Section 2 CONVERSION FACTOR CPT MODIFIERS CCI EDITS Modified For :15 to 10:00 AM 44 Susan Vannoni

Medicare participating fee schedules NIB Fee schedules vary considerably among all the carriers, therefore we only include a few limited fee examples with this work book

Fee Schedule Background The current Physicians Fee Schedule (PFS) system started in PFS pays for covered physicians services under Medicare part B. Relative Value Units (RVU) are assigned to more than 7000 AMA Current Procedural Terminology (CPT) described services. The RVU covers physician work, overhead practice expense, and malpractice. The RVU times Geographic Practice Cost Index, (GPCI) times CF equals physician payment dollars. 5

The Medicare conversion factor has been calculated each year based on the Gross Domestic Product Index using the Sustainable Growth Rate formula. Medicare Conversion Factor 5 5

The National Conversion Factor is that number assigned by CMS which, when multiplied by the RVU, results in the dollar value of the procedure as allowed by Medicare The National Conversion Factor is that number assigned by CMS which, when multiplied by the RVU, results in the dollar value of the procedure as allowed by Medicare EXAMPLE: EXAMPLE: If the professional RVU is 2.50 If the professional RVU is 2.50 And the technical RVU is 5.25 And the technical RVU is 5.25 Then the global RVU is = 7.75 Then the global RVU is = 7.75 If the current conversion factor is $34.02, therefore; If the current conversion factor is $34.02, therefore; 7.75 X $34.02 = $ global payment National Conversion Factor 5

Conversion Factor 2008 it was increased to $ it was increased to $ The CF dropped to $ The CF dropped to $ , To prevent the scheduled -20% reduction, the CF was temporarily set at $ , To prevent the scheduled -20% reduction, the CF was temporarily set at $ , set at $ , the CF had not been this low since 1997! 2012 set at $ set at $ % reduction due to sequestration Frozen at $ /90

The AMA’s Current Procedural Terminology (CPT) has been published since 1966, starting just 2 years after Medicare became law. The standardization of nomenclature by CPT has unified professional and hospital billing throughout the health care industry. CPT and ICD9-CM NIB

Seventy two specific radiation oncology codes exist Seventy two specific radiation oncology codes exist Of these codes Hospitals or centers for radiation therapy may report 28 technical-only codes Of these codes Hospitals or centers for radiation therapy may report 28 technical-only codes The radiation oncologist has access to all series E /M Codes The radiation oncologist has access to all series E /M Codes The radiation oncologist may also utilize other specific codes from other specialties The radiation oncologist may also utilize other specific codes from other specialties Radiation Oncology CPT Codes Section 2, pages 1-4 6/90

Categories of CPT-4 codes Category I codes. These are currently active common use codes, 5 digit #, (77334) Category II codes. These codes are supplemental tracking codes, used for performance measures, an alpha and 4 digits, (G0243) Category III codes. These codes are for emerging technologies, and are used for tracking usage, 4 digits and an alpha ( 0083T) 2 NIB

The Index of CPT Procedures is covered on pages 2.01 to The CPT codes are followed by the CPT descriptors and the section of the User’s Guide where they may be found. Covered by pages

Modifiers for use in Radiation Oncology Covered by pages

One of the most misunderstood, and consequently under-utilized sections of CPT, is the portion dealing with modifiers. These are some of the most common modifiers that are likely to be useful in radiation oncology. Modifiers 7

Modifiers Selected By BMSi Seminars As Most Applicable To Radiation Oncology Billing 7

- 22 Increased Procedural Service “substantially” greater This modifier is used when the work required is “substantially” greater than the services usually required for the listed procedure. In radiation oncology, -22 would be appropriate for attaching to the more complex of the various codes such as: , , or , , 77427, or , and Detailed, written explanation and documentation of the reason for the extra work is required. -22 Modifier Covered by page 8

9 Modifier -22

- 25 Significant separately identifiable Evaluation & Management Service by the same physician on the day of a procedure significant separately identifiable E&M service The physician needs to indicate that on the day a procedure or service was performed, the patient’s condition required a significant separately identifiable E&M service. This circumstance may be reported by adding the modifier –25 to the appropriate level of E&M service. -25 Modifier Covered by page 9

An example is a fiberoptic endoscopy (31575) done on the day of a follow-up exam. You should bill this as: Follow-up Visit endoscopic examination of the larynx. the larynx. -25 Modifier Covered by page 9

Another example was the use of any up front code done on the day of the initial evaluation, , , , You should bill this as: Initial office visit 77263Complex treatment planning ruling This was a ruling ( ) to allow “set and treat”, or just getting started on the initial set up situations in radiation therapy -25 Modifier 10

– 25 may not work Starting in 2013 many of the carriers have started to bundle all procedures done on the day of an initial evaluation or follow-up examination into the value of the E/M procedure. CHECK YOUR 2013 LCD See, set, start, and treat may no longer be possible without considerable loss of revenue. THIS USE MAY NO LONGER BE AVAILABLE. CHECK YOUR 2013 LCD Section 5

- 26 Professional Component When the physician component is reported separately from the technical service, the service must be identified by adding the Modifier -26 to the procedure code. This will apply to almost all of the physician's billing in a hospital setting. The hospital will be billing the technical component to the APC utilizing the same CPT codes but without the - 26 modifier. -26 Modifier Covered by page 10

WHY NO -26 NEEDED? professional only , 77427, 77431, 77432, 77435, and all 99XXX codes are professional only, so no professional modifier needed. technical only 77336, 77370, 77371, 77372, 77373, , 77422, 77423, , are all technical only codes, so no professional component available. both components All the rest have both components, so the -26 is needed to indicate professional only billing NIB

- 52 Reduced Services This code is used to downgrade the charge for a procedure that is being performed at less than the usual intensity. Modifier -52 is not recommended for use in radiation therapy except when a procedure has been terminated early and is incomplete. -52 Modifier Covered by page 11

- 58 modifier -58, staged or related procedure or service by the same physician during the post op period Most commonly used for multiple HDR procedures on same date of service Page 12

-59 Modifier -59, Distinct Procedural Service. Used to indicate that a procedure or service was distinct from other services performed on the same day When multiple procedures are performed on the same date, and a CCI edit has a ”1”, this modifier may be used to identify the secondary or lesser procedures that may be billed utilizing the same original CPT codes. May be used with E/M code and other procedure May be used for repeat HDR procedures. May be required for BID treatment delivery codes Covered by page 12

-59 Modifier Use the 59 modifier only when you are seeking to unbundle a NCCI edit, and no other modifier works. When repeating the same service on the same patient, on the same date, use modifier 76 after the 1st procedure.

-76 Modifier -76, Repeat procedure by the same physician on the same date of service When multiple procedures are performed on the same date, and a CCI edit has a ”1”, this modifier may be used to identify the secondary or lesser procedures that may be billed utilizing the same original CPT codes. This modifier may be required by your carrier for services such as 77300, 77334, and which may be multiple on the same date Page 14

The -GC modifier is used when services are performed in part by a resident and under the direction of a teaching physician. The -GE modifier is used when a service is performed by a resident without the presence of a teaching physician. These modifiers should accompany each code that is reported. If a resident is not present when the procedure is done, these modifiers would not be used. -GC – GE Modifiers Covered by page 14

Proper notation of involvement of the resident in the direct care of a patient 15

When any modifier is being used, with the exception of -26, GC or GE modifiers, your claim may subject to Carrier review. When appealing the claim, it is strongly recommended that a detailed report be attached to the bill explaining the necessity for the additional procedure. Detailed Report Needed 15 36/90

Physician Cross Coverage A series of examples are in your book related to two Radiation Oncology Physicians, DR GREEN DR BROWN and the complex set of rules related to how physicians may cross cover for each other under various scenarios. 16

-Q5 MODIFIER two unrelated practices. The –Q5 is used for reciprocal billing between two unrelated practices. -Q5 Services provided by a substitute physician. Reciprocal billing is for out of the department, time off, weekend or other on call between two unrelated practices of the same or similar specialties. If Dr Green’s patients are seen by Dr Brown, those cases will be billed by Dr Green using the –Q5 modifier, very similar to a locums arrangement, but only a letter of understanding is required. 17

-Q6 MODIFIER The -Q6 modifier is used to indicate the services of a locum tenens physician The covered physician must be absent from the practice A written contract is required. Service is limited to 60 continuous days 17

The requirements for submission of claims under locum tenens billing are the same as regular claims submission. The locums’ physician is paid a contract value for services performed, or per diem All codes requiring the Q-5 or Q-6 modifier are submitted under the NPI of the covered physician 17

LOCUMS SIGNATURE REQUIRED WITH REGULAR ATTENDING PHYSICIAN SIGNATURE 18

NATIONAL CORRECT CODING INITIATIVE EDITS (CCI) This is Medicare's editing software that bundles code combinations to limit payment of these codes on the same date of service This is Medicare's editing software that bundles code combinations to limit payment of these codes on the same date of service Covered by pages 19 46/90

The rules of CCI edits are supposed to apply only to services performed on the same date for the same patient by the same physician If an edit exists, and the proper modifier is not used on one of the codes, the claim will be denied payment 19

Code Pair Combinations Mutually exclusive code pair edits Comprehensive component code pair edits Three CCI indicators are used “0” “1” “9” 20

“0” Indicator A “0” marked on a code edit signifies that these code combinations should not be billed together and that only one will be paid regardless of any circumstance or modifier. An example is vs ”0”. 20

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“1” indicator codes could be billed on the same date of service if a modifier is appropriately used. The most common modifiers are a -59 (distinct procedural service), or -76 (repeat procedure by same physician) No modifier is used on the first report, but used on all subsequent reports (77334, ) 20

“9” Indicator The modifier “9” indicator typically means that the mutually exclusive edits, which previously applied, have been deleted. An example of codes that were once mutually exclusive is: An example of codes that were once mutually exclusive is: vs ”9” effective 4/

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MEDICALLY UNBELIVEABLE MEDICALLY (UNLIKELY) EDITS MUE’s apply a unit of service limit to virtually every CPT code MUE’s apply a unit of service limit to virtually every CPT code Similar to CCI, but originally no modifier override Similar to CCI, but originally no modifier override May now try -55, -76, -77, -59, but generally is still denied. Modifier GD wont work. May now try -55, -76, -77, -59, but generally is still denied. Modifier GD wont work. Exceed a MUE, and the service is denied Exceed a MUE, and the service is denied The purpose of MUE is to prevent “ billing errors from incorrect entry or misunderstanding interpretation of codes” The purpose of MUE is to prevent “ billing errors from incorrect entry or misunderstanding interpretation of codes” 22

Comments by D. Scott Simmons, HOW TO USE NCCI ON-LINE Teaches you how to use the government web site for old, current, and new rules and regulations. See the last section of the book 23

PRINCIPLES OF BILLING, CODING AND COMPLIANCE IN RADIATION ONCOLOGY BMSi 2014