Transcript Coding with Modifiers - Home | Oregon Medical Association

Coding with Modifiers
Oregon Medical Association
October 29, 2009
Frann M. Britton, RN, CCS,CCS-P
CPT Categories
• Category I
– Describe a procedure or service identified
with a 5-digit numeric CPT code
– Generally based on the procedure being
consistent with contemporary medical practice
– Being performed by many physicians in a
clinical practice in multiple locations
2
CPT Categories
• Category II Performance Measurement
– Are intended to facilitate data collection by
coding certain services and/or tests results
that are agreed on as contributing to positive
health outcomes and quality patient care.
– Tracking codes for performance
measurement
– May be services that are typically part of an
Evaluation and management service
3
CPT Categories
• Category II Performance Measurement
– May be a component part of a service and are
not appropriate for Category I CPT codes.
– Do not have relative value
– No payment associated with these codes
– Will decrease need for record abstraction and
chart review
– Minimize administrative burden on physicians
and health plans
4
CPT Categories
• Category II Performance Measurement
– Performance Measures Advisory Group
• Evidenced-based measurements with
established ties to health outcomes
• Measurements that addresses clinical
conditions of high prevalence, high risk, or
high cost
• Well-established measurements that are
currently being used by a large segment of
the health care industry nation wide.
5
CPT Categories
• Category II Performance Measurement
– The use of these codes is optional and is not
required for correct coding.
6
CPT Categories
• Category III Emerging Technology
– Temporary set of tracking codes for emerging
technologies, services, and procedures.
– Intended to facilitate data collection and
assessment of these services and
procedures.
– Used for data collection purposes to
substantiate widespread usage or in the FDA
approval process.
7
CPT Categories
• Category III Emerging Technology
– Must have relevance for research, either
ongoing or planned.
– Once approved by Editorial Panel are added
to Level I CPT codes
– No relative values
– Payment subject to payer policies
– Archived after 5 years if not added to CPT
8
HCPCS Coding System
• HCPCS
– CMS‘s Health Care Common Procedure
Coding System
– Developed in 1983 to standardize the coding
systems to process Medicare claims on a
national basis.
– 2 levels CPT and HCPCS
9
HCPCS Coding System
• Level I CPT
– Makes up the majority of the HCPCS system
• Level II National Codes
– Durable medical equipment
– Ambulance services
– Medical and surgical supplies, drugs
– Orthotics, prosthetics, dental and eye services
10
HCPCS Coding System
• Level II National Codes
– 5 character alphanumeric codes
– First character is a letter A-V (except I)
followed by 4 numeric digits (A4550)
– Alphabetic (eg, RT) and alphanumeric (eg,
E2) modifiers
– Updated annually by CMS
– Required for reporting most medical services
and supplies provided to Medicare and
Medicaid patients.
11
National Correct Coding Initiative
• Edit of code pairs of CPT or HCPCS that are not
separately payable except under certain
conditions.
• Same beneficiary, same physician, same date
• Promote national correct coding
• Eliminate improper coding
12
National Correct Coding Initiative
• Developed by CMS to prevent
inappropriate payment of services that
should not be reported together.
• 2 NCCI tables:
– “Column One/ Column Two Correct Coding
Edit Table” and “Mutually Exclusive Edit
Table”.
13
National Correct Coding Initiative
• Each edit table contains edits of pairs of
HCPCS/CPT codes in general should not
be reported together.
• If a provider reports the two codes of an
edit pair, the column two code is denied.
• When clinically appropriate to utilize an
NCCI-associated modifier, both the
column one and column two codes are
eligible for payment.
14
National Correct Coding Initiative
• Column two codes are often a component
of a more comprehensive column one
code it is not true for many edits.
• The code pairs simply represents two
codes that should not be reported
together.
• Vaginal hysterectomy and total abdominal
hysterectomy code together.
15
National Correct Coding Initiative
• NCCI is used by all practioners, hospitals,
providers or suppliers eligible to bill
Medicare.
16
National Correct Coding Initiative
• Coding conventions defined in CPT
• Current standards of medical and surgical
care
• Input from specialty societies
• Analysis of current coding practice
• Updated on quarterly basis
• Denial based on NCCI edits may not bill
patient
17
National Correct Coding Initiative
• 2 columns, 1st lists CPT code
• 2nd (component) code, integral to Column
1
• Denied without modifier
• Mutually exclusive edit
– 2 codes cannot reasonably be performed
together based on code definitions or
anatomic considerations.
18
Procedures and Global Period
All procedure on the Medicare Physician Fee Schedule are
assigned a Global period of 000,010,090,XXX,YYY or ZZZ.
The global concept does not apply to XXX
procedures.
The global period for YYY procedures is defined
by the Carrier.
All procedures with a global period of ZZZ are
related to another procedure, and the global
period for the ZZZ code is determined by the
related procedure.
19
Procedures and Global Period
NCCI edits are applied to same day services by the same
provider to the same beneficiary.
An E/M service is separately reportable on the same DOS
as a procedure with global days, 000,010,090 under limited
conditions.
Minor procedures global days are 000 or 10.
Major procedures have 90 global days.
20
Procedures and Global Period
If an E/M is performed on the same date of service as a
major surgical procedure for the purpose of deciding
whether to perform this surgical procedure, append modifer
-57 to the E/M.
The decision to perform a minor surgical procedure is
included in the payment for the minor surgical procedure
and should not be reported separately as an E/M service.
A significant and separately identifiable E/M service
unrelated to the decision to perform the minor surgical
procedure is separately reportable with modifier-25.
21
Procedures and Global Period
Medicare example:
“If a physician determines that a NEW patient with head
trauma requires sutures, confirms the allergy and
immunization status, obtains informed consent, and
performs the repair, an E/M service is not separately
reportable.
HOWEVER, if the physician also performs a medically
reasonable and necessary full neurological examination,
an E/M service may be separately reported”.
22
Procedures and Global Period
XXX procedures have inherent pre-procedure,
intra-procedure and post-procedure work usually
performed each time the procedure is completed.
(EKG’s. x-rays, ultrasounds)
This work should never be reported as a separate
E/M.
An separate E/M can be reported with -25 if it is
significant, separately identifiable.
23
NCCI Modifiers
• Anatomic modifiers
• E1-E4, FA, F1-F9, TA, T1-T9, LC, LD, RC,LT,RT
• Global surgery modifier
•
•
•
•
•
•
•
-25 Significant E/M same day as Procedure
-58 Staged or related Procedure during Postop
-78 Unplanned Return to OR during postop
-79 Unrelated procedure during postop
-59 Distinct Procedure
-91 Repeat Clinical Diagnostic Lab
-27 Multiple Outpatient E/M on same Date
24
NCCI Modifiers
Important to use NCCI-associated
modifiers only when appropriate
– Separate patient encounter
– Separate anatomic sites
– Separate specimens
– Paired organs
25
Modifiers
Evaluation and Management Only
-24 Unrelated E/M Unrelated E/M during the
postoperative period
.
-25 Separate E/M
-57 Decision for Surgery
26
Modifiers
Evaluation and Management Only
-24 Unrelated E/M Unrelated E/M during the
postoperative period
• The same physician and unrelated to the original
surgery
• Separate note if he/she evaluates the previous
surgical site and determines the site requires care,
this would not be part of the new encounter.
27
Modifiers
Evaluation and Management Only
-25 Significant, separately identifiable E/M service
performed by the same physician on the day of a
procedure.
Modifier -25 is critical to appropriate
communication about what happened in a patient
encounter on a given date
• Procedures with 0,10, global days, endoscopies,
XXX services.
28
Modifiers
•
Modifier was added by CMS in 1992 to help reduce the
documentation burden on physicians.
•
Says the provider went “above and beyond” the other service
provided.
•
Modifier-25 is not restricted to any level or SOS.
•
The same diagnosis may accurately describe the nature or reason
for the encounter and the procedure.
The record, however—should document an important,
notable, distinct correlation with signs and symptoms to
make a diagnostic classification or demonstrate a distinct
problem.
29
Modifiers
• Evaluation and Management Only
• -57 Decision for Surgery is appended to an E/M
only when that service represents the initial
decision to perform a major surgical procedure.
• E/M the day prior to or day of a major procedure
with a 90 day global period.
• Be prepared to submit consultation, visit or
hospital note to support decision for surgery.
30
Modifiers
-22 Unusual Procedure
• When the service provided is greater than that
usually required for the listed procedure.
• Used in the following sections:
–
–
–
–
–
Anesthesia
Surgery
Radiology
Laboratory and Pathology
Medicine
31
Modifiers
-22 Unusual Procedure operative cases
• 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
• Increased time resulting from extra work by the
physician
• Needs a concise statement about how the service
differs from the usual
• An operative report submitted with the claim
32
Modifier -22
• Occasionally a provider may perform two procedures
that should not be reported together based on an NCCI
edit.
• If the edit allows use of NCCI-associated modifiers to
bypass it and the clinical circumstances justify use of
one of these modifiers, both services may be reported
with the NCCI-associated modifier.
• If the NCCI edit does not allow use of NCCI-associated
modifiers to bypass it and the procedure qualifies as an
unusual procedural service, the physician may report the
column one column one HCPCS/CPT code of the NCCI
edit with modifier 22.
33
Modifier -22
• The Medicare carrier cannot override an
NCCI edit that does not allow use of
NCCI-associated modifiers,
• The carrier has discretion to adjust
payment based on modifier 22.
34
Modifiers
-26 Professional Component
– Certain procedures are a combination of a physician
component and a technical component. When the
physician component is reported separately add -26.
– If the radiologist owns the equipment, interprets the
test, and pays the technologist, modifier TC and 26 do
not apply.
– Physician does not own the equipment -26
– Facility provided the equipment and technician –TC
– CPT 76140 only has a professional component
modifier -26 would not be used.
35
Modifiers
-26 Professional Component
– CPT 51725 simple cystometrogram (CMG)
This code includes all supplies, equipment,
and the technician’s work, including
interpretation of the results.
If the physician only interprets the results and
dictates a report, modifer -26 would be
appended to the code.
The hospital would submit the same code with
36
-TC
Modifiers
-50 Bilateral Procedure
• Unless otherwise identified in the listings, bilateral
procedures that are performed at the same
operative session should be identified with -50.
• Bilateral procedures are typically performed on
both sides of the body (mirror image) during the
same operative session.
• Append to unilateral code as a one-line entry, unit
of one
• Modifier does affect payment 2nd pr at 50%
37
Modifiers
-50 Bilateral Procedure
•
•
•
•
If the procedure is performed unilaterally and
the descriptor indicates bilateral, append
modifier-52.
69210 removal cerumen one or both ears
Do not use -50 code
Procedure performed unilaterally and descriptor
indicates bilateral add -52
38
Modifiers
-50 Bilateral Procedure
•
Many payers will not accept -50 for radiology
use LT and RT
•
Medicare allows LT and RT instead of -50 when
the code does not indicate a bilateral
procedure.
39
Modifiers
-50 Bilateral Procedure bilateral code sets:
69210 Ear wax removal 1 or both ears
55300 Vasotomy, unilateral or bilateral
27158 Osteotomy, pelvis, bilateral
30801 Cautery and/or ablation, mucosa turbinates
unilateral or bilateral
40843 Vestibuloplasty; posterior, bilateral
35548 Bypass graft, with vein, unilateral
35549 Bypass graft, with vein, bilateral
40
Modifiers
-51 Multiple Procedures
• Used when multiple procedures, other than E/M,
are performed at the same session by the same
provider, the primary procedure or service is listed
first.
• -51 is add to the additional procedures.
• List procedures in ranking order highest RVU
listed first.
• -51 not needed for Medicare
41
Modifiers
-51 Multiple Procedures
has 3 applications
• Multiple, related surgical procedures performed at
the same session
• Surgical procedures performed in combination
whether through the same or another incision or
involving the same or different anatomy
• A combination of medical and surgical procedures
performed at the same session
42
Modifiers
-51 Multiple Procedures
• Do not append -51 to E/M service
• Do not append to “add- on “ codes
• Do not append to “each additional”
(finger fracture's, tendon repair)
• “List separately in addition to primary
procedure.” (lesions, vertebral segments)
• Modifier 51 exempt symbol Ø
43
Modifiers
-51 Multiple Procedures
• Two or more physicians at same operations
• Each surgeon reports his/her own CPT codes
without modifer -51
• Modifier -51 same surgeon, same session,
multiple procedures as long as they are not
considered incidental or bundled
44
Modifiers
-51 Multiple Procedures
• 100% first procedure
• 50% 2nd – 5th each additional
•
after 5th “by report basis”
• 100, 50, 25 Other payer specific payment
policy
45
Modifiers
-52 Reduced Service – part of service
or procedure reduced or eliminated at
the physician’s discretion.
• Provides a means of reporting reduced
services without disturbing the
identification of the basic service.
46
Modifiers
-52 Reduced Service –
• May or may not affect reimbursement
• Chart note or op note should be sent
with claim
• Not all carriers recognize
• Not recognized with E/M – CMS
47
Modifiers
•
-53 Discontinued Procedure
• When patients experience unexpected responses
(hypotension, arrhythmia) causing a procedure to be
terminated
• Procedure stopped due to patients life-threatening
condition
• After anesthesia is administered to patient
• Payers cover only the primary procedure
• Not for laparoscopic or endoscopic procedure converted
to an open procedure
48
Modifiers
-54 Surgical Care Only
-55 Postoperative Management Only
-56 Preoperative Management Only
49
Global Surgical Package
• Refers to payment policy of bundling
payment for the various services
associated with an operation into a single
payment covering;
– Operation
– Postoperative hospital visits
– Normal typical follow-up care
50
Global Surgical Package
• CMS
– Preoperative period begins one day prior to
surgery in or out of the hospital and continues
for 90 days.
– Carefully monitored by Medicare – may
lengthen preoperative period.
51
Modifiers
-54 Surgical Care Only
When one physician performed a
surgical procedure and another
provided preoperative and/or
postoperative management.
52
Modifiers
-54 Surgical Care Only
– Intraoperative care only
– Fracture reduction in the ED
• 69% of the global fee
• 25605-54 closed reduction distal radius
53
Modifiers
-55 Postoperative Management Only
When one physician performed the
postoperative management and another
performed the surgical procedure.
54
43770-54 Laparoscopy, gastric band
Bariatric surgery
43770-55 Laparoscopy, gastric band
Bariatric surgery
55
43770 Laparoscopy, gastric band
Bariatric surgery
Work
17.85
Expense
7.72
Mal Practice
2.19
Pre 9%
Intra 81%
Post 10%
56
Modifiers
-55 Postoperative Management Only
• Date of surgery plus number of days
– 35321-55 x5 units
• Bill after patient is seen initially in f/u
• Payment 10-20% of post-op allowable
• Transfer of care documented
57
Modifiers
-56 Preoperative Management Only
When one physician performed the
preoperative care and evaluation and
another performed the surgical
procedure.
58
Modifiers
- Needs to be communication between
the surgeon and the physician providing
either pre-op or post-op services.
- Discharge summary of the hospital or
ASC
59
Modifiers
- Payment
- Modifier -56 based on the preoperative
value of the global surgery fee
- Report date of surgery on 1500
- CPT 33400-56 Aortic valve repair
60
Modifiers
-58 Staged or Related Procedure or Service by the
same physician during the postoperative period
• Planned prospectively, more extensive than the
original procedure or represents a therapeutic or
diagnostic procedure or service
• Used during the global surgical period for the original
procedure
• New postoperative period begins
• Not used for return to the operating room for
treatment of a problem
61
Modifiers
• If a diagnostic endoscopic procedure
results in the decision to perform an open
procedure, both procedures may be
reported with modifier-58 appended to the
CPT code for the open procedure.
• If the scope is a “scout” procedure to
asses anatomic landmarks and or/extent
of disease it is not report separately.
62
A surgeon performed a radical mastectomy
(19200) on a 56-yr-old woman. The patient
indicated that she preferred a permanent
prosthesis after the surgical wound healed.
The surgeon took the patient back to the
operating room during the post-op period and
inserted a permanent prosthesis.
CPT code:
63
A diabetic patient with advanced circulatory
problems had three gangrenous toes
removed from her left foot (28820, 28820-51,
28820-51). During the post-op it became
necessary to amputate the patient’s left foot.
CPT code:
64
Rational:
• Because there is a possibility, in the light of
the patient’s condition, that amputation
might be necessary, this is considered a
staged procedure.
65
• 35840 Exploration for postoperative
hemorrhage thrombosis or infection;
abdomen
• Code:
66
Modifiers
• -59 Distinct Procedural Service
Documentation must support:
• Different Session or Pt Contact
• Different procedure or surgery
• Different site or organ system
•
•
•
•
Separate incision or excision
Separate lesion
Separate injury
Separate area of surgery in extensive injuries, not
ordinarily encountered or performed on the same day,
by the physician
67
Modifiers
• Modifier -59
– For “exceptions” to the normal rules
– By passes the NCCI edits
– Using incorrectly – tells payer every service is
an exception
– Leads to further review of a provider’s billing
practices
– Inappropriate or indiscriminate use of the NCCI
modifiers could be considered fraudulent or
abusive
68
Modifiers
• Modifier -59
– Use of modifier -59 to indicate different
procedures/surgeries does not require a
different diagnosis for each CPT/HCPCS code.
– Different diagnoses are not adequate criteria
for use of modifier -59. The codes remain
bundled unless the procedure are performed at
different anatomic sites or separate encounters.
69
Modifiers
• Modifier -59
– Different anatomic sites includes different
organs or different lesions in the same organ.
– Does not include treatment of contiguous
structures of the same organ.
• E.g. nail, nail bed, and adjacent soft tissue
constitutes treatment of a single anatomic site.
70
Modifiers
• Modifier -59
– Treatment of posterior segment structures in
the ipsilateral eye constitutes treatment of a
single anatomic site.
– Arthroscopic treatment of a shoulder injury in
adjoining areas of the ipsilateral shoulder
constitutes treatment of a single anatomic site.
71
Modifiers
• Modifier -59
– CPT 38221 bone marrow, biopsy
– CPT 38220 bone marrow, aspiration only
– Code both if different anatomic sites same
incision do not code and do not use -59
– Medicare CPT 38221 and G0364 (bone marrow
aspiration performed with bone marrow biopsy
through same incision on the same DOS).
72
Modifiers
• Modifier -59
• Should not be used when another, more
descriptive modifier is available
• Documentation needs to be specific to the
distinct procedure or service and be
clearly identified in the medical record
• By passed NCCI edits
73
Modifiers
• Modifier -59
– CPT 87070 Culture bacterial, blood
• Different site (both arms)
– CPT 87071 Culture bacterial; quantitative,
aerobic of two sites
• Wound infection, lower leg with cultures from
proximal wound and distal wound site
74
Modifiers
• Modifier -59
– CPT 97597 Removal devitalized tissue
Patient’s right hip and ankle
• 97597-59 later in the day debrided another 20sq cm
from the sacral area
75
Surgeon removed a soft tissue 3cm
tumor from a patient’s left wrist in the
outpatient surgery department. During
the same operative session, a 0.8-cm
lesion was excised from the patient’s
right leg.
CPT code:
76
Patient had a total colonoscopy with
random biopsies from the ascending colon,
transverse colon and sigmoid colon. A hot
biopsy destroyed a 3-mm polyp in the
sigmoid colon.
CPT code:
77
70 yr old woman, with SOB under went
chest x-ray single view. Later in the day
the radiologist asked the patient to return
for a more extensive study.
CPT code:
78
Modifiers
-62 Co-surgeon two surgeons performing
distinct part(s) of a procedure
• Complexity of the procedure
• The patient’s condition or both
• Additional surgeon is not acting as assistant but
is performing a distinct portion of the procedure
79
Modifiers
-62 Co-surgeon two surgeons performing
distinct part(s) of a procedure
• Each surgeon bills the same CPT/ICD
• Separate operative reports to document
their level of involvement in the surgery
• Spine surgery – physicians discuss in
advance what portion of the procedure
each is expected to perform
80
Modifiers
-62 Co-surgeon two surgeons performing
distinct part(s) of a procedure
• Spine surgery opens and closes only, -62
is appended to the primary procedure only
• -80 when needed to continue as assistant
81
Modifiers
-62 Co-surgeon two surgeons performing
distinct part(s) of a procedure
• For surgical procedures
• Endovascular repair (34800, 34802,
34804, 34812, 34813,34820, 34825)
• Radiological procedures
– CPT 77778-26-62 urologist
– CPT 77778-26-62 radiologist
82
Modifiers
-62 Co-surgeon two surgeons performing
distinct part(s) of a procedure
• Review payer guidelines
• Documentation must support need for 2
surgeons,
• Each bills with same CPT/ICD codes
• Each surgeon must dictate his/her own operative
report
• Not used for surgeon acting as “the assistant
surgeon”
83
Modifiers
-63 Procedure Performed on Infants
Less than 4 kg
• Increased complexity and physician work
• Used only with codes from Surgery section of CPT
• Only invasive surgical procedures
• Not for surgery that assumes the patient is a neonate or
infant (eg. Surgery to correct a congenital abnormality)
the relative value already reflects the additional work.
• Use -22 or -63 not both at same session
84
Modifiers
Modifier 66 Surgical Team
Highly complex procedures requiring the
concomitant services of different specialties,
performing different portions of a procedure.
Heart transplant
Lung transplant
Liver, pancreas
85
Modifiers
Modifier 66 Surgical Team
• Each surgeon bills with -66 appended to the
procedures
• Requires usually requires prior authorization
• Send op report
86
Modifiers
-76 Repeat Procedure by Same Physician
• Intended to describe the same procedure or
service repeated rather than the same procedure
being performed at multiple sites.
• Modifier indicates not a duplicate
• Must be same procedure, same physician
87
Modifiers
-76 Repeat Procedure by Same Physician
– Surgical procedure –same date or during global
– Medical – same date
•
•
•
•
93010 EKG
93010-76 2 EKG’s same day
71010-26 Chest x-ray
71010-76-26 same day for chest tube placement
88
Modifiers
-77 Repeat Procedure by Another Physician
• Medical necessity must support reason for
the repeat procedure
• Second physician is not affected by first
physician’s service
89
Modifiers
-78 Return to the Operating Room for a Related
Procedure during the Post-operative Period
– Subsequent procedure is related to the first and
requires the use of the operating room
– May be used on the same day or during global period
– Do not use the code for the original procedure
– Repeat surgery is due to a complication of the original
procedure
– Append modifier to each procedure performed that
requires treatment for the complication
90
Modifiers
-78 Return to the Operating Room for a Related
Procedure during the Post-operative Period
– Do not use for procedures that indicate in the
descriptor “subsequent, related, or redo”
– If the complication does not require return to the OR do
not append -78
– Reimbursement intra-operative portion only
– New global days do not begin
– Use a complication diagnosis code not the same dx as
the original surgery
91
Modifiers
-78 Return to the Operating Room for a Related
Procedure during the Post-operative Period
Complications of Surgical and Medical Care, Not Classified
Elsewhere
• 998.11 Hemorrhage complicating a procedure
• 998.32 Disruption of external surgical wound
• 998.59 Post-operative wound infection
– 682.6 knee, 682.2 back, 041.12 MRSA
92
Modifiers
-78 Return to the Operating Room for a
Related Procedure during the Postoperative Period
Mechanical Comp Internal Ortho Device
• 996.42 Dislocation of joint
• V43.64 Total hip
– Use with CPT 27265 only
93
Modifiers
-78 Return to the Operating Room for a
Related Procedure during the Postoperative Period
Complications of Surgical and Medical Care, Not
Classified Elsewhere
• 998.59 Post-operative wound infection
94
Medicare Operating Room
• Operating room or place equipped
specifically for procedures.
–
–
–
–
–
–
Hospital operating room
Ambulatory surgery center
Cardiac cath suite
Laser suite
Endoscopy suite
ICU when patient to sick to move
95
Modifiers
-79 Unrelated Procedure or Service by Same
Physician During the Postoperative Period
–
–
–
–
–
–
Different diagnosis
Does not require a return to the OR
Is not limited to surgical procedures
Restricted to the same physician
Append -79 to all procedures that apply not just first
Begins new 90 day global period
96
Modifiers
80-82 Assistant Surgeons
– 80 Assistant Surgeon
– 81 Minimum Assistant Surgeon
– 82 Assistant Surgeon (when qualified
resident not available)
-AS Physician assistant, nurse practitioner,
clinical nurse specialist
97
Modifiers
Co surgeon (-62) share responsibility for a surgical procedure,
each serving as a primary surgeon during some portion of the
surgery. Both must be surgeons, and usually of different
specialties.
• CMS, to qualify as assistant the surgeon must actively assist.
Must be involved in the actual performance of the procedure.
• To qualify for CMS definition of an assistant surgeon
(-80), the assistant surgeon needs to be able to take over the
surgery should the primary surgeon become incapacitated.
• The surgical note should clearly document what the assistant
surgeon did during the operating session.
98
Modifiers
-81 Minimum Assistant Surgeon
• Assistance for a short period of time
• Medicare 13% of allowable
• Work Comp
99
Modifiers
-82 Assistant Surgeon (When Qualified
Resident Surgeon Not Available)
• Prerequisite unavailability of qualified
resident (teaching hospitals)
100
Modifiers
-90 Reference (Outside) Laboratory
• Laboratory bills the physician and the
physician office bills the insurance
company.
• 36415 lab draw
• 80061-90 Lipid panel
101
Modifiers
-91 Repeat Clinical Diagnostic Test
• Necessary to repeat the same lab test
– Not to:
– Confirm initial test results
– Due to testing problems encountered with
specimens or equipment
– For any other reason, one-time reportable
result is all that is required
102
Modifiers
-91 Repeat Clinical Diagnostic Test
• Follow-up potassium level after treatment
of hyperkalemia
• Repeat ABG’s
• Drug testing for each drug
– 80100 Cocaine
– 80100-91 methamphetamine
– 80100-91 THC
103
Modifiers
-91 Repeat Clinical Diagnostic Test
• 82948 Glucose, blood, reagent strip
• 82948-91
• 82951 glucose, three specimens
104
Modifiers
-91 Repeat Clinical Diagnostic Test vs
modifier -59
• -59 Same procedure for a different
specimen
• Laboratory test that is performed more
than once on the same day for the same
patient. To obtain subsequent test results.
105
Modifiers
HCPCS Level II
• 33 Anatomic modifiers
• 10 Anesthesia modifiers
• 300 CMS
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Modifiers
Anatomical - HCPCS
-LT Left side of the body
-RT Right side of the body
-FA Left hand – thumb
-T5 Right foot - Great toe
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Modifiers
HCPCS Level II
• -GA ABN signed
• -QW CLIA waved test
• -TC Technical component
• -GY Item or service does not meet the
definition of a Medicare benefit
• -GZ Item or service expected to be denied
as not reasonable and necessary
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Modifiers
HCPCS Level II
• -GY modifier : physicians, practitioners, or suppliers want to
indicate that the item or service is statutorily non-covered or
is not a Medicare benefit.
• -GZ modifier: to indicate that they expect that Medicare will
deny an item or service as not reasonable and necessary
and they have not had an Advance Beneficiary Notification
(ABN) signed by the beneficiary.
• -GA modifier: when physicians, practitioners, or suppliers
want to indicate that they expect that Medicare will deny a
service as not reasonable and necessary and they do have
on file an ABN signed by the beneficiary.
109
Modifiers
HCPCS Level II
Foot Care
• Q7 One class A finding
• Q8 Two class B findings
• Q9 One class B and two class C findings
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“Never Events”
Invasive procedures include a range of procedures
from minimally invasive dermatological procedures
• Biopsy, excision, and deep cryotherapy for
malignant lesions.
• Extensive multi-organ transplantation
• Percutaneous transluminal angioplasty and
cardiac catheterization.
• Placement of probes or catheters requiring the
entry into a body cavity through a needle or
trocar.
• Do not include
– use of instruments such as otoscopes for examinations.
– very minor procedures such as drawing blood.
111
“Never Events”
• A surgical or other invasive procedure is
considered to be the wrong procedure if it
is not consistent with the correctly
documented informed consent for that
patient.
112
“Never Events”
• Surgical or other invasive procedure is
considered to have been performed on the
wrong body part if it is not consistent with the
correctly documented informed consent for that
patient including surgery on the right body part,
but on the wrong location on the body;
• Left versus right (appendages and/or organs), or
at the wrong level (spine).
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“Never Events”
• The event is not intended to capture
changes in the plan upon surgical entry
into the patient due to the discovery of
pathology in close proximity to the
intended site when the risk of a second
surgery outweighs the benefit of patient
consultation; or the discovery of an
unusual physical configuration (e.g.,
adhesions, spine level/extra vertebrae).
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Modifiers
HCPCS PC
• PA: Surgery Wrong Body Part
• PB: Surgery Wrong Patient
• PC: Wrong Surgery on Correct Patient
115
Modifiers
HCPCS
• PA:
Surgery Wrong Body Part
E876.7 Correct operation on wrong body part
• PB:
Surgery Wrong Patient
E876.6 Performance of operation on pt not scheduled for surgery
• PC:
Wrong Surgery on Patient
E876.5 Wrong operation correct patient (wrong device
implanted into correct surgical site
116
Modifiers
HCPCS PC
82 yr old male had surgery performed on his
right knee for a torn meniscus. The left knee
had the torn meniscus.
Code:
117
Questions
118
Resources
• http://www.cms.hhs.gov/Transmittals/downloads/R1
02NCD.pdf
• CPT 2009, Edition, American Medical Association
• International Classification of Diseases, 2009 Edition
• Coding with Modifiers, AMA
• Center for Medicare and Medicaid Services, Program
Manual
• Medicare Claims Processing Manual
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