1. -25 -76 -73 -XS -59

2.  As part of your job as a coder you may be assigning: …….and just when you think you have it all figured out and there couldn’t possibly be anything else to keep track of, you find out there are these things called…. Diagnosis codes CPT codes ICD Procedure codes HCPCS codes WHAT !!

3. But, once you understand – Then you’ll see how easy they will become to apply.  Why they were developed  The categorized modifier groups  What situations to apply them in…. Clap your hands say yeah..

4.  Understand why modifiers were developed  Be familiar with the different categories of modifiers  Understand the guidelines for applying modifiers  Be able to successfully apply modifiers to case scenarios “ Once you learn to quit, it becomes a habit ” ~ Vince Lombardi ~

5.  The answer to WHO created the NCCI edits is Medicare (CMS) CMS started using the National Correct Coding Initiative (NCCI) in January 1996. The policies that control the edits were derived from several areas of knowledge. This information was used to determine which procedures could be coded together (charged on claim) and those procedures that would never be performed together. Medical Community Current Coding Conventions Coding Guidelines National & Local Medicare Policies (NCDs / LCDs) Standard Surgical Best Practices Standard Medical Best Practices

6.  WHO is required to follow the NCCI policies? …….So, pretty much everybody except Inpatient Services NCCI Edit Adherence Physicians & Non- Physician Practioners Ambulatory Surgery Centers Outpatient Therapy Services Home Health Agencies Comprehensive Outpatient Rehab Facilities Hospital Outpatient Services Skilled Nursing Facilities

7.  WHAT Do They Look Like?  Modifiers are two characters long and usually numeric but some are alpha numeric. 25, 77, 50, 22, F4, FA, LC, T6, QN, E1, XU  WHAT Do They Do?  They give extra info of how, when and why a procedure was performed. 33 – Preventative Services 57 – Decision for Surgery  Tell us where on the body the procedure was performed. RT – Right leg LD – Left anterior descending coronary artery (used in hospitals for coronary proc.)  Give us details on extenuating circumstances of the procedure. 77 – Repeat procedure by another physician 74 – Discontinued procedure after anesthesia administered  They can allow for increased or decreased reimbursement. 22 – Increased procedural service 52 – Reduced Services

8.  WHY were the National Correct Coding Initiatives Developed? This may come as no surprise, but the answer is “Money”……. Medicare realized a need for the control of improper coding which was leading to CMS making improper claim payments to providers. Because of this, “code pair edits” & MUE (Medically Unlikely Edits) were developed. Code pair edits were made to prevent certain codes from being submitted together on a claim. MUE edits were developed to prevent multiple units of certain CPT codes from being billed. The edit will tell you if a modifier can be added to allow for separate payment. You can add the modifier and get a separate payment if certain criteria are met. No, there is never a modifier that can be added to get paid separately.

9.  NCCI Edit Types The edits are a “warning” to “STOP” and take a look to verify the CPT’s coded are correct. 1 st Code Pair Edits  Appear when certain code pairs appear together on a claim for the same patient on the same date of service.  Modifiers can be added to reflect why the two CPT’s are being submitted together OR after review, correction of the CPT’s can be made prior to claim submission. 2 nd MUE’s – Medically Unlikely Edits  Appear when an inappropriate multiple units of service are charged for the same patient on the same date of service.  Reflects that it is “unlikely” or “unreasonable” that the units of service billed is correct OR that it exceeds Medicare’s allowed units of service to be billed.

10.  Many CPT codes include procedures (like imaging) that also have a separate CPT that can be added in error by the department where the procedure was performed. 49083 – Abd paracentesis with imaging guidance 76942 – Ultrasound guidance for needle placement By reading the description of these two codes, we can see that it would be inappropriate to submit both of these codes together on a claim – 49083 includes any imaging guidance. Prior to the NCCI edits development, CPT combinations like the ones above, could have been submitted together on a claim and receive payment for each, which would in fact be an “over payment”. Now with the automated edits, a message like the one below in red, will appear to alert you of this error.

11.  Another example of the this would be adding a CPT code for a service that is an inherent part of a procedure. Coding for surgical access or closure when a procedure is performed – the access & closure of the surgical wound is an inherent part of the procedure and so are not coded separately. This will result in an edit like the one below. It would NOT be appropriate to add a modifier to CPT 12002 simply to “pass” the edit. It is your job as the coder to use your best judgement in deciding if a procedure is an integral part of the more “comprehensive” treatment which is being billed. In this case the CPT that was billed in error should be removed according to client protocol.

12. Another type of NCCI Edit that may occur is when two procedures are coded that should NEVER be billed together. This will result in the edit example below. For Example: If a Lab Draw was done and CPT’s were added for both “with manual differential” and “without manual differential”, this is the edit that you will see. NOTE: When this edit appears, there is NO modifier that should be added. This edit indicates that these two procedures simply CANNOT be billed together. In this case the CPT that was billed in error should be removed according to client protocol.

13.  MUE (Medically Unlikely Edits) occur when the Units of Service (UOS) are over the accepted limit for that CPT. CMS has set a “unit” limit on many CPT’s (but not all) to prevent duplicate and unlikely payment for services.  The pre-determined limits are set for the maximum number of units that a provider would report under most circumstances for a single beneficiary on a single date of service.  This “limit” has been set based on the code descriptions, CPT Chapter coding instructions, anatomic considerations, nature of the procedure and clinical judgement. Example of a MUE Edit: It gives an alert which is based on the Reported Units of Service (2), that it is “unlikely” the patient had two left heart catheterizations on the same date of service. If the edit is left as is, this will result in denial and no payment will be received for the heart catheterization at all. NOTE:In this situation, one of the units of this CPT would need to be removed following client’s protocol. MUE Edits

14. There are different modifiers to apply depending on whether you are coding for the physician or in the facility (hospital) setting. The following screens review modifiers that are for use in the hospital setting. 1 st Group – Modifiers used in conjunction with an E/M code Modifiers 25 & 27 ModifierDescription 25Identifies a significant separate evaluation and management (E/M) services provided on the same date as a procedure or other service. Example: ER visit with a laceration repair. Modifier 25 is added to the ER E/M code. 27Added when multiple E/M visits occur on same date of service. (This can occur in ER when a patient comes twice in 1 day or if billing has moved an E/M from another department in the facility onto the encounter you are currently coding. NOTE: Modifier 25 & 27 are ONLY applied to E/M codes

15. Here is an example of a Modifier 25 Edit. This indicates that Modifier 25 needs to be added to the E/M since there is also a “S” status code on same date of service (29505). NOTE: Modifier 25 is ONLY added the E/M codes. It would NEVER go on the associated Status ”S” or Status “T” code.

16. Another set of modifiers are used in conjunction with CPT codes when a procedure has been performed. Below are some of the more frequently used modifiers with procedure CPT’s. 2 nd Group – Modifiers used in conjunction with operative CPT’s ModifierDescription 50Bilateral procedure - Example: ER visit with removal of foreign body from both ears. Modifier 50 would be added to 69200 “removal of foreign body from ear” 52Reduced Service - Added when only a portion of a service described by the CPT is performed and there is no other CPT to describe the reduced procedure. Modifier 52 would be added to the CPT indicating that not all of the components of the described procedure were performed. 73Discontinued outpatient procedure prior to anesthesia administration - The CPT of the planned procedure is coded with the addition of modifier 73. 74Discontinued outpatient procedure after anesthesia administration - The CPT of the planned procedure is coded with the addition of modifier 74.

17. The 3 rd set of modifiers are used in conjunction with Radiological Services. When a Radiology Service is performed more than once, on the same date of service, then a modifier from this group would need to be added. 3 rd Group – Modifiers used in conjunction with radiology CPT’s ModifierDescription 76Repeat radiology procedure by same physician- Example: Observation visit due to pleural effusion. Chest x-ray is performed twice on the 1 st date of service to monitor the lungs. If the chest x-rays were performed by the same physician, then modifier 76 is added to only the repeat radiology CPT code, (i.e. 71010, 71010-76). 77Repeat radiology procedure by different physician - same example as above, but a different physician performs the service.

18. This modifier is ONLY used in conjunction with laboratory services. When the same lab test is performed on a patient, multiple times on the same date of service, then modifier 91 needs to be added to only the repeat laboratory CPT codes ( i.e., ). 4 th Group – Modifiers used in conjunction with Laboratory Tests ModifierDescription 91 Repeat Clinical Diagnostic Laboratory Test- This does not apply to tests performed to simply confirm a lab result. Example: ER visit due to uncontrolled diabetes. Insulin is administered and patient is monitored and advised to follow up with their primary physician. Lab draws were taken to monitor patient’s glucose during the encounter. If the same lab test was performed, multiple times then only the repeat CPT’s would have modifier 91 added (i.e., 82947, 82947-91, 82947-91).

19. This last modifier has always been the topic of MUCH discussion… Modifier 59. In January 2015, modifier 59 was expanded to include the addition of 4 sub-sets; XE, XS, XP & XU – these are referred to as the “X” modifiers and are to be used instead of modifier 59 if the situation applies. Why was this change brought about?  Modifier 59 was being too broadly applied - Many coders simply used this modifier to bypass the NCCI edit – not in a fraudulent manner, but because there was a lack of understanding of what the addition of the modifier was doing…..which is over payment of services to the provider.  Abuse & Fraud - Modifier 59 has been tracked by Medicare for a long time and they have found considerable abuse with its use, where it was applied by some to knowingly get paid for both procedures.  Need for more specificity when both codes should be paid - NCCI edits were originally developed to prevent unbundling and overpayments. But it was also know that there are times when both CPT’s effected by an edit should be billed and this is why modifier 59 was created. However, up till now there has been no way to track the reason why both CPT’s should be paid. With the addition of the “X” modifiers, there will be better tracking for data trending. NOTE: The “X” modifiers are used INSTEAD of mod. 59 when the situation applies. You would never add both an “X” modifier AND a 59 modifier – it is either one or the other.

20. Modifier 59 sub-sets  XE – Separate Encounter This is used instead of modifier 59 to describe separate encounters that occurred on the same date of service. Example - a patient comes in via ER, some type of procedure is performed in ER and then patient is sent to observation where subsequently another procedure is performed. If an NCCI edit appears on the CPT’s in question, then the addition of modifier XE would be appropriate.  XS – Separate Structure This is used instead of modifier 59 to describe two or more procedures that are performed on the same date of service but were performed on a separate organ or body structure. Example – two separate cultures are taken, at different locations (i.e. forearm & knee). The same culture test is run for both. If an NCCI edit appears on the Pathology CPT’s, then it would be appropriate to apply the XS modifier.

21. Modifier 59 sub-sets (con’t)  XP – Separate Practitioner This would be used instead of modifier 59 to describe services that are distinct & separate because they were performed by different practitioners. There is still a lot of discussion on the particular use of this new “sub-set”. Just know that it is there - however the situations for its use is rare compared to the other “X” modifiers  XU – Unusual Non-overlapping Services This would be used instead of modifier 59 to describe services that are distinct because they are not part a component of the main service. This new “X” modifier will likely be the most used. Example: A patient presents to ER with acute back pain. An injection is administered to help alleviate the pain. Patient is then sent to radiology where a CT with contrast of the spine is performed. This will cause an NCCI edit because an injection of contrast given during the CT is a component of the CT. However, since the injection that is being reported is for the injection of pain meds in the ER, modifier “XU” can be added to the injection code to reflect that it is separate from the CT.

22.  Modifier 59 can still be used at this point, BUT with the instruction that it should only be used if a more specific “X” modifier doesn’t apply. “X” marks the Spot !!

23. The last category of modifiers in this review are referred to as “anatomical”. This is because they give specificity to the area of the body that a procedure was performed. (big toe, left ring finger, right leg etc.) These modifiers do not effect payment but when applied, provide a better description of what was done.  Right (RT) / Left (LT) – this which arm or leg had a procedure done when a patient presents with a fracture.  Eyelids – E1 (upper left), E2 (lower left), E3 (upper right), E4 (lower right)  Left Hand Digits – FA (thumb), F1 (2 nd digit), F2 (3 rd digit), F3 (4 th digit), F4 (5 th digit)  Right Hand Digits – F5 (thumb), F6 (2 nd digit), F7 (3 rd digit), F8 (4 th digit), F9 (5 th digit)  Left Foot Digits – TA (great toe), T1 (2 nd digit), T2 (3 rd digit), T3 (4 th digit), T4 (5 th digit)  Right Foot Digits – T5 (great toe), T6 (2 nd digit), T7 (3 rd digit), T8 (4 th digit), T9 (5 th digit)

24.  The correct application of modifiers is as important as the correct application of diagnosis codes and CPT procedure codes. They effect payment and help to provide a clear picture of what has occurred during an outpatient encounter.  It is your responsibility as a coder to know the “tools of your trade” and know their correct application.  Take the time to know the modifiers and their correct application and you will become a better coder because of it.