Transcript Medicare Modifiers - LSUHSC Shreveport

Medicare Modifiers
Presented by:
Pinnacle Medicare Services
A Medicare Contractor for:
Arkansas, Louisiana, and Rhode Island
Created September 2008
Educational Objectives
• Emphasize the importance of using modifiers
• Become familiar with all Medicare modifiers
• Determine usage of pricing modifiers
• Additional information regarding the Medicare
Physician Fee Schedule indicators
Medicare Physician Fee
Schedule Database
Attachment A
• Status indicators
Attachment B
•
Global periods
Attachment C
• Endoscopy families
Medicare Physician Fee
Schedule Data Base (MPFSDB)
•
•
•
•
•
Status Indicator list
Gives information about specific Codes
Updated quarterly by CMS
Changes listed in Medicare Provider Newsletter
Indicator list in the Publications list on your states
web site.
MPFSDB- Status Indicators
A-Active
C-Carrier determined allowance
D-Deleted Code
H-Deleted modifier
R-Special coverage
T-Injection administration
F-Not valid for Medicare
Medicare Physician Fee Schedule Database
Attachment A (continued)
- Status Indicators
Medicare Physician Fee Schedule Database
• Attachment B
Global Surgery Post-Operative Days and
Percentages
• Attachment C
Endoscopy Families
Global Surgery
Includes
•
•
•
•
•
•
Preoperative visits
Intraoperative services
Supplies
Postoperative complications
Postoperative pain management
Miscellaneous services
Not Included in Global Package
• Evaluation and Management services for:
 New patient’s
 unrelated conditions
•
•
•
•
Diagnostic tests & procedures
Immunosuppressive therapy
Other unrelated services
Modifiers may be required
Not Included in Global Package (continued)
• Evaluation and Management services for:
 New patient’s
 unrelated conditions
Global Surgery Packages
Indicator 000
• Same day as surgery/procedure
Indicator 010
• Same day as surgery/procedure
• 10 days postoperative care
Indicator 090 (Major Surgery)
• Day before surgery
• Same day as surgery/procedure
• 90 days postoperative care
Global Surgery Period
In Addition to 000, 010, and 090, you may find the
following global surgery indicators:
XXX – The global concept does not apply
YYY- Carrier determines whether global concept
applies and establishes postoperative period, if
appropriate, at the time of pricing
ZZZ- Code related to another service and is always
included in the global period of the other service.
Evaluation and Management
Modifiers
Modifiers specifically for evaluation
and management services:
• 24
• 25
• 57
Same physician
Same beneficiary
Evaluation and Management
• 24 – Unrelated E/M service during a post - op
period
Use with E/M Codes only
Modifier 24 applies to unrelated E/M during post-op of
Major or minor surgical procedure
Evaluation and Management
• Modifier 25
Significant, separately identifiable
Evaluation and management service by the
Same physician on the day of the procedure
Use on established patient
New illness
Follow up visit with multiple complaints
Evaluation/Management
• Modifier 57
Decision for surgery – An E/M service
resulting in the initial decision to perform
surgery may be identified by adding the modifier 57
to the appropriate level of service.
Modifier Combinations
May be necessary to
completely describe the
circumstances at hand
57 24
Procedure Modifiers
Modifiers specifically for procedures:
 58
 78
 79
Same physician
Same beneficiary
Modifier 76
Procedure Modifier
• Modifier 58
Staged or Related Procedures or
Service by the Same Physician
During the Prospective Period
Procedure Modifiers
• Modifier 76
– Repeat Procedure By Same Physician
• Modifier 78
– Unplanned Return to the Operating/Procedure
Room by the Same Physician Following Initial
Procedure for a Related Procedure During the
Postoperative Period
Global Surgery - Split Care
Transfer of care during global period
Split care modifiers
 54 - surgery only
 55 - postoperative care only
Assistant surgeon
 Reimbursement does not include pre- or postoperative
care
Billing for Split Care
Surgery only
 Bill appropriate procedure code
 Use modifier 54
Post-operative care only




Bill one service
Use surgery date
Use surgery code
Use modifier 55
Preoperative Services
Services payable under the Physician Fee
Schedule are covered based on medical
necessity
 ABN required
Use appropriate ICD-9-CM code
 V72.81 - V72.84
Services not payable under the Physician
Fee Schedule are denied as routine
 ABN not required
Correct Coding Initiative
Defines correct coding practices
Changes issued quarterly
FREE - CMS Web Site
 www.cms.hhs.gov/nationalcorrectcodinited
 Quarterly Update to CCI Edits, Version 14.2,
Effective July 1, 2008 (includes all previous versions and
updates from January 1, 1996).
Reference: Trans 1517, CR #6045,Pub. 1004-04, MLN: MM6045
CCI List
 Column I – Primary code
 Column II – bundled into column I code
 Last column CCI “Modifier Indicator”
1- can use modifier 59 or other CCI
modifier on column II code
 0-not allowed
 9-not applicable
Modifier 59
Distinct procedural service on the same
date of service by the same physician
 Different anatomical sites
 Different sides of the body
 Different procedure, or
 Different session
Modifier 59
Definition:
To indicate that procedure or service was distinct
or independent from other non E/M service
performed on the same day. Modifier 59 is used to
identify procedures ore services other than E/M
services that are not reported together but are
appropriate under the circumstances.
Procedure/Surgical Modifiers
Modifier 50
• Bilateral Procedure
• A procedure that can be performed on both sides of
the body (e.g. arms, breasts, ears, eyes, legs) at
the same operative session
• The MPFSDB indicates procedures which are
eligible (indicator 1)
• Bill code once with modifier
Surgical Modifiers
Modifier 51
• Multiple surgical procedures by the same
physician (same operative session)
• MPFSDB indicates procedures that require
modifier 51
• The Medicare system will assign the modifier if
appropriate based on the services billed.
Procedure/Surgical Modifiers
• Modifier 22
- Increased procedural Services
Surgical Modifiers
Modifier 62- Co-Surgery
• Two Surgeon together as primary surgeons
performing distinct part of a procedure
• Both Surgeons must agree to use modifier 62
• MPFSDB indicator must be 1 or 2
• Both reimbursed each at 62.5% of Medicare
allowance
Surgical Modifiers
• Modifier 80 – Assistant Surgeon
Modifier 81 - Minimum assistant surgeon
• Modifier 82 - Assistant Surgeon
(when qualified resident surgeon not available)
• Modifier AS - Physician Assistant (PA), Clinical
Nurse Specialist (CNS) or Nurse Practitioner (NP)
services for assistant-at-surgery.
Procedural Modifiers
Coronary Artery
• LC - Left circumflex coronary artery
• LD – Left anterior descending coronary artery
• RC - Right coronary artery
Advance Beneficiary Notification
Modifiers
GA
Advance beneficiary notice
was given to the patient
GY
Advance beneficiary notice
was not given to the patient
GZ
Item or service expected to be
denied as not reasonable &
necessary
Routine Notice Prohibition
Not Allowed Unless:
 Services which are always denied for medical
necessity;
 Experimental items and services;
 Frequency limited items and services; and
 Medical equipment and supplies denied
because the supplier had no supplier number
or the supplier made an unsolicited telephone
contact.
Professional/Technical Modifiers
Indicators Located on the Physician Fee Schedule
• 26 – Professional component only
• TC – Technical component only
Hospice Care
Modifiers
• GV
Attending physician not employed or paid und
agreement by the patient’s hospice provider.
• GW
Service not related to the hospice patient’s
terminal condition.
Therapy Modifiers
• Extended to December 31, 2009
• Providers resume submitting claims with the KX modifier
for therapy services that exceed the cap furnished on or
after July 1, 2008
• Limit for PT & SLP services combined remains the same
at $1810 for CY2008.
• OT services remains the same at $1810
Therapy Modifiers
•KX – When the beneficiary qualifies for a therapy cap
exception, the provider shall add a KX
modifier to the therapy HCPS subject to the
cap limits.
Continue to use• GN- Services delivered under an out patient speech
language pathology plan of care.
• GO - Services delivered under an outpatient
Occupational Therapy plan of care
• GP - Services delivered under an outpatient physical
plan of care
Class Finding Modifiers (footcare)
• Q7 – One Class A finding
• Q8 – Two Class B finding
• Q9 – Two Class C with one Class B
Competitive Acquisition Program
(CAP)
•J1 – Competitive Acquisition Program, no-pay submission
for a prescription number
•J2 – Competitive Acquisition Program (CAP), restocking of
emergency drugs after emergency administration and a
prescription number
•J3 – Competitive Acquisition Program (CAP), drug not
available through CAP as written, reimbursed under
average sales price (ASP) methodology (cannot be used J1
or J2 modifiers)
•MS - Medicare Secondary Payer
Drug Wastage with Modifier
JW – Drug amount discarded/not administered to any
patient
Document in the patient’s medical record:
Date and time
Amount of medication wasted
Reason for the wastage
Billing of Drug Wastage with ModifierJW
Example:
Drug A has a short 3-hour life span. HCPCS JXXXX
is for one unit. It is sold in vials of 50 units. The normal
dose, per patients is 10 units. The provider schedules 4
patients within the 3-hour life span to reduce wastage. The
last 10 units that are unused are billed to the last patient.
The claim for the administered portion for this patient, along
with the wastage amount should be billed with:
JXXXX
JXXXX JW
10 units
10units
Required Modifiers for ESAs
Non End Stage Renal
Disease (ESRD)
Effective January 1, 2008
Non-ESRD claims billing J0881 and
J0885
Report applicable modifier:
 EA: ESA, anemia, chemo-induced
 EB: ESA, anemia, radio-induced
 EC: ESA, anemia, non-chemo/radio
Chiropractic Modifier
AT – Use this modifier acute treatment with CPT
codes 98940, 98941, and 98942 only.
•
•
•
When modifier not used, services will be
considered maintenance care
MLN Matters 3063
www.cms.hhs.gov/mlnmattersarticles
Customer Service Corner
Optimal Service is our Goal
Customer Service Quick Tips
Comprehensive Error Rate Testing
(CERT)
Purpose of the CERT Program
Two separate contractors
 CERT Documentation Contractor (CDC)
• Requests and receives documentation
 CERT Review Contractor (CRC)
• Reviews documentation
CERT Call/Letter Schedule
Day 0
Initial Call/Letter
Day 30
Second Call/Letter
Day 45
Third Call/Letter
Day 60
OIG Letter
Day 76
If no MR response/No Doc/ No Response error
CERT Reports
Gross Paid Claims Error Rates
Affiliated
Carrier (AC)
Carrier:
RI Cluster
Carrier:
AR/LA/MO/O
K/NM
Cluster
All AC
Clusters
(Average)
Nov 2006
Report
(Claims
submitted
from
4/1/2005 to
3/31/2006)
Nov 2007
Report
(Claims
submitted
from
4/1/2006 to
3/31/2007)
May 2008 Interim Report
(Claims submitted 10/1/ 2006 to
9/30/ 2007)
5.0%
3.9%
4.9%
4.1%
3.9%
4.3%
5.0%
4.8%
4.5%
Recovery Audit Contract Initiative
(RAC)
The Medicare Prescription Drug Improvement and
Modernization Act of 2003 (MMA, Section 306) directs the
secretary of the U.S. Department of Health and Human
Services (DHHS) to demonstrate the use of RACs under
the Medicare Integrity Program . . .
 Identify underpayments and overpayments for Part A and
Part B; and
 Recouping overpayments
RAC – Recovery Audit Contract
• The “Tax Relief and Health
Care Act” of 2006 made the
program permanent and
urged expansion to all 50
states by 2010.
• Already expanded to South
Carolina and Massachusetts
• CMS plan to expand to all 50
states by March 2010
• www.cms.hhs.gov/rac
The RACs are Coming
What Can I Do to Prepare?
Implementation Strategy: By 2010, CMS plans to expand to all states.
AR/RICAC0908
Revised CMS – 855
Medicare Enrollment Applications
•
•
•
•
Will continue to accept 2006 version through June
2008
Providers and suppliers should begin to use the
new Medicare enrollment applications immediately
Initially, these applications will be available only
from the CMS provider enrollment web site
MLN: SEO810 www.cms.hhs.gov/mlnmattersarticles
Individuals Authorized Access
to CMS Computer Services Provider Community (IACS-PC)
• New online enterprise application
• Medicare fee-for-service provider
• Registration process
– MLN SE0747 Revised
– MLN SE0753 Revised
– MLN SE0754 Revised
•
Please note that CMS will notify providers
as internet applications become available,
and provide clear instructions that specify
which providers should register in IACSPC. Do not register until you are notified
by CMS or one of its contractors to do so
and only if you meet the criteria in the
notice.
Medicare Contractor
Provider Satisfaction Survey
• Medicare Contractor Provider
Satisfaction Survey (MCPSS)
• Conducted by Westat
• 2008 results available online at:
www.cms.hhs.gov/MCPSS/
• Annual CMS Survey
Provider
satisfaction
is a top
priority
for
Pinnacle
Medicare
Services!
References:
©CPT codes, description and other data only are copy right 2007 American
Medical Association. All rights reserved. Applicable FARS/DFARS
clauses apply. CDT codes and description are copyright 2007 American
Dental Association. All right reserved. Applicable FARS/DFARS apply.
• Internet Only Manual (IOM), Publication 100-4 Medicare Claims
Processing Manual, Chapter 12, Section 40.3
• List-serv message 7/16/08 – Extension of Therapy Cap Exceptions
•
•
•
•
•
www.arkmedicare.com
www.lamedicare.com
www.rimedicare.com
www.cms.hhs.gov/nationalcorrectcodinited
http://www.cms.hhs.gov/manuals/downloads.clm104c 18.pdf