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

2. 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

3. 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

4. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 4 -22 Increased Procedural Service Indicates services significantly greater than usual Accompanied by written report with supportive documentation Describes increased physician work

5. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 5 -23 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

6. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 6 -24 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

7. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 7 -25 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

8. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 8 -26 Professional Component Professional component (physician, -26) Technical component (technician + equipment, -TC) Example: Radiologist reviews x-rays (-26) taken by supervised technician (-TC)

9. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 9 -32 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

10. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 10 -33 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

11. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 11 -47 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

12. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 12 -50 Bilateral Procedure Bilateral –Example: Procedure on hands Caution: Some codes describe bilateral procedures; in these cases do not apply modifier -50

13. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 13 -51 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 …)

14. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 14 -51 Multiple Procedure (…Cont’d) List most resource intense first (highest RVU value) Next other procedure(s) + -51 (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

15. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 15 -52 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 = 40500-52

16. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 16 -53 Discontinued Procedure Surgical/diagnostic procedures Started then stopped due to patient’s condition Does not apply to presurgical discontinuance (Cont’d…)

17. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 17 -53 Discontinued Procedure (…Cont’d) DO NOT USE -53 WHEN: –Patient cancels scheduled procedure –With E/M codes –With time-based code

18. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 18 -54 Surgical Care Only Physician provides only procedure (intraoperative) Documented patient transfer must be in record –Some payers require copy of transfer

19. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 19 -55 Postoperative Management Only Physician provides only care after hospital discharge –If transferred while patient hospitalized, report postop management with subsequent hospital codes 99231-99233 Documentation of transfer in medical record Surgery code billed with -55 modifier and surgery date of service Bill after first postoperative visit

20. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 20 -56 Preoperative Management Only Physician provided only preoperative care Not acceptable for Medicare –Requires surgical code with modifier -56

21. 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

22. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 22 -57 Decision for Surgery Used With E/M, 99201-99499 Medicine, 92012-92014 ophthalmologic services Medicare: Only for preop period of major surgery (day before or day of) –90 day global

23. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 23 -58 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…)

24. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 24 -58 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

25. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 25 -59 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…)

26. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 26 -59 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 + -59 –Indicates biopsy distinct procedure, not part of lesion removal

27. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 27 -62 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

28. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 28 -63 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

29. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 29 -66 Surgical Team Team: Several physicians (3 or more) with various specialties plus technicians and other support personnel Very complex procedures Payers may increase payment

30. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 30 -76 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 (94640-76)

31. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 31 -77 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

32. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 32 -78 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

33. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 33 -79 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

34. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 34 -80 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

35. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 35 -82 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

36. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 36 -90 Reference (Outside) Laboratory Physician has business relationship with outside lab Physician pays lab Physician bills payer for lab services Cannot use for Medicare

37. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 37 -91 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

38. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 38 -92 Alternative Laboratory Platform Testing Indicates kit or transportable instrument Usually single use, disposable Example: 86701, HIV test kit

39. Copyright © 2012, 2011, 2010, 2009, 2008, 2007, 2006, 2005, 2004, 2002 by Saunders, an imprint of Elsevier Inc. Slide 39 -99 Multiple Modifiers Used when service needs more than one modifier but payer only allows for one modifier with each code

40. 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

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