Modifier Mania Presented by: Pat Cox, COC, CPC, CPMA, CPC-I, CEMC Lisa Deel, CPC, CEMC, COBGC Denise Taylor, CPC, CEMC, CGSC

Increased Procedural Services Modifier 22 Increased Procedural Services

Modifier 22 Use this modifier when the work required to provide a service is substantially greater than typically required. It may be identified by adding modifier 22 to the usual procedure code Documentation must support the Substantial additional work and reason for the additional work ie, increased intensity, time, technical difficulty of the procedure, severity of patient’s condition, physical and mental effort required What type of documentation would support use of the modifier -22? (Increased risk to the patient caused by complications, difficulty of the procedure, excessive blood loss, or other circumstance that significantly altered the delivery of the service. When the modifier -22 is used, a report must be sent to document why this is an unusual practice.) Because this modifier is overused and because it increases payment by as much as 20%-30%, it is subject to special scrutiny by third-party payers. Its primary purpose is to denote circumstances for which a procedure or service required an “unusual” amount of time or effort to perform. Anatomical variants Trauma extensive enough to complicate the particular procedure and that cannot be billed with additional procedures Significant scarring requiring extra time and work Extra work resulting from morbid obesity

Modifier 22 May be used in these CPT code set sections Anesthesia Surgery Radiology Laboratory and pathology Medicine Not on E&M

Guidelines Use only when work factors requiring the physician’s technical skill involve significantly more Work Time Complexity For surgical and nonsurgical procedures Mod 22 indicates the a procedure was complicated, complex, difficult or took more time than usually required by the provider to complete the procedure. Its use implies that the procedure or service was distinctly more time-consuming or difficult to perform – more c

Guidelines Relative value units for services represent average work effort and practice expenses for a service Increased or decreased payment only under unusual circumstances and after medical records and documentation review Claim submission requirements Written report - concise statement about how the service differs from the usual (Kiss letter) Operative report Manual review common; submit requesting consideration of the claim with the payment increase requested. Even when justified, it may be difficult at best to obtain higher than normal reimbursement form the majority of payers. Send information upfront.

KISS Letter “Kiss Letter” I am requesting special consideration for the operative procedure performed on Patient X on January 12, 2015. I am requesting a payment increase of 25 percent above my usual fee for this procedure, which is proportionate with the extra work effort due to (indicate special condition here) This information needs to be clear and to the point. What made this case more difficult than other cases. Include the op note with areas underlined that show the additional work or complication. Medicare states that they want “a concise statement about how this service differed from the usual.”

KISS Letter Example Letter (Continued): Then, briefly describe the difficult nature of the service Include typical average circumstances vs. actual circumstance Compare to normal time to complete procedure End letter by referencing the OP note

Modifier 22: Example Laminotomy with decompression of nerve root with a partial facetectomy, foraminotomy, and excision of herniated disk During surgery, difficult-to-control hemorrhage requiring 60 additional minutes CPT Code(s) Billed: 63020 22—Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk; one interspace, cervical Physician spent additional time – document normal surgical time in KISS letter. Normal operative time should be included in the letter. For those cases that typically take 1-2 hrs, reimbursement will typically be the same whether it takes 1 or two hours. Reimbursement is based o the average

Modifier 22: Example Using an example of a gallbladder surgery, if a patient has a BMI of 48.4 and had previous upper abdominal surgery such that adhesions in the upper abdomen were extremely dense, the gallbladder was densely adherent to the gallbladder bed on the liver and the surgery time was two and one-half hours, that would be a case where the surgeon is justified in using the 22 modifier and asking for extra reimbursement.

Modifier 22 Don’t assign the modifier if: There is not supportive documentation There is an existing “add on” code available Append to secondary procedures Use for re-operations Unlisted procedures

Tips The physician’s documentation should be thorough. If it does not indicate the substantial additional work, carriers will not increase the fee. The additional work must be significant. Most carrier say that unless 25% more work was performed, then modifier 22 should not be appended. When possible, use the diagnosis codes that further describe the circumstances warranting the use of modifier 22. Use dx codes to support hemorrhage, obesity, adhesions, and other complications.

Tips Modifier 22 should not be overused. Abuse of this modifier will attract unwanted scrutiny by an insurance carrier and may trigger an audit. Medicare has suggested that modifier 22 should be used with fewer than 5 percent of all surgical cases.

Tips Remember not every difficult case merits a modifier 22. The procedure must be unusually difficult in relation to other procedures of the same type. Per the AMA-”Only rare, outlying cases-those that are far beyond the average difficulty-call for modifier 22” Check with your carrier regarding any special requirements.

So what’s not a 22?

Modifier 51 Use modifier 51 Multiple procedures to show that the same provider performed multiple procedures (other than E/M services, Physical Medicine and Rehabilitation services or provision of supplies) during the same session.

Modifier 51 Modifier 51 indicates: The same procedure performed on different sites; Multiple operations during the same session; or One procedure performed multiple times. Key word – “1” “1” encounter or session; “1” procedure; “1” site; or Separate incision, excision, injury, lesion, or body part. Key - “1” “1” site “1” organ “1” session

Modifier 51 Used to identify the secondary procedure, or additional procedures. It is not appended to the primary code. Not appended to “add-on codes” or modifier 51 exempt codes (found in Appendix E of CPT). Refer to the 'Mult Surg' indicator in the Medicare Physician Fee Schedule database (MPFSDB) to determine if CPT modifier 51 is applicable to a particular procedure code.

Reimbursement Rank codes according to the highest relative value unit using the total RVU not wRVU. The primary procedure will be reimbursed at 100% of the allowable 50% of the fee schedule amount for the remaining procedures. Surgical procedures beyond the 5th may priced differently depending on the circumstances and/or carrier. The primary (highest fee schedule allowable) procedure is allowed at 100% Base payment for each ranked procedure based on the lower of the billed amounts 100% of the fee schedule amount for the highest valued procedure 50% of the fee schedule amount for the second- highest valued procedure Surgical procedures beyond the fifth are priced by carrier on a “by-report” basis

Multiple Surgery Reduction Rule Multiple endoscopy payment rules apply for procedure billed with another endoscopy in the same family Endoscopy includes arthroscopy For endoscopy performed on the same day as another in the same family, the payment for the procedure with the highest RVUs is 100% of the maximum allowed fee The maximum allowed fee for every other procedure in the family is reduced by the value of the base code for the family No separate payment for a base procedure when other endoscopies in the same family are performed on the same day

Example of Modifier 51 The patient presents for removal of a 3.5 cm benign skin lesion on the face. A layered closure of the resulting wound is performed in the same operative session. The procedure would be coded as follows: 12052 Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm 11444-51 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 3.1 to 4.0 cm. Per some insurance plans, modifier 51 may be applicable for twin deliveries. Bill 59400 and 594019-51. This is not the case with Anthem or HK Plus.

Modifier 59 Modifier 59 Distinct procedural service indicates a: Different encounter or session; Different procedure; Different site; or Separate incision, excision, injury, lesion, or body part. Indicates that a procedure is separate from another procedure that was done the same day Used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances

Modifier 59 Modifier 59 should be used only if no more descriptive modifier is available and the use of modifier 59 best explains the circumstances should it be used. “Modifier of last resort.” Appending modifier 59 indicates that the procedure is not considered a component of another procedure but is a distinct, independent procedure.

Modifier 59 Some payers do not accept modifiers 51 or 59 Coders should avoid using modifier 59 to simply override a payer edit. Should be used with caution. As a modifier that affects payment and “unbundling”, it is watched closely by payers. Documentation needs to be specific and easy to identify. Use only when no other already established, appropriate modifier available……..

Example from NCCI Book-Surgery: A patient underwent placement of a flow-directed pulmonary artery catheter for hemodynamic monitoring via the subclavian vein (93503). Later in the day, the catheter had to be removed and a central venous catheter was inserted through the femoral vein. CPT Code(s) Billed: 93503-Insertion and placement of flow directed catheter (eg, Swan-Ganz) for monitoring purposes 36010 59-Introduction of catheter, superior or inferior vena cava

Which to use…51 or 59 Were the services performed at separate encounters? – append “59” Did the services involve different sites or organ systems? Separate incisions, excisions? Separate lesions or injuries? Append “59” to the second code, if not append “51

Modifier -59 Subsets New HCPCS modifiers; XE - Separate Encounter, a service that is distinct because it occurred during a separate encounter; 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; and XU - Unusual Non-Overlapping Service, the use of a service that is distinct because it does not overlap usual components of the main service. CMS provides a subset of modifier 59 with HCPCS Level II modifiers. The subset of modifiers are more selective versions of modifier 59 so it would be incorrect to include both modifiers on the same line. So, sticking with the statement…Should be used only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances