Provided by Coventry Health Care ©2011 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care. Usual and Customary Medical Bill Reviewer Training Program Unit 1 Module 1: General Guidelines Allowable Codes Billed With Other Codes

Usual & Customary Training – General InformatonJuly 2011 Overview Hello again… lets continue our journey in exploring the U&C guidelines. In this unit well discuss allowed codes, modifiers and reports. Part I: General Information Allowed Codes Physical Status Modifiers Unlisted Procedures Special Reports

Usual & Customary Training – General InformatonJuly 2011 Allowable Codes There are codes that may be appropriately billed with other procedure codes on the same bill. The complete list of codes can be found in Appendix A of the U&C State Reference Guide (SRG). Here is a small example of the codes. The following codes may be billed in conjunction with other codes…

Usual & Customary Training – General InformatonJuly 2011 Physical Status Modifiers (P1 through P6) Anesthesia modifiers are used to distinguish between various levels of complexity of the anesthesia services provided. These modifiers require a report in order to substantiate giving the extra units. If billed, key the modifier in the Modifier (s) field.

Usual & Customary Training – General InformatonJuly 2011 If the necessity of the services has been verified, and the service authorized, additional information may be requested about the procedure, or an online search may be performed. Unlisted Procedures Every effort should be made to identify the service performed with a specific code rather than an unlisted procedure. The unlisted code billed may represent a slightly different version of an established code which would still be appropriate.

Usual & Customary Training – General InformatonJuly 2011 Unlisted Procedures Every effort should be made to identify the service performed with a specific code rather than an unlisted procedure code. As you know, providers often misuse the unlisted code when a more appropriate code is available. Hmm, which code should I use?

Usual & Customary Training – General InformatonJuly 2011 Special Reports Special Reports (CPT 99080) are reports specifically requested by the insurer. These are the only payable reports and are reimbursed at 80% of Usual and Customary. Special Reports

Usual & Customary Training – General InformatonJuly 2011 Modifiers Modifiers indicate that a procedure was altered by additional circumstances, but was not changed from its standard definition. Modifiers may indicate circumstances such as: Only part of the whole procedure was performed. A bilateral procedure was performed. Modifiers are covered in the context of billed codes.

Usual & Customary Training – General InformatonJuly 2011 Stated previously, modifiers indicate that a procedure was altered by additional circumstances, but not changed from its standard definition. Lets take a look at examples of U&C States modifiers: Modifiers Keep in mind, the system is programmed to recognize some defined limitations on the modifiers. It will set an event code if the modifier used is inappropriate for the procedure code or type of service code. ModifierDescription 25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service 27 Multiple Outpatient Hospital E/M Encounters on the Same Date 50 Bilateral Procedure 52 Reduced Services 58 Staged or Related Procedure or Service by the Same Physician During the Postoperative Period

Usual & Customary Training – General InformatonJuly 2011 Summary Description of separate procedures and unlisted procedures. Defined special reports. Circumstance of Modifier use.