not separately billable. In the event that a resident is not available and a physician is used, the modi-fier reports that a resident was not available.

When an assistant at surgery service is reported, the surgery indicators should be known, as not all services are appropriate to utilize an assistant. The Assistant at Surgery Indicators published by CMS and found in the CMS National Physician Fee Schedule Relative Value File (NPFSRV) identify:

Indicator Definition

0Assistantsurgeonmaybepaidwithdocumentationsupportingmedicalnecessity

1 Assistantsurgeoncannotbepaid

2 Assistantsurgeoncanbepaid

9 Assistantsurgeonconceptdoesnotapply

While an assistant surgeon does not need to complete a separate individual report, the primary surgeon does need to capture the role the assistant surgeon played in the procedure and must also identify the assistant surgeon in the primary operative note. The assistant surgeon must play a medically necessary role in the performance of the procedure and not just be an observer. It is not sufficient documentation to just indicate in the header of the report the name of the assistant surgeon. It is also not sufficient to identify terms like “we” and “us” to indicate an assistant surgeon was present.

Co-Surgeons62 Two Surgeons—When two surgeons perform distinct portions of a single procedure and both must capture their services with the same CPT® code modifier 62 should be reported on both surgeon services. When two surgeons are


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involved in the same operative episode but their unique services can be identified with different CPT® codes, this modifier is not appropriate and not necessary. However, if the physicians are co-surgeons, one is not simply assisting; both should be reimbursed for their portion of the service. When modifier 62 is utilized, the total expected reim-bursement would be at 125 percent of the allowable charge and split between the surgeons with each receiving 62.5 percent of the allowable amount.

For example: CPT® 62223 Creation of shunt; ventriculo-peritoneal, -pleural, other terminus often requires the skills of both a neurosurgeon and a general surgeon for comple-tion. When this occurs, the two surgeons each provide their unique service; both would report the 62223-62.

It would not be needed, when two surgeons are involved in the operative episode, but each have a clearly defined sepa-rate procedure. One example of this would be when both an abdomino-vaginal vesical neck suspension is performed by a urologist and a total abdominal hysterectomy is per-formed by a gynecologist during the same operative event. Since the vesical neck suspension can be reported with 51845 and the hysterectomy with 58150; modifier 62 is not needed, as both physicians have a code to capture their unique services.

DistinctandSeparateModifier59Modifier 59 is often termed the modifier of last resort as it is often misused and overused and has a high impact on reimbursement so is very closely monitored by payers. The NCCI edits have thousands of procedures that are bundled together and not separately reportable in most cir-cumstances. However, there are instances for a particular patient on a particular day by a particular physician, the services are truly distinct and separate and should be reim-bursed separately.

When this occurs and there is no anatomical modifier to clearly distinguish the distinct and separate nature of the procedures performed, modifier 59 should be utilized.

The NCCI edits identify a status of 1, 0, or 9 and this status further clarifies when a 59 may be appropriate. If the status is a 0, a modifier 59 should never be utilized and the codes are never reportable for the same patient on the same date in any circumstance. If a status of 9 is attached, the NCCI edit is no longer applicable and the codes are no longer bundled together, so no modifier would be needed. In those instances in which procedure codes are bundled

together, but have a status indicator of 1, it identifies that in certain circumstances a modifier is allowed to receive separate payment. The article found at: www.cms.gov/NationalCorrectCodInitEd/Downloads/modifier59.pdf should be read, as it clearly identifies the needs for modi-fier 59.

Modifier 59 should be used to identify distinct and sepa-rate when the services involve separate excisions, separate incisions, separate body parts, or different time of day. This modifier should never be used simply to bypass an edit to allow for additional reimbursement, which is why it is a perceived compliance risk.

If it is the “way it is always done” or “we have to do both” or “we have to use a 59 every time,” there is a high risk that the modifier is being used inappropriately.

A biopsy service is bundled with an excision, as a biopsy is not separately reimbursable if the more extensive excision of the lesion is performed at the same setting. However, if a biopsy of one lesion on the back is performed and an excision of a completely separate lesion on the back is per-formed, modifier 59 would be appropriate on the biopsy code. This clearly is saying that it is understood that nor-mally these codes are not reportable at the same operative episode, but on this particular patient the services are dis-tinct and separate.

Another example would be a rhythm strip, which is included in a 12 lead EKG. However, if a rhythm strip was run on a patient at 10 am in the morning and a 12 lead EKG was completed at 3 pm in the afternoon on the same day, the services were performed at different times of day and are separately reportable. In this instance, modifier 59 needs to be attached to the rhythm strip to capture that it is distinct and separate and should be reimbursed separately.

IncreasedProceduralServiceModifier22When the work required to provide a service is substan-tially greater than typically required, it may be identi-fied by adding modifier 22 to the usual procedure code. Documentation must support the substantial additional work and the reason for the additional work (e.g. increased intensity, time, technical difficulty of procedure, severity of patient’s condition, physical and mental effort required). This modifier is often not well recognized by payers and it is nearly always necessary to file the claim on paper so that a copy of the operative report can be submitted, which must clearly capture the substantial additional work.


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While it is appropriate to increase fees based on the sub-stantial increased work, payers may not increase payment for the services.

AnesthesiaPhysicalStatusPhysical status is obtained by the anesthesiologist on every patient prior to surgery. The physical status modifier identifies the status of the patient and further clarifies the risk of taking the patient to surgery. Often this may help identify potential negative outcomes based on significant risk. This information should be captured in the anesthe-siologist’s pre-operative record on all patients. Certainly appropriate diagnosis codes should support the use of the physical status modifier used. The systemic diseases and any co-morbidities documented would help support the medical needs and severity of the patient.

yy P1yNormalyhealthyypatient

yy P2yPatientywithymildysystemicydisease

yy P3yPatientywithysevereysystemicydisease

yy P4yyPatientywithysevereysystemicydiseaseythatyisyayconstantythreatytoylife

yy P5yyAymoribundypatientywhoyisynotyexpectedytoysurviveywith-outytheyoperation

yy P6yyAydeclaredybrain-deadypatientywhoseyorgansyareybeingyremovedyforydonorypurposesy(thisyisyneverybilledytoytheypatient,yityisytypicallyyseenyinyaytransplantysituation)

While the physical status modifiers are not recognized by all payers, there are payers that will allow additional reim-bursement and increase the base units for P3, P4, and P5. It is critical, to capture this information to allow for proper reimbursement when payers do allow additional base units. Documentation and diagnoses must clearly support the status as noted above.

Modifier23Unusual Anesthesia—Modifier 23 is utilized to capture situations in which a procedure that normally does not require anesthesia for some particular circumstance, does require general anesthesia. The medical record must dis-tinctly identify why a general anesthetic is needed.

A cystoscopy, for example, does not usually require a gen-eral anesthetic. However, when this procedure is performed on a young child and the patient is unable to be controlled to safely perform the procedure, a general anesthetic may

be necessary. When this occurs, modifier 23 should be attached to the cystoscopy procedure.

Many different types of providers may now be furnishing or assisting in the anesthesia services during a surgical pro-cedure. Payment for anesthesia services is directly related to the type of provider performing the services. It is critical to use the correct modifier to clearly capture the correct iden-tity of the provider performing the anesthesiology services.

The CMS link to captures information on anesthesia ser-vices is www.cms.gov/center/anesth.asp. Based on CPT®, anesthesia services reported without the appropriate modi-fier can be paid at the lowest allowable percentage, which would be 50 percent, so modifiers are critical for appropri-ate payment.

Other modifiers which are utilized in anesthesia come into play when a physician anesthesiologist is a supervising physician and directing multiple operative episodes. Based on CMS, a physician anesthesiologist may also direct up to four procedures concurrently. However, there are require-ments which must be met. The supervising physician must:

yy Performytheyinitialyevaluation

yy Prescribeytheyanesthesiayplanyandypersonallyyparticipateyinytheymostydemandingyprocedures

yy Personallyyperformyinductionyandyemergencyyservices

yy Monitorytheycourseyofyanesthesiayadministrationyandyremainyphysicallyypresentyduringyanyyemergencies

yy Performynecessaryypost-anesthesiaycare

Concurrent procedure reimbursement is made at an amount equal to 50 percent of the anesthesiologist’s normal fee schedule.

ModifierAAServices personally furnished by the anesthesiologist—This includes those services provided by faculty anesthesiolo-gists that may involve a resident. This service should not be reported in conjunction with modifier QX.

For example: When a physician is acting as a supervising physician, there are also various modifiers which could be reported.

Modifier QX ServicesprovidedbyCertifiedRegisteredNurseAnesthetist(CRNA)

Modifier AD Reportedwhenthemedicalsupervisionbyaphysicianisformorethanfourconcurrentanes-thesiaservices .


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Modifier QK Medicaldirectionoftwo,three,orfourconcur-rentanesthesiaproceduresinvolvingqualifiedindividuals .

Modifier QS Reportedformonitoredanesthesiaservices

Services identified with the QS modifier for monitored anesthesia services (MAC) are identified by the anesthe-siologist giving medications, which helps the patient relax during a procedure but differs significantly from general anesthesia because the patient continues to breathe on their own and does not have a breathing tube. However, the anesthesiologist is in constant attendance and monitors the services just the same as he or she would during general anesthesia. If at any time a breathing tube must be inserted and a patient cannot maintain appropriate breathing on their own, the service is reported as a general anesthetic, even if initially started as MAC.

MAC is most often used for procedures that do not require general anesthesia but are uncomfortable for the patient, such as endoscopies and colonoscopies.

AdvancedBeneficiaryNoticeorStatutorilyExcludedModifierGAWaiver of liability statement on file—This modifier is critical but relies completely on the physician and/or des-ignee to obtain the correct Advance Beneficiary Notice (ABN)when appropriate. An ABN should be obtained for CMS beneficiaries when a service may not be covered for a specific reason. If the service is only considered medi-cally necessary for certain diagnoses or if the service has frequency limitations and the patient does not fit the necessary criteria, a complete and accurate ABN should be obtained. This ABN should identify what service may not be covered, why it may not be covered, and how much the patient will owe in the event it is not covered. It allows patients to make informed decisions for their health care. After completing all the necessary steps and obtaining a signed ABN, modifier GA should be attached to the ser-vice. In the event that the service is not covered by CMS, the claim is the patient’s responsibility. If an ABN is not obtained and the service is considered not medically neces-sary, the service must be written off and the patient is not held responsible. Important notes: Blanket ABNs signed for all services or by all patients for a particular service are not allowed. Utilizing the wrong form or the form being completed incorrectly is valid and do not support a GA modifier.

For example, if a patient is ordered to have a laboratory service 83036: Hemoglobin; glycosylated (A1C), but does not have a known diagnosis that is covered by the NCD for the service, the patient needs to be informed that the service may not be covered. If an appropriately executed ABN was obtained from the patient, this service would then be reported with a GA modifier which identifies that you are aware it may not be considered medically neces-sary, and that you have a complete and appropriate ABN on file. This will change the type of denial and instead of being denied as not medically necessary, the service will be denied as patient responsibility and the patient should be billed.

Failure to appropriately obtain ABNs and utilize the GA modifier can result in services being denied as not medi-cally necessary and when that occurs, the service must be written off, having a significant negative financial impact to the organization.

ModifierGZItem or service expected to be denied as not reasonable and necessary—Modifier GZ is often not utilized, but is an important modifier for CMS claims. This modifier is used on services that have limited coverage issues, either based on medical necessity, diagnostic reasons, or frequency limitations when an ABN was not obtained. This modi-fier should be attached to all services that are anticipated to be denied for a specific reason, and alerts that there was not a valid ABN completed. If a significant volume of GZ modifiers are submitted there is need for education on the proper use and needs of an ABN.

Utilizing the same example as above, the GZ would be attached if the 83036 laboratory test was ordered and the diagnosis of the patient did not meet the medical crite-ria as identified by the NCD; however, an ABN was not obtained. If denied as not medically necessary as expected and without an ABN, the service must be written off and revenue will be lost for the organization.

ModifierGYItem or service statutorily excluded or does not meet the definition of any Medicare benefit—The GY modifier should be utilized anytime a statutorily excluded service is going to be filed with CMS. This modifier identifies the provider understands CMS does not cover the service and that a denial is expected. Often, particularly if a benefi-ciary has a secondary policy, the provider needs the denial before they file it to their other insurance; however, you do want CMS to understand you do not expect payment so it


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does not appear that you are trying to recoup money from CMS on statutorily excluded services.

Patient transport, for example, is a non-covered service for CMS and is statutorily excluded from coverage. If however, patient transport occurs and is going to be included on the claim form, a modifier GY should be attached to indicate that you know it is non-covered and expect it to be denied.

ModifiersUsedinthePQRSInitiativesMany modifiers are utilized for a variety of circumstances and help create a true and accurate picture of the patient. Physicians and/or organizations participating in the Phy-sician Quality Reporting System (PQRS), formerly the Physician Quality Reporting Initiative (PQRI), have needs involving a different group of modifiers. When a patient meets the requirements of a PQRS measure but for some reason the requirement of the initiative cannot be com-pleted, this is also identified by use of the correct exclusion modifier. Anytime a Performance Measure Exclusion needs to be identified the following should be utilized:

1P DuetoMedicalReasons

2P DuetoPatientChoice

3P DuetoSystemReasons

8P Actionnotperformed,Reasonnototherwisespecified

If a patient meets the criteria for a PQRS measure, such as the patient is a diabetic and should have an A1C per-formed, but refuses to have the test performed, modifier 2P should be appended to the PQRS measure code. This clearly identifies that the measure is known, but the patient chose not to have the necessary services to meet the measure’s criteria.

ModifiersIdentifyParticularTypesofProvidersModifiers can also identify the type of health care provider that is providing a particular service to a patient:

AE RegisteredDietician

AF SpecialtyPhysician

AG PrimaryPhysician

AH ClinicalPsychologist

AJ ClinicalSocialWorker

AK NonParticipatingPhysician

AM Physician,TeamMemberService

There are instances in which it is necessary to identify the type of provider for informational purposes, but can also impact payment if services are restricted to certain types of providers. For example, in a critical access hospital, if nutrition services are rendered by a registered dietician, modifier AE must be reported and payment will be at 85 percent of the MPFS.

Another example would be to use the AJ modifier any time the service is provided by a clinical social worker, and as based on WPS Medicare, the carrier for Iowa, Kansas, Missouri, and Nebraska, services will be reimbursed at 75 percent of the physician fee schedule or the actual charge, whichever is less, and only on the basis of assignment. If the AJ modifier was not attached for a service provided by a CSW and reimbursement was obtained at 100 percent, it would be an overpayment based on the WPS Medicare policy and a refund would be necessary.

PhysicianofRecordModifierAIThis modifier was newly created and became necessary when CMS excluded payment of all consultation codes to allow the physician of record for a hospitalization to be clearly identified. The AI modifier should be attached to the initial hospital service code by the physician who is the phy-sician of record or attending physician for that hospital stay.

For example: A patient presents to the ER and their con-gestive heart failure is completely out of control; there is a high level of fluid build-up and patient is extremely short of breath. The hospitalist comes to assume care of the patient in the ER and admits the patient. The hospitalist then calls in the cardiologist and both the hospitalist and the cardiologist report a 99223 for their individual initial hospital service.

The hospitalist claim should also include the AI modifier, captured as 99223-AI, which distinguishes that the hospi-talist is the primary physician and the physician of record.

OtherMiscellaneousModifiersModifierGGPerformance and payment of a screening mammogram and diagnostic mammogram on the same patient, same day—If a screening mammogram is performed and com-


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pleted on the same day, following the radiologist’s recom-mendations in which a diagnostic mammogram is also completed, modifier GG must be utilized. This modifier should be attached to the diagnostic mammogram service code. In this circumstance, both services can and should be covered. The key element to remember is the screening service was not converted during the test, but both were separately performed.

ModifierGHThis modifier is very similar to modifier GG and under-standing the difference is necessary in utilizing the correct modifier. If a screening mammogram is started and fol-lowing the radiologist’s recommendation is converted to a diagnostic mammogram and the diagnostic mammogram is completed, modifier GH should be utilized. This identi-fies that the mammogram began as a screening service. In this circumstance, only the diagnostic mammogram is covered. GH would be appended to the diagnostic mam-mography code.

ModifierQWCLIA waived test—If the physician’s office performs in-office laboratory services and has a CLIA waived certificate which allows them to provide CLIA waived testing, the QW modifier may be needed. The QW modifier simply identifies specific laboratory services as being CLIA waived. CMS publishes an accurate list of all services that meet the criteria for a CLIA waived service and indicates which of these services requires the QW modifier. This information can be found at www.cms.gov/CLIA/downloads/waivetbl.pdf. For example, a prothrombin time test provided in the physician’s office with a CLIA waived certificate, the service should be reported with 85610-QW.

ModifierQ6Service furnished by a locum tenens physician—Locum tenens physicians often are utilized to cover when a physi-cian is out on medical leave or away on an extended vaca-tion or a sabbatical of some type. When a locum tenens physician is being utilized, the NPI number of the regular physician that is out for whatever reason is reported for the service and modifier Q6 is attached to the billed CPT® and HCPCS Level II codes to identify that a locum tenens physician provided the service. There are clearly defined rules for locum tenens services, which must be followed. The following apply when utilizing a locum tenens:

yy Theyphysicianymustybeyabsentyfromytheypracticeydueytoyillness,yvacation,yCME,yorytheyphysicianymayyhaveyleftytheypractice

yy Theyregularyphysicianymustybeyunavailableytoyprovideytheyservice

yy Thisyisyayphysicianyruleyandymayynotybeyutilizedyforymid-levelyproviders

yy Thereyisyaylimityofy60ydaysyforyeachylocumyphysician,ycountedyfromytheyfirstydayytheylocumyseesyaypatient.yThisy60ydaysyincludesydaysythatytheylocumydoesynotyseeypatients,ysuchyasyhisyoryherydayyoff.

yy Aftery60ydays,ytheylocumymayynoylongerybillyforythatylocum.yIfyservicesyareystillyneeded,yaydifferentylocumymustybeyobtained

yy BillyforytheylocumyunderytheyNPIyofytheyphysicianywhoyisynotythereyandyuseytheyQ6ymodifieryonytheyclaim

yy Aylistyofypatientsyseenybyytheylocumyshouldybeyretained

yy Theylocumyisypaidyonyayper-diemyoryayfee-for-timeybasis

ConclusionModifiers add to the story making it better because they further explain, identify, clarify, and capture additional information to make it complete. While there are many modifiers and this is not a comprehensive list of every modifier available, coders should review all modifiers in both CPT® and HCPCS Level II to determine what modi-fiers may pertain to the services they are reporting.

Modifiers when used appropriately will help organizations and physicians obtain accurate reimbursement for the ser-vices they provide. While modifiers should never be used just to get paid, they should always be utilized when neces-sary to allow for payment. Know your payers, know what they want. Track modifier denials to help understand your payer needs.

Talk to the physicians! Help them understand documenta-tion needs to support the various modifiers and how modi-fiers clarify coding and proper utilization. Documentation, as with all coding, is the key to the services being sup-ported and the services being billable. Anytime a modifier is utilized, the record must support the use of the modifier. Modifiers: use them wisely, use them well.


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DISCLAIMERThis is not an all inclusive list of every modifier; this is an overview of many modifiers and their intended usage.This material is designed to offer basic information on the use of modifiers in coding. This information is based on the experience, training and interpretation of the author. Although the information has been carefully researched and checked for accuracy and completeness, the instructor does not accept any responsibility or lia-bility with regard to errors, omission, misuse or misin-terpretation. This handout is intended as an educational guide and should not be considered a legal/consulting opinion.

RESOURCESThere are many references and resources that you should be familiar with to assist you with questions on coding. Staying on top of the rules and regulations, utilizing resources and networking are critical to the success of the coder. The Centers for Medicare & Medicaid Services (CMS) has a very useful website that includes bulletins and updates on coding, past and current fee schedules, copies of the official 1995 and 1997 Evaluation and Management Documentation Guidelines.www.cms.gov Also at the CMS site you can download the most current CCI edits available, free of charge:www.cms.hhs.gov/physicians/cciedits

The fee schedule, which is able to be searched by code or code-range, is found at:www.cms.hhs.gov/physicians/mpfsapp/default.asp

Another valuable service is the user friendly publications provided at MedLearn Matters, which gives you up to date news and changes:www.cms.hhs.gov/medlearn/matters

AAPC is a valuable resource to coding staff and their membership a bevy of qualified coders to assist, advise, and guide:www.aapc.com

Check out your local carrier, both for CMS and Med-icaid. Stay abreast of all changes. Utilize information provided from the American Medical Association.


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Hands-onExercisesWorkthroughtheexamplesbelowfordiscussion:It should be noted that multiple codes or multiple modifiers may be needed to capture the correct information, so if it asks is a modifier needed, know that in some instances more than one may be necessary.

1. A patient presents to the general surgeon’s office as gallstones have been identified by ultrasound and the patient’s primary care physician referred the patient to a surgeon. The general surgeon completes a detailed history; expanded problem focused exam, and determines that the patient does need to have surgery for removal of the gallbladder. Sur-gery is scheduled for the following week:

What type of service should be reported?

Is a modifier needed?

Why or why not?

The day before surgery the patient returns for a brief visit, to insure that there is no infection, that all pre-operative services necessary were performed and to review the needs for the following day.

What type of service should be reported?


Why or why not?

2. An asthmatic patient is seen in the office in severe exacerbation. The patient’s pulse Ox is taken and is low, so a nebu-lizer treatment is given in the office. Following the treatment another pulse Ox is taken and is higher, but still not sat-isfactory and another treatment is given. The patient also receives a therapeutic injection during the visit. A complete evaluation and management service is completed.

What services should be reported?


Why or why not?

3. A patient has hip replacement performed by the orthopedic surgeon. During the 90 day global period, the patient slips and falls and tries to catch herself and fractures her wrist. The orthopedic doctor who performed the hip replacement surgery is called into the Emergency Department to assume care and after a comprehensive evaluation and manage-ment service; the decision is made to take immediately to surgery for repair of the wrist.


Is modifier needed?

Why or why not?


16 AAPC 1-800-626-CODE(2633)

4. A physician goes on a 3 month sabbatical and a locum tenens physician is obtained from a locum service to cover for the physician in his absence. The locum does have a license in the state, but is not credentialed for the group. He does cover all services of the physician that is not there.

How are services reported?

What NPI number is utilized?

Can the locum’s services be billed?


Can the locum cover the entire absence?

5. After a fall from a tree, a patient presents with fractures of the left thumb, left first and left middle finger. All of these fractures are identified by a three view X-ray and set with manipulation and splinted. A two view X-ray also identified a subluxed left elbow, which is treated.

What types of services should be reported?


Why or why not?

6. A patient with severe osteoarthritis presents to the orthopedic office and has significant pain in both knees and the right shoulder. The patient has not had any therapeutic treatment, but the pain is worsening. After a complete evalu-ation and management service, the physician determines that joint injections may help relieve some of the patient’s pain. They discuss the procedure and the risks of the procedure and the patient opts to have the injections on the same day and all three joints causing the most pain are injected.



Why or why not?

7. In a teaching facility a physician is performing surgery which requires an assistant at surgery. He utilizes a resident to assist him in surgery.

How are the resident’s services captured?


Why or why not?

In the above scenario, if a resident is not available and another physician must assist.How are these services captured?


Why or why not?


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8. A patient presents to the Emergency Department on Saturday and a general surgeon is called in due to severe abdomi-nal pain. The surgeon determines the patient needs to have an appendectomy, but this cannot be performed until the following day. The surgeon that saw the patient is not available the following day as he is going on a week-long vaca-tion, but his surgical partner will perform the surgery. He does indicate to the patient that he will be back and will follow in the office during the post-operative recovery time?

How is the initial service reported?

How does the physician that performs surgery report his service?


Why or why not?

When the original physician performs post-operative services in the global period, what is reported?


Why or why not?

9. A CMS beneficiary presents to have a Pap smear. While this service is only covered once every two years and the patient had this service one-year prior, the service will not be covered. She is informed and Advanced Beneficiary Notice (ABN) is obtained.

How should the service be reported?


Why or why not?

If an Advanced Beneficiary Notice is not obtained does it change the way the service is reported?How should the service be reported in this instance?


Why or why not?

10. A patient has a mastectomy performed by the general surgeon. During the 90 day global post-op period of the surgery, the patient develops a sinusitis and sees her primary care physician for an evaluation and management service.

How should this service be reported for the primary care physician?


Why or why not?


18 AAPC 1-800-626-CODE(2633)

SummaryofModifiersAddressed:


1P Performancemeasureexclusion;duetomedicalreasons

2P Performancemeasureexclusion;duetopatientchoice

3P Performancemeasureexclusion;duetosystemreasons

8P Performancemeasureexclusion;reasonnotspecified

AA Servicespersonallyfurnishedbyanesthesiologist

AD Reportedwhenthemedicalsupervisionbyaphysicianisformorethanfourconcurrentanesthesiaservices .

AE Registereddietician

AF Specialtyphysician

AG Primaryphysician

AH Clinicalpsychologist

AI Physicianofrecord

AJ Clinicalsocialworker

AK Nonparticipatingphysician

AM Physician,teammemberservice

AS Assistantatsurgerybynon-physicianprovider(NP,CNS,PA)

E1 Upperlefteyelid

E2 Lowerlefteyelid

E3 Upperrighteyelid

E4 Lowerrighteyelid

F1 Leftseconddigithand

F2 Leftthirddigithand

F3 Leftfourthdigithand

F4 Leftfifthdigithand

F5 Rightthumb

F6 Rightseconddigithand

F7 Rightthirddigithand

F8 Rightfourthdigithand

F9 Rightfifthdigithand

FA Leftthumb

GA Certificateofwaiverobtained(ABNexecuted)


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GGPerformanceandpaymentofascreeningmammogramanddiagnosticmammogramonthesamepatient,sameday

GH Diagnosticmammogramconvertedfromscreeningmammogramonsameday

GY Itemorserviceexpectedtobedeniedasstatutorilyexcludedornotabenefit

GZ Itemorserviceexpectedtobedeniedasnotreasonableandnecessary,nowaiverobtained

P1 Normalhealthypatient

P2 Patientwithmildsystemicdisease

P3 Patientwithseveresystemicdisease

P4 Patientwithseveresystemicdiseasethatisaconstantthreattolife

P5 Amoribundpatientwhoisnotexpectedtosurvivewithouttheoperation

P6 Adeclaredbrain-deadpatientwhoseorgansarebeingremovedfordonorpurposes

Q6 Servicesprovidedbyalocumtenensphysician

QK Medicaldirectionoftwo,three,orfourconcurrentanesthesiaproceduresinvolvingqualifiedindividuals .

QS Reportedformonitoredanesthesiaservices

QW CLIAwaivedservice

QX ServicesprovidedbyCertifiedRegisteredNurseAnesthetist

T1 Leftseconddigitfoot

T2 Leftthirddigitfoot

T3 Leftfourthdigitfoot

T4 Leftfifthdigitfoot

T5 Rightgreattoe

T6 Rightseconddigitfoot

T7 Rightthirddigitfoot

T8 Rightfourthdigitfoot

T9 Rightfifthdigitfoot

TA Leftgreattoe

22 Increasedproceduralservice

23 Unusualanesthesiaservicesrequired

24 Unrelatedevaluationandmanagementserviceinthepost-operativeperiod

25 Separateandsignificantevaluationandmanagementservice

50 Bilateralprocedure

51 Multipleprocedure

52 Reducedservice

53 Discontinuedprocedure


20 AAPC 1-800-626-CODE(2633)

54 Surgicalcareonly

55 Post-operativeservicesonly

56 Pre-operativeevaluationonly

57 Decisiontoperformsurgery

58 Stagedorrelatedprocedureinthepost-operativeperiod

59 Distinctandseparateprocedures

62 Co-surgeons

76 Repeatprocedurebythesamephysician

77 Repeatprocedurebyadifferentphysician

78 Relatedprocedureinthepost-operativeperiod

79 Unrelatedprocedureinthepost-operativeperiod

80 Assistantatsurgery

81 Minimumassistantatsurgery

82 Physicianassistantatsurgerywhennoqualifiedresidentisavailable

91 Repeatlaboratoryservice


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Slide Presentation


22 AAPC 1-800-626-CODE(2633)

ModifiersThe Rest of the Story

1

DisclaimerThis is not an all inclusive list of every modifier; this is an overview of many modifiers and their intended usage.

This material is designed to offer basic information on the use of modifiers in coding. This information is based on the experience, training and interpretation of the author. Although the information has been carefully researched and checked for accuracy and completeness, the instructor does not accept any responsibility or liability with regard to errors, omission, misuse or misinterpretation. This handout is intended as an educational guide and should not be considered a legal/consulting opinion.

2


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CPT® Coding

• CPT® codes identify a particular procedure or serviceservice

• If a specific CPT® does not exist that identifies the procedure or service, an unlisted code must be utilized

• Coding is the translation between the physician’s written word and the dictionary used

3

physician s written word and the dictionary usedby payers to interpret them into numbers

What Do the Codes ‘Say’?

• A patient comes in for a reason which translates into the diagnosis(s) codediagnosis(s) code

• A service is provided or supply is given which translates into a CPT® or HCPCS Level II code– This tells the story to the payer about what was done and

why it was done

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THE CODING NEEDS TO TELL THE RIGHT STORY


24 AAPC 1-800-626-CODE(2633)

Lost in the Maze• Don’t know which way to go

• Instructions vary

• Even the carrier seems unsure

• Learn how and when to apply

5

The Role of the Modifier

• Provide more informationCl if• Clarify

• Expand upon• Enhance Specificity• Identify separation• …they add to…or CHANGE the story

6

y y


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Types

• Informational Modifiers• Payment impacting modifiersPayment impacting modifiers• Status of patient modifier• Type of service

– Both CPT® modifiers and HCPCS Level II modifiers• Many commercial payers do not require HCPCS Level II

modifiers• All modifiers have a vital role in accurate coding.

7

g• NOT all payers recognize modifiers • KNOW your payers!

Payment• Adding a modifier may get a claim paid

• MUST make sure the modifier should be added• MUST make sure the modifier should be added

• Adding a modifier JUST to get it paid, if not supported, is fraud

Failure to use a modifier when appropriate may risk lost reimbursement; over-utilizing or using a modifier for payment when not appropriate can put

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the physician and practice at risk.


26 AAPC 1-800-626-CODE(2633)

Denials• Monitor and track denials that occur due to modifier

issues; to identify how your payers recognize modifiers and when– When a denial is received that indicates a modifier is

needed• EASY fix: apply modifier• NOT correct

– This denial really states that if a modifier was utilized, if appropriate and supported by documentation on this particular day for this particular

9

supported by documentation on this particular day for this particularpatient for a particular reason, this claim may have been covered

» Staff working denials MUST be very familiar with the use and needs of modifiers

Let’s Get Started

10


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Anatomical Modifiers

Modifiers TA-T9, FA-F9: To identify that procedures were done on separate fingers or toesprocedures were done on separate fingers or toes

– ONLY appropriate on procedures and services, NOT diagnosis codes or E/M codes

– If hammertoes are repaired on all toes, you could report the same code 10 times, identifying each toe individually with a modifier

11

individually with a modifier

Anatomical ModifiersModifier RT, LT: To identify that procedures were done on separate ‘sides’ of the bodydone on separate sides of the body

– ONLY appropriate on procedures and services, NOT diagnosis codes or E/M codes

– Some payers would also rather see an RT, LT, and not the 50 for bilateral, must know what the payers want

– Lesion removed from right arm, excision taken from left arm modifier RT and LT will identify that they were from a

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arm, modifier RT and LT will identify that they were from adifferent location


28 AAPC 1-800-626-CODE(2633)

Anatomical…and the Eyelids

• E1 Upper left

• E2 Lower left

• E3 Upper right

• E4 Lower right

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Examples of Anatomical Modifiers• Blepharoplasty done on the right and left upper eyelid during the same

operative episode– The procedure should be reported on two separate line items; one with an

E1 d ith E3 difiE1 and one with an E3 modifier• While reimbursement would face multiple procedure reduction rules; expected reimbursement would

be 100% for the first and 50% for the second. • Failure to use a modifier could result in a denial of the second procedure; as can appear to be a

duplicate

• Hammertoe repair done on the right second, third, and fourth toe– T6, T7, T8 should be reported with the hammertoe repair, each on a

separate line item• Again, this clarifies that it is not a duplicate, but three distinct and separate procedures

– Expected reimbursement would be 100% of the first and 50% of both the second and the third

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pprocedure

– Without the modifiers; there is a potential risk of only being paid for the initial procedure and the others denied as a duplicate claim


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Surgical Modifiers58 Staged or related procedure in the post-op period by the same

physicianPatient had a lumpectomy and after pathology, it was determined that mastectomy needed to be performed. Mastectomy, more extensive and related to the initial surgery, modifier 58, identifies that it is staged/related in the post-op period.

78 Return to the OR for a related procedure during the post-op periodPatient had open heart surgery, during hospitalization, began bleeding and had to be taken BACK to the OR for more surgery. It was NOT ‘STAGED,’ it is NOT more extensive than initial surgery, modifier 78 identifies a return to the OR.

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79 Return to the OR for an unrelated procedure during the post-op periodPatient had surgery to repair a fractured hip. During recovery, he slipped and fell fracturing his wrist and had to have an ORIF performed, modifier 79 must be utilized.

Impact of Payment of Surgical Modifiers

The primary and main concern of failure to use the appropriate and necessary surgical modifiers is completeappropriate and necessary surgical modifiers is completedenial of the 2nd procedure, as ‘inclusive’ as it may be automatically denied, due to being in the global period. Based on the procedure completed, this can be quite costly

– Appeals and resubmissions are expensive to any organization; as failure to capture the right information the first time is the most

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effective and efficient ‘cleans claim’ billing process


30 AAPC 1-800-626-CODE(2633)

Global Days

HCPCS Mod Description Global

National Physician Fee Schedule Relative Value File

Days

20612 Aspirate/inj ganglion cyst 000

20615 Treatment of bone cyst 010

20650 Insert and remove bone pin 010

20660 Apply rem fixation device 000

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20660 Apply, rem fixation device 000

20661 Application of head brace 090

http://www.cms.gov/PhysicianFeeSched/01_Overview.asp#TopOfPage

Splitting the Global Surgical Package

54– Surgical Care ONLYSurgical Care ONLY– To identify that a provider ONLY did the surgery, that someone

else will be billing the post-op care (OPHTH-OPTOMETRY for ‘comanaged cataract patients)

55– Post-op Management ONLY– Physicians can SHARE the post-op care as well– Reported with procedure code original date of surgery NOT the

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– Reported with procedure code, original date of surgery, NOT thedate the patient was seen

56– Pre-op Management ONLY


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Example of Splitting the Global Package

Let’s split the global package of the extracapsular cataract surgery; 66984 (allowable $742 38)cataract surgery; 66984 (allowable $742.38)

66984-56 Pre-operative service provided by the ophthalmologist doing the pre-operative work-up ($74.24)

66984-54 Surgery only, by the ophthalmologist performing surgery ($519.67)

66984-55 Post-op follow-up provided by the optometrist that

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66984-55 Post-op follow-up, provided by the optometrist thatthe ophthalmologist referred patient to, for follow up and glasses ($148.48)

Multiple/Bilateral ProceduresModifier 51

– Modifier ONLY recognizes that it is a multiple procedure– Is NOT a pricing modifier, although many payers reduce reimbursement for multiples O a p c g od e , a t oug a y paye s educe e bu se e t o u t p e

procedures. 100% paid for the highest physician fee schedule amount and 50% of the fee schedule for each additional procedure.

• MANY payers do not require this modifier; Medicare no longer requires it. In some areas, claims will be denied if the modifier is utilized.

Modifier 50– Bilateral modifier, to indicate that the EXACT same procedure was performed on both sides

of the body. – Only appropriate for those areas, where you have ‘two’– Bilateral knee replacement

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Bilateral knee replacement– Also, NOT a pricing modifier

• Expected reimbursement is 150% but this is based on multiple procedure reduction rules

• Some payers would rather have RT and LT on separate line items


32 AAPC 1-800-626-CODE(2633)

Example of Bilateral and Payment Impact

Bilateral modifier 50 and the RT and LT modifier to those payers, t i i th difi 50 ill h th tnot recognizing the modifier 50 will have the same payment

impact– Sticking with the extracapsular cataract 66984 service code; if

done on both eyes, a modifier 50 would be appropriate• 66984-50 with 1 unit on one line item would be reimbursed at 150%:

$1113.57• If reported with an RT and LT, it would be two separate line items

66984 RT

21

– 66984-RT– 66984-LT

» Reimbursement would be 100% for the first; 50% for the second, still resulting in 150% of $1113.57

Additional Work or DiscontinuedModifier 22

– When a procedure/service took more work more time or– When a procedure/service took more work, more time, orwas unusual from what was expected

– May charge more, when modifier is used– May not be reimbursed more by payers– Will expect documentation

Modifier 53Di ti d d h d HAD t b

22

– Discontinued procedure, when a procedure HAD to bestopped, due to the condition of the patient. Still bill the code of the procedure that was being attempted.


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Examples of Additional Work or Discontinued Procedures

• Patient is prepped and the plan is for a diagnostic colonoscopy; when the sigmoid junction is reached, the blood pressure of the patient increases dramatically; causing the physician to discontinue the proceduredramatically; causing the physician to discontinue the procedure– The colonoscopy 45378 should be reported with a modifier 53

• The procedure was not completed, it was discontinued due to the condition of the patient.

– BILL at full fee; anticipate submitting with the operative report; payment may be reduced, in this example to the allowable for a sigmoidoscopy, as that is the level reached; however, do not reduce claim, not all payers will reduce payment.

• Due to a patient’s morbid obesity and the tremendous amount of adhesions from a prior colectomy; the abdominal surgery took 3 hours

23

y g ylonger than expected for a very common appendectomy– In this instance a modifier 22 would be appropriate

• Increasing fees is also appropriate; however, not all payers will increase payment

Reduced Services from Code Description

Modifier 52

– Reduced services– If for some reason, the entire service was not provided, but only

a portion of it, this modifier may be used – Physician should determine how much of the procedure/service

was done, and how much the fee should be reduced– NOT TO BE USED JUST TO REDUCE THE FEE

24

Example: If a pure tone audiometry, air, CPT® 92552 is performed only on the left ear, modifier 52 should be appended (92552-52). This procedure is a bilateral procedure and was reduced because it was only performed on one ear.


34 AAPC 1-800-626-CODE(2633)

Physician Identifier

AI: Physician of recordy

This modifier became necessary for Medicare when consultation codes become non-reimbursable to distinguish the attending

25

Example of AI ModifierA patient presents to the ER and their CHF is completely out of control; there is a high level of fluid build-up and patient is ; g p pshort of breath.

– The Hospitalist comes to assume care of the patient in the ER and admits the patient

– The Hospitalist then calls in the Cardiologist• Both the Hospitalist and the Cardiologist report a 99223 initial

hospital service

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– The Hospitalist claim should also include the AI modifier, captured as 99223-AI, which distinguishes that the Hospitalist is the primary physician and the physician of record


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Physical StatusAnesthesiologists must capture the ‘status’ of the patient which identifies the risk of putting the patient to sleep

P1 Normal healthy patientP2 Patient with mild systemic diseaseP3 Patient with severe systemic diseaseP4 Patient with severe systemic disease that is a constant threat to

lifeP5 A moribund patient who is not expected to survive without the

operationP6 A declared brain dead patient whose organs are being removed

27

P6 A declared brain-dead patient whose organs are being removedfor donor purposes• Helps clearly identify the risk; also some payers increase the base units

based on the risk, so may impact payment

Anesthesia

Modifier 23 If a procedure that does not usually require anesthesia butIf a procedure that does not usually require anesthesia, butbecause of circumstance requires general anesthesia; this modifier should be utilized

Record must clearly indicate why general anesthesia was required

Example: A cystoscopy does not usually require general anesthetic. However, if performed on a young child who cannot be

28

controlled, general anesthetic may be necessary. Append modifier 23 in this case.


36 AAPC 1-800-626-CODE(2633)

RepeatsModifier 91

– FOR use on REPEAT LAB TESTS, ONLY.f– If the exact same test is done, on the same date, because they

want to compare data, this is appropriate.

Modifier 76– Repeat procedure by same doctor, same date.– Chest X-ray done at 10 am, 1 pm, and 3 pm.– Modifiers needed on the 1 pm and 3 pm service.

Modifier 77

29

– Repeat procedure by different doctor, same date.– Works just like the 77 modifier, but identifies that it is a different

physician.

Payment Impact and Use of ‘Repeat Modifiers’

• Patient presents to the office and two nebulizer treatments are given to try to get the pulse oximetry measurement to be satisfactory due to a severe asthma attackoximetry measurement to be satisfactory, due to a severe asthma attack

– The second nebulizer would be reported with a modifier 76• An inpatient has two EKGs during the same hospital day, as first shows abnormalities; and

separate Cardiologists read the two tracings; 93010 would be reported by the first and 93010-77 would be reported for the second cardiologists reading

• A blood glucose was taken in the morning and was repeated every 4 hours throughout the day; to insure that the glucose levels were stabilizing

– Each repeat lab would be submitted with modifier 91• Why? Impact without?

• It is important to identify to the payer that these are ‘repeat’

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p y p y pservices, so that each service is separately reimbursable

• Failure to utilize the modifiers can result in claims being denied as duplicate procedures


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CLIA Waived

QW CLIA waived laboratory service

Should be attached to most CLIA waived services when POS testing done in the office that has a CLIA waived certificate

• Some CLIA waived tests do not require the modifierCMS bli h ti li t f th t t id d

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– CMS publishes an active list of those tests consideredCLIA waived and which require the modifier

Assists

80 Surgical assistant services may be identified by adding modifier 80 to the usual procedure number(s).

81 Minimum surgical assistant services are identified by adding modifier81 Minimum surgical assistant services are identified by adding modifier81 to the usual procedure number.

82 The unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s)

AS Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery

Assistant does not need to dictate a separate operative report, but

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operative report of primary must capture the medical necessity of the assistant and the role the assistant played in the surgery. Cannot just show ‘assisted by’ in the header and use terms like ‘we’ and ‘us.’


38 AAPC 1-800-626-CODE(2633)

Assists Example

At a teaching hospital a patient undergoes a hysterectomy All qualified residents arehysterectomy. All qualified residents areassisting in other cases. A physician is required to assist on this case. Modifier 82 is appended.

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Assistant Reimbursement Impact

• While reimbursement for assistants at surgery may change somewhat by payer; if a physician is providing the assistant, the CMS allowable is 16% of the allowable for the procedure

• Reimbursement changes, when an AS is used to identify that the assistant is a mid-level provider and is at 13% of the allowable for the procedure

• When an 82 modifier is utilized, it is reimbursed the same as when the 80 modifier is used, at a rate of 16%; however, this modifier differs in that it allows for payment in a teaching facility for an assistant. When a qualified resident is available, no separate reimbursement is allowed

– If the modifiers are not utilized appropriately and the code is reported by both the primary and the assistant; a duplicate denial will occur

– If a duplicate denial does not occur; and full fee happens to be paid for both the i d th i t t t h b d d f d i i d

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primary and the assistant; an overpayment has been made and a refund is requiredRegence in Oregon for example: reimburses at 20% for the 80 and 82 and 10% for the AS and the 81: http://www.or.regence.com/provider/library/policies/reimbursement-policies/modifiers/modifier-80-81-82-and-as-assistant-at-surgery.html

Medicare rarely pays for modifier 81/Minimal assist


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Co-Surgeons62 Co-surgery should only be reported when 2 surgeons work together on the

same procedure and each provides distinct parts; where the surgery for each would have to be reported with the same CPT® code.– If surgeons perform surgery together, but each does a uniquely

identified procedure; they each would report their own procedure code• Based on the CMS National Physician Schedule Relative Value

File; the values include

Value Description

0 Co-surgeon not permitted

1 Co-surgeons may be paid; supporting documentation required to establishmedical necessity

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2 Co-surgeons permitted; no documentation required if 2 specialty requirements met

9 Co-surgeon concept does not apply

Co-Surgeon Reimbursement

• When utilized, both surgeons have to be completing a primary portion of the samecompleting a primary portion of the samesurgical code– Reimbursement would be based at 125% of the

allowable, with each physician receiving 62.5% of the allowable

– When the Value is a 0 or a 9, it is never appropriate to

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utilize modifier 62


40 AAPC 1-800-626-CODE(2633)

New Modifiers as Things Change

33 The US Preventive Services Task Force as part of the evidence based service createdpart of the evidence based service createdthe need for a modifier 33 to be utilized when reporting a service that the intent was preventive in nature.

– If the code description already identifies it is a preventive service, this modifier is not necessary

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preventive service, this modifier is not necessary

More on Modifier 33While this modifier is not in the CPT® book, it was announced in April of 2011 and made retroactive to January 2011.p y

– If a screening colonoscopy is being provided (to a non-Medicare patient) and CPT® code 45378 would be appropriate, but during colonoscopy a polypectomy was performed and CPT® 45383was actually completed; the modifier 33 is necessary to show that it started as a screening service

• While modifier 33 does not have an impact on the allowable amount; it has a significant impact on the patient responsibility,

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as preventive services, based on the new piece of legislation have no cost-share


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Mandated Services

32 This modifier should be attached when the service is mandated by a third party: legalservice is mandated by a third party: legal,insurance company, etc.

– Since the disseverment of confirmatory consults, when insurance needs a second opinion, on occasion this modifier must be utilized to capture the service

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was mandated.

Example of Modifier 32• A cardiologist determines that a patient needs a mitral valve

replacement for a mitral valve prolapse; however, the patientp p p ; , phas had this condition for several years.

• The insurance company does cover mitral valve repair, but requires a second surgical consolation prior to surgery.– The cardiologist providing the second opinion, should report his

service with a modifier 32 to show that it was mandated by the insurance company

• Failure to report the modifier can result in a denial based on not

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• Failure to report the modifier can result in a denial, based on notmedically necessary; as another physician has already provided this service

– This alerts the insurance company that this was a requirement of their policy and the service should be covered


42 AAPC 1-800-626-CODE(2633)

Why ‘G’??GA Waiver of liability statement issued as required by

payer policy, individual caseSh ld b d l h l d ABN i l d f hShould be used only when a properly executed ABN is completed for theservice

GZ Item or service expected to be denied as not reasonable and necessaryUtilized for those services in which an ABN should have been obtained, the service is expected to be denied, but an ABN was not garnered

GY Item or service statutorily excluded does not meet the

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GY Item or service statutorily excluded, does not meet thedefinition of any Medicare benefit or for non-Medicare insurers, is not a contract benefit

Examples of GA, GY, GZ, and Impact to Reimbursement

Medicare reimburses for a screening colonoscopy in a high risk patient every 23 months. A patient chooses to have this service p y pevery year. It is explained to the patient that it will be outside the frequency parameters and will not be covered every year and if denied, the patient would be responsible and an appropriate ABN is executed.

– A GA modifier is attached to the colonoscopy code, which alerts Medicare that it is expected to be denied as not reasonable and necessary and that the patient was informed.

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necessary and that the patient was informed.• CRITICAL to denial, as when the GA is attached, the service will be

denied as ‘patient responsibility’ instead of ‘not medically necessary’– If denied as not medically necessary, the service cannot be balance billed to the

patient, resulting in lost revenue to the organization.


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GA,GY, GZ continued…• In the colonoscopy example, where the service is outside the

frequency parameters, but no ABN was obtained, a GZ modifier should be attachedshould be attached– While this is a modifier you do not wish to utilize; as it implies you know

the service may not be covered, you do not have an ABN; and expect a denial. LOST REIMBURSEMENT, when a denial is received, patient cannot be billed because no ABN was obtained

• Some services are never covered, when this occurs, an ABN is not necessary, but the claim also should not be billed to CMS; however, if a denial is needed and wanted, it can be filed and a modifier GY

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should be attached. This clearly tells CMS that you know the service is statutorily excluded and will not be covered.– Patient can be balance billed or can be filed with a secondary policy if

one exists

G…I don’t knowGG Performance and payment of a screening

mammogram and diagnostic mammogram on themammogram and diagnostic mammogram on thesame patient, same dayDone as completely separate services, but on the same day, as a direct result of Radiologist findingsBoth services will be covered

GH Diagnostic mammogram converted from screening mammogram on same day

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g yDone at one setting and the plans changed based on Radiology determination•Only diagnostic mammogram will be covered


44 AAPC 1-800-626-CODE(2633)

E/M ModifiersModifer 25

Very common modifier– Very common modifier– For use on an E/M code ONLY– Identifies that the E/M service is separate and significant

from any other service provided on that date– Documentation MUST support

• DO NOT have to have a different diagnosis• DO HAVE to show that it was separate and significant

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• DO HAVE to show that it was separate and significant

Example of Modifier 25• Patient presents to the office for upper respiratory symptoms, and following

chest X-ray a pneumonia is identified. During the course of the examination, a suspicious lesion is identified on the back and it is recommended that a biopsysuspicious lesion is identified on the back and it is recommended that a biopsybe taken, which is done during the visit. The E/M service was separate and significant from the biopsy.

– Modifier 25 must be attached to the E/M service– The diagnoses should be linked appropriately with the upper respiratory symptoms or definitive diagnosis if

determined with the visit and the unspecified skin lesion for the biopsy– If the modifier 25 is not attached to the E/M service, often the visit will be denied as included or bundled in

the procedure– Financial impact can be lost revenue of the E/M service, based on the level of service medically necessary

and supported• Let’s say, that based on the medical necessity of the visit and the final diagnosis of pneumonia a level

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y, y g pfour service was supported and no modifier was used, the potential lost reimbursement could be about $75.00 per visit

– Easy to see, that if failure to use this modifier, over time and frequent occurrences, could have an impact to a physician’s practice financially


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E/M Modifier

Modifier 24For use on an E/M service when it is provided during– For use on an E/M service, when it is provided duringthe ‘global surgical package,’ but is unrelated

• Patient had knee surgery. Total Knee Replacement has 90 day global period. During 90 days, sprained ankle. Modifier 24 needs to be attached on the office visit to show it was NOT related and not part of the global surgical package

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p g g p g

Reimbursement Impact of Modifier 24

• If the modifier 24 is not attached to the E/M service the E/M service will be denied asservice, the E/M service will be denied as‘inclusive in the global package’

• The financial impact to the organization would be determined by the level of service which had been reported, as medically necessary and supported

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supported– Lets say that the sprained ankle was of low

complexity and a 99213 was reported; this would be potential lost revenue of about $50.00


46 AAPC 1-800-626-CODE(2633)

E/M ModifierModifier 57

– For use when an E/M service is within 24 - 48 hours– For use when an E/M service is within 24 - 48 hoursof a MAJOR SURGICAL procedure, but was the visit when it was determined that surgery was necessary

• Patient with severe abdominal pain, was sent to General Surgery for evaluation. During the visit, the surgeon determined that the patient needed surgery immediately and it was scheduled for later that same day. Modifier 57 needed

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yon the visit, or it will be included in the ‘global surgical package’

Reimbursement Impact of Modifier 57

• If the E/M when the initial decision to perform surgery is submitted without modifier 57; it will besurgery is submitted without modifier 57; it will beconsidered ‘inclusive to the global package’ and not separately reimbursable– The impact of total dollars would be based on the

type of E/M service involved and the level of service involved

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• For example, if this visit occurred as a level four ER visit, lots revenue would be about $115; if this visit was a level three hospital admission, it might be $194 in lost revenue


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Risky ModifierModifier 59

– Modifier of LAST RESORT– Only use if an anatomical modifierOnly use if an anatomical modifier

can not clearly identify that it was separate and significant

– NOT just to be attached to bypass an edit

– Must be DISTINCT AND SEPARATE (separate incision, separate excision, separate time of day, etc)MUST be supported by chart

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– MUST be supported by chartdocumentation

http://www.cms.gov/NationalCorrectCodInitEd/Downloads/modifier59.pdf

Reimbursement, Use, and Affect of Modifier 59

• 17000 for destruction of a pre-malignant lesion is ‘bundled’ in the NCCI dit ith 17110 f d t ti f b i l i ( t 14) itNCCI edits with 17110 for destruction of benign lesions (up to 14); itis not expected that both procedures will be done at the same visit– However, if destruction of an actinic keratosis occurs on the back and

destruction of 3 warts occurs on the hand; the procedures are clearly distinct and separate

• 17000• 17110-59

– MUST be reported to clearly capture that the services were not bundled, as they identified distinct and separate services based on separate lesions

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identified distinct and separate services based on separate lesions– The ‘indicator’ in the NCCI edits is that a modifier is allowed, when appropriate

» Will allow for separate reimbursement of both services» If modifier is not utilized; only one procedure will be covered, losing the full

reimbursement of the second procedure to the organization.


48 AAPC 1-800-626-CODE(2633)

Modifier 59, continued• Do not use modifier 59 if there is a more appropriate modifier• Review NCCI edits for Medicare and payers who use CCI Edits

http://www.cms.hhs.gov/NationalCorrectCodInitEd/NCCIEP/list.asp#TopOfPage

– Status indicator “0” cannot be submitted separately. Modifier 59 can not be used, no exceptions

– Status indicator “1” can submit modifier if supported by the documentation.

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– Status indicator “9” not subject to CCI edits

NCCI Example

Column Column Effective D t

Deletion D t

Modifier

1 2 Date Date

11006 64550 20090401 20090401 9

11006 69990 20050101 * 0

11006 93000 20090401 * 1

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Thank You

Jennifer Swindle RHIT CPC CPMAJennifer Swindle, RHIT,CPC, CPMA,CEMC, CFPC, CCS-P, CCP-P, PCS

Vice President Coding/Compliance PivotHealth, LLC

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