Modifiers- Navigating the Modifier Maze IHIMA Annual Meeting May 9, 2016

Objectives Understand the need and the appropriate use of modifiers Grasp the impact modifiers have on appropriate reimbursement Acknowledge the risk of improper use of modifiers 2

Accurate & Compliant Coding 3 Accurately and completely reflects the quality of patient care and services received by your patients Minimizes compliance RISKS to the individual provider as well as the organization Coding ‘tells a story’ — make sure it tells the CORRECT tale 1 2 3

Navigating Can be Confusing 4 Not all payers follow same rules

5 Evaluation & Management Modifiers FEW modifiers belong on E&M codes; however, those that do are critical to correct payment. 25 Separate and Significant Service 24 Unrelated to the surgery during post operative period 57 Decision to perform surgery 5 These modifiers SHOULD ONLY go on an E&M service!

6 Modifier 25 Highly monitored modifier DOES not require separate diagnosis DOES require separate and significant work If a procedure is performed during the office visit, but the office visit is separate and significant, documented and level of service supported a modifier 25 needs to be placed on the E&M code REMEMBER a ‘mini-E&M is included in all procedures, MUST be SEPARATE AND SIGNIFICANT Patient presents to the PCP for acute sinusitis. During the course of the exam, while listening to the lungs a lesion is noted on the back. After discussion, the PCP excises the lesion. Both services are reportable, a modifier -25 should be placed on the E&M code. 6

7 Modifier 25 Modifier 25 is required on an if done at the same time as a preventive service 17 year old established patient is scheduled for an annual physical, but also complains of right shoulder pain following a fall in a basketball game, which is separately evaluated and level 3 supported 7 Examples one: 99394Z M25.511, W19.XXXA, Y93.67

8 Modifier 57 Evaluation and Management services (pre-operative) for major surgical procedures occurring day before or day of surgery are part of the global surgical package and not separately billable. However, if a complete E&M service is provided and it is the visit when the NEED for surgery is determined and it occurs within 48 hours of surgery, a modifier -57 is necessary to show it should NOT be part of the global package. Example Patient referred to surgery by PCP due to severe abdominal pain. After complete E&M service and upon reviewing US results, surgeon schedules immediate gallbladder removal. Surgery is going to be the following morning. A modifier -57 needs to be placed on the surgeon’s E&M code. 8

9 Modifier 24 During the ‘global period’ of a surgery, all E&M services provided by the same physician that completed surgery are included in the global surgical package. However, if the patient is seen during this time for a different reason, unrelated to the surgery, a modifier -24 should be added to the E&M service to make this clear. Example Patient has hip replacement by ortho surgeon on 9/27/06. This procedure has a 90 day global period so all follow-up visits to ortho for 90 days are part of the global package (reported with 99024) and there is no charge. Patient experiencing severe wrist pain and numbness and presents to Ortho on 11/1/06. A modifier -24 must be reported on the E&M to show it is a visit unrelated to the hip surgery. 9

GE this service has been performed by a resident without the presence of a teaching physician under the primary care exception GC This service has been performed in part by a resident under the direction of a teaching physician For RIGGS; this must go on all ‘procedure’ codes when the resident is providing the service; documentation must show teaching physician present Resident Modifiers

GZ Item or service expected to be denied as not reasonable and necessary GY Item or service statutorily excluded, does not meet the definition of any Medicare benefit or for non- Medicare insurers, is not a contract benefit GA Waiver of liability statement issued as required by payer policy, individual case Medical Necessity

Modifier GY Utilized when a service is statutorily NON-Covered »Only for services that are never covered based on Medicare statute »Preventive medicine »Some eye services »Some hearing services If it is a service that has limited coverage, based on specific diagnoses or frequency, a GY should never be attached

Screening Colonoscopy with ‘findings’ changing procedure Patient presents for a screening colonoscopy, polyps identified and biopsy performed Procedure code now changes PT modifier »Colorectal cancer screening test; converted to diagnostic test or other procedure

Modifier 59 Used with caution High risk modifier Over-utilized »Should only be used when two procedure codes are bundled together and for a particular patient, particular day and particular reason should not be Separate time of day Separate incision Separate excision Effective 1/1/2015 new modifiers to further expand and should be used in place of modifier 59 when appropriate

Modifier 59 (NEW X modifiers) XS: Separate structure, a service that is distinct because it was performed on a separate organ/structure XP: Separate practitioner, a service that is distinct because it was performed by a different practitioner XE: Separate encounter, a service that Is distinct because it occurred during a separate encounter XU: Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service

Modifier 59 (NEW X modifiers) SHOULD not be used when services are bundled and have a status ‘0’ for NO MODIFIER ALLOWED:

Modifier 50 Bilateral »Exact same procedure or test done bilaterally »1 unit of service, 1 line item »Increased fee to cover both sides »Not to be reported if test includes unilateral and or bilateral **some payers prefer two separate line items one with an RT and one with an LT

Modifier SL Rationale »Drug cannot be billed for, as state has already supplied it to the organization »Drug code is reported so they can tell which vaccine is being given »Payment is made for Administration of that drug and the SL modifier shows it was state supplied vaccine so they should only pay for admin »If patient OVER age 19 or has commercial insurance, the SL should NOT be used

Modifier U1, U2, U3 MEDICAID »By HCPCS definition the U modifier identify Medicaid level of care »In IN, Medicaid utilizes them on pregnant patients to identify the trimester U1First trimester U2Second trimester U3Third trimester **should be used with all claims that have a Z34.XX code ***just a note, Z33.1 should never be primary

Modifier 80 vs 62 80Assistant at Surgery »One physician helps another physician during the course of surgery »Separate OP note is not needed HOWEVER, OP note must show what medically necessary role the assistant performed; can’t just be a name in the header of the report or use terms such as ‘we’ or ‘us’ »If at location where residents are utilized, residents should be assistants, if none available 82 modifier used instead of 80 »If mid-level is assistant, an AS modifier should be used 62Co-Surgeons »Two distinct surgeons provide portions of the same surgery and need to repot same CPT code »Both surgeons must have separate OP note for their portion »If in same surgery but different CPT codes, modifier 62 no appropriate Impact to reimbursement??

Modifier 76 or 77 76Repeat procedure by same provider »Same service was done twice on the same day, both being medically necessary »Often reporting ‘units’ results in MUE edits or duplicate claim issues »Report on two line items with 76 on the 2 nd ! 77Repeat procedure by different provider »Same as 76 modifier but reporting provider a different member of the group

Modifiers- Misc. (not an exhaustive list) Can capture type of provider »SWservices provided by certified diabetic educator »SBservices provided by a nurse midwife Can capture more specific location »T1left foot, 2 nd digit »E3upper right eyelid Can capture why it is done »H9court ordered Can capture what it is combined with »EP Service provided as part of Medicaid early periodic screening diagnosis and treatment (EPSDT) program OTHER »QWCLIA waived lab test »91repeat clinical lab test Varied uses and information can be captured with modifiers!

Modifiers- Information As with all aspects of documentation; modifier MUST be supported If DENIAL shows a modifier was needed; still must confirm that modifier is appropriate Modifier use is often payer specific with many commercial payers not recognizing all the HCPCS modifiers (most recognize CPT modifiers)

24 Questions ? ? ?

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