Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 1 CHAPTER 14 MODIFIERS

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 2 CPT Modifiers Used to describe alterations to CPT code Full list, CPT, Appendix A

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 3 Modifier Functions Altered (i.e., more or less) Bilateral Multiple Only portions of service (i.e., professional service only) More than one surgeon Unusual service

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide Increased Procedural Service Indicates services significantly greater than usual Accompanied by written report with supportive documentation Describes increased physician work

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide Unusual Anesthesia Use of anesthesia where no anesthesia or local would be the norm –Example: Highly agitated senile patient Only used with anesthesia codes Written report with submission of modifier may be required

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide Unrelated E/M Services by Same Physician During a Postoperative Global Period E/M Service not related to surgery is separately billable –Use -24 on E/M code only –If E/M provided during post-op global period, no separate payment for E/M related to surgical procedure –Example: Patient is in global period for hip surgery and is now seen for a fractured collarbone

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide Significant, Separately Identifiable E/M Service, Same Physician and Same Day of Procedure or Other Service Documentation must support service –Example: Patient seen for sinus congestion, physician performs H&P, prescribes decongestant, notes lesion on back, and removes Code: Procedure + E/M-25 –Example: A patient seen on consultation by pain management and subsequent to rendering an opinion was given a nerve injection. Modifier -25 is placed on E/M code

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide Professional Component Professional component (physician, -26) Technical component (technician + equipment, -TC) Example: Radiologist reviews x-rays (-26) taken by supervised technician (-TC)

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide Mandated Service Mandated by payer, workers’ comp, or official body Not request of patient, patient’s family, or another physician –Example: Workers’ Comp requests examination of person currently receiving disability benefits

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide Preventive Services New in 2012 CPT Patient Protection and Affordable Care Act of 2010 requires coverage without cost United States Preventive Services Task Force grades preventive services –Grade A: substantial –Grade B: moderate

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide Anesthesia by Surgeon Physician administers regional or general anesthesia –Acts as surgeon & anesthesiologist Only used with Surgery codes No separate payment when used on Medicare patients

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide Bilateral Procedure Bilateral –Example: Procedure on hands Caution: Some codes describe bilateral procedures; in these cases do not apply modifier -50

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide Multiple Procedure—Three Types Same Procedure, Different Sites –Example: Multiple lacerations repaired Multiple Operation(s), Same Operative Session Procedure Performed Multiple Times –Example: Trigger point injections (20552) (Cont’d …)

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide Multiple Procedure (…Cont’d) List most resource intense first (highest RVU value) Next other procedure(s) (unless code is - 51 exempt or an add-on code) Usual payment: 1 st procedure 100%, 2 nd 50%, 3 rd 25% Medicare: 1 st procedure paid 100%, 2 nd –5 th paid 50%, more than 5, priced manually

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide Reduced Services Service reduced from code description Physician directed reduction Documentation substantiates reduction Not for patients unable to pay fee Submit full charge, payer will adjust –Example: Lip shave (40500) but advancement flap not performed =

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide Discontinued Procedure Surgical/diagnostic procedures Started then stopped due to patient’s condition Does not apply to presurgical discontinuance (Cont’d…)

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide Discontinued Procedure (…Cont’d) DO NOT USE -53 WHEN: –Patient cancels scheduled procedure –With E/M codes –With time-based code

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide Surgical Care Only Physician provides only procedure (intraoperative) Documented patient transfer must be in record –Some payers require copy of transfer

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide Postoperative Management Only Physician provides only care after hospital discharge –If transferred while patient hospitalized, report postop management with subsequent hospital codes Documentation of transfer in medical record Surgery code billed with -55 modifier and surgery date of service Bill after first postoperative visit

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide Preoperative Management Only Physician provided only preoperative care Not acceptable for Medicare –Requires surgical code with modifier -56

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 21 Usual Reimbursement for Portions, Surgical Package 10% preoperative 70% intraoperative 20% postoperative Each payer determines portions

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide Decision for Surgery Used With E/M, Medicine, ophthalmologic services Medicare: Only for preop period of major surgery (day before or day of) –90 day global

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide Staged/Related by Same Physician During Postoperative Period Subsequent procedure planned or related to the first surgery –During postop of previous surgery in series –Example: Multiple skin grafts completed in several sessions –Global period starts over (Cont’d…)

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide Staged/Related by Same Physician During Postoperative Period (…Cont’d) Do not use when code describes a session –Example: 67208: lesion destruction of retina, one or more sessions

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide Distinct Procedural Service Different session or encounter Different procedure Different site Separate incision, excision, lesion, injury Do not use when another HCPCS modifier is appropriate (Cont’d…)

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide Distinct Procedural Service (…Cont’d) Example: Physician removes several lesions from patient’s leg, also notes and biopsies a mole of torso –Biopsy code for mole –Indicates biopsy distinct procedure, not part of lesion removal

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide Two Surgeons Both function as co-surgeons (equals) Usually different specialties Each surgeon reports same surgery code appending -62 Each surgeon dictates his/her portion of procedure

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide Procedure Performed on Infants Less Than 4 kg Kilogram: 2.2 lb (4 kg = 8.8 lb) Small size increases complexity Use with all Surgery section codes except Integumentary and those exempt by parenthetical notes

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide Surgical Team Team: Several physicians (3 or more) with various specialties plus technicians and other support personnel Very complex procedures Payers may increase payment

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide Repeat Procedure/Service by Same Physician Note: “Same Physician” Used to indicate necessary repeated service, not typographical error –Example: X-rays before and after fracture repair –Aerosol treatment for an asthma attack repeated in 90 minutes ( )

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide Repeat Procedure/Service by Another Physician Note: “Another Physician” Performed by one physician, repeated by another physician Submitted with a written report to establish medical necessity may be requested

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide Unplanned Return to Operating/Procedure Room Same Physician Following Initial Procedure for a Related Procedure During Postoperative Period For complication of first procedure –Example: Patient has outpatient procedure in morning, was returned to operating room in afternoon with severe hemorrhage Indicates not typographical error Does not change global period time

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide Unrelated Procedure or Service by Same Physician During Postoperative Period Example: Several days after discharge for procedure, patient returns for an unrelated procedure/service –Diagnosis would be different –Remember the E/M code would have -24 –If surgery is unrelated to original procedure, a new global period starts

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide Assistant & -81 Minimum Assistant Surgeons -80 Assistant –Reimbursed at 15–30% –Payers identify procedures for which they reimburse assistant -81 Minimum Assistant Surgeon –Services at a level less than that described in -80 (Assistant Surgeon) –Reimbursed at 10%, if at all

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide Assistant Surgeon Teaching hospitals: –Have residents who assist as part of education—no fee, no modifier -82 –Must demonstrate no qualified resident available Unavailability documented in written report

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide Reference (Outside) Laboratory Physician has business relationship with outside lab Physician pays lab Physician bills payer for lab services Cannot use for Medicare

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide Repeat Clinical Diagnostic Laboratory Test Repeat same laboratory tests on same day for multiple test results Not tests rerun to confirm original test results Not malfunction of equipment or technician error

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide Alternative Laboratory Platform Testing Indicates kit or transportable instrument Usually single use, disposable Example: 86701, HIV test kit

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide Multiple Modifiers Used when service needs more than one modifier but payer only allows for one modifier with each code

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 40 CMS-1500 Figure: 14.2 CMS-1500 (08/05) has places for multiple modifiers

Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 41 Conclusion CHAPTER 14 MODIFIERS