(1)Modifier Magic
April 15, 2015
MMBA
Modifiers
•“Modifiers should be reported to bypass a clinical edit ONLY if the
criteria for the use for the modifiers is met and supporting
documentation is included in the member’s medical record. “ This is a
direct quote from BCN Provider Manual.
•For additional information on modifiers, providers should consult the
available resources on procedure codes published by the American
Medical Association ( your CPT and HCPCS books) and the Centers for
Medicare & Medicaid Services.
Anatomical Modifiers
• Anatomical modifiers are used to indicate that a procedure or service
was performed at a specific anatomic site or to indicate that a
procedure was performed at two separate and distinct anatomic
sites. Examples of anatomical modifiers are: E1–E4, FA, F1–F9, TA, T1–
T9, LT, RT, LC, LD and RC.
•Use of anatomical modifiers facilitates the identification of separate
and distinct services. For example, a provider may report modifier F2
on one line and modifier F3 on another line when procedure code
*26455 is reported as performed on each of those fingers, instead of
reporting a count of two on one line.
Anatomical Modifiers
•Anatomical modifiers should be reported instead of modifier 59,
when possible. For example, if a provider performs foot surgery,
reporting code 28285 and code 28292 at the same operative session
but on different sites, anatomic modifiers should be appended to
each line to indicate that the procedures performed were separate
and distinct. Modifier 59 is to be used only when there are no other
modifiers that accurately indicate the nature of the service
performed.
Anesthesia Modifiers
•Anesthesia claims must be reported with the appropriate modifier for the
practitioner administering the anesthesia:
•Modifier AA, AD, QK or QY is reported for a physician who administers the
anesthesia or who supervises its administration.
•Modifier QX or QZ is reported for a certified registered nurse anesthetist
who administers the anesthesia. Services performed by CRNAs without the
medical direction of an anesthesia physician are paid the charge or 85
percent of the maximum payment, whichever is lower. Anesthesia services
performed by CRNAs or anesthesia assistants in physician offices are not
eligible for payment.
Physical Medicine & Rehab Services Modifiers
•A physical medicine and rehabilitation service must be reported with the
appropriate therapy modifier indicating the discipline performing the
therapy. The modifiers are GN, GO and GP.
•The codes requiring these modifiers include the following: *92507, *92508,
*92521‐*92524, *92526, *92597, *92605‐92609, *96125, *97001‐*97004,
*97010‐*97012, *97014, *97016‐*97028, *97032‐*97039, *97110‐
*97124, *97139‐*97140, *97150, *97530, *97532‐*97537, *97542,
*97750, *97755, *97760‐*97762, *97799, G0129, G0283, G0329, S8948,
S8950, S9152 or S9476 . If the procedure code is reported without the
modifier, the service may be denied because the required modifier is
missing. The reporting of these modifiers indicating the type of therapy
performed does not supersede the provider’s reimbursement arrangement
with third party payers.
Physical Medicine & Rehab Services Modifiers
•The CPT codes *97597, *97598, *97602, *97605, *97606, G0281 and
G0329 are classified by the CMS as “sometimes therapy” procedure
codes. (Code G0329 is for BCN Advantage members only; it is not
covered for BCN commercial members.) When these services are
provided for active wound management, they should not be reported
with therapy modifiers (GN, GO or GP).
Behavioral Health Modifiers
•To receive the correct reimbursement, board‐certified child and
adolescent psychiatrists should bill with the HA modifier rather than
the AM modifier. All claims with an HA modifier will be audited to
ensure that only board‐certified child and adolescent psychiatrists are
billing the HA modifier.
Discarded Drug Modifiers
Modifier JW may be used to identify drugs that are discarded or not
used for a member. When reporting the modifier for drugs
administered from a single‐use vial or single‐use package, providers
should follow these guidelines:
• Modifier JW should not be reported when the billing unit is greater
than the actual dose provided. For example, if the procedure code
nomenclature for the drug is 10 mg but the dosage administered was
5 mg and the vial contains only 10 mg, then the unit reported on the
claim would be 1 because the billing unit provides for full
reimbursement of the 10‐mg dosage.
Discarded Drug Modifiers
•The modifier JW may be reported if the billing unit is less than the
actual dose provided. For example, if the procedure code
nomenclature for the drug is 1 mg but the dosage administered was 5
mg and the vial contains 10 mg, then two lines would be reported:
o Line 1: Report the five units used.
o Line 2: Report the five units discarded with the JW modifier.
The JW modifier should be noted only on the line for the wasted
drug.
•Note: Multi‐dose vials should not be reported with the JW modifier
Evaluation & Management Modifiers
•Modifier 24 is used to report a subsequent but unrelated E&M service performed
during the global surgery period that should be evaluated separately.
•When reporting an office/outpatient or inpatient consultation procedure code
with a minor surgical procedure (0 or 10 day) performed on the same day, if the
E&M service provided was distinct from the surgical procedure, it needs to be
reported with modifier 25. If not reported with the modifier, the E&M visit may
receive an edit indicating it was considered part of the global surgical package.
Note: BCN audits health care practitioners who report modifier 25 at a rate much
higher than their medical specialty peers.
•Modifier 25 should be used with E&M codes only and should not be appended to
the code for the surgical procedure or other service (for example, therapeutic
injections, therapeutic infusions or diagnostic X‐rays or scans).
Evaluation & Management Modifiers
•Documentation must be maintained in the member’s clinical record
to substantiate the use of modifier 25. To document the extra work
performed, the member’s clinical record must clearly indicate the
extra or unusual work. The documentation must support that the
E&M service being billed is distinct from the other service performed.
Evaluation & Management Modifiers
•Modifier 26: Certain procedures are a combination of a physician's
professional component and a technical component. One example is
the ultrasound performed during surgery where the hospital owns
the equipment but the surgeon uses during a procedure for proper
placement of hardware. The Surgeon needs to document the use of
the ultrasound and findings in the OP note to support billing for the
ultrasound reading(s).
Evaluation & Management Modifiers
•Modifier 32: Services related to mandated services such as
consultations and/or related services eg: third party payers,
governmental, legislative regulations.
•Modifier 33 for Preventative Services. When the primary purpose of
the service is the delivery of an evidence based service in accordance
with a US Preventive Services Task Force A or B rating in effect and
other preventive series identified in the preventive services
mandates, the services are identified by applying modifier 33.
Evaluation & Management Modifiers
•It is not appropriate to report modifier 57 for major surgeries that are
planned in advance. When modifier 57 is reported with a procedure that
falls within one of the categories of planned surgeries, the E&M service will
be denied. The categories of planned surgeries include:
•Spine surgery, excluding fractures and dislocations
•Arthroplasty: total, partial and revision
• Congenital/deformity procedures (for example, clubfoot)
• Transplant procedures
• Chronic/subacute conditions (for example, tennis elbow or cataract
surgery)
• Modifier 57 should not be used with E&M services performed on the same
day as minor surgical procedures
Other Modifiers
•
GA ‐ Advance notice of non‐coverage provided: use this modifier to tell us that
you provided a notice of Medicare non‐coverage to the patient. If you bill for
non‐covered services without using the GA modifier indicating you did not give
notice of non‐coverage to the patient, insurance carriers will deny your claim. It
will go to provider liability.
•
GY ‐ Service is not covered by Medicare by statute
1. Under Original Medicare the GY modifier identifies that a service is not
covered by Medicare by statute and does not require that notice of non‐
coverage be provided.
2. Under Medicare Part C (Medicare Advantage) rules:
•
You MUST give a patient notice that a service will not be covered, even when the service
provided or referred is not covered by statute. You should then bill their insurance for the
non‐covered, statutorily excluded service.
•However, if you do use the GY modifier, this means you have not given the member a notice
of non‐coverage and the claim will go to provider liability.
Other Modifiers
•
GZ ‐ Service is not covered by Medicare
•Under Original Medicare the GZ modifier identifies that
1) an item or service is expected to be denied as not reasonable
and necessary, and
2) no advance notice of non‐coverage was supplied to the
member. You may bill with this modifier. Payers follow Original
Medicare billing rules, which are that claims having the GZ
modifier:
•Should be denied automatically
•Are not subject to complex medical reviews
•Will be provider liability
Other Modifiers
Using modifier 22, unusual procedural services
•Each procedure code has an expected range of complexity, length, risk, and
difficulty. When the service provided exceeds these normal ranges (more
complicated, complex, difficult, or requiring significantly more time than
usual), add modifier 22 to the procedure code.
•When use of modifier 22 is valid, an additional payment may be allowed.
Additional payment consideration may not apply to every code paid.
•Additional reimbursement will be considered only when the
documentation submitted clearly states the exceptional nature of the
service provided.
•Modifier 22 always requires code review.
•Do not append modifier 22 to unlisted codes.
Modifiers 22
Documentation is key!
•Documentation within the operative report should reflect the unusual
circumstances of the procedure. It is the responsibility of the surgeon
to submit all necessary documentation.
•An explanation of how the service provided differs from the usual
service must be included
•Priority Health has a specific form that they require when using
modifier 22 on claims.
Modifier 22
When modifier 22 is valid:
•Validity requires two or more of the following factors, OR one of the
following factors in addition to extended anesthesia:
•Extreme obesity that significantly complicates surgery
•Co‐morbidities that cause complications during the surgery
•Trauma extensive enough to complicate the particular procedure and
not billed as additional procedure codes
Modifier 22
When modifier 22 is valid:
•Other pathologies, tumors, malformations (genetic, traumatic,
surgical) that directly interfere with the procedure but are not billed
separately
•The services rendered are significantly more complex than described
for the CPT code in question
•Excessive blood loss for the particular procedure
•Difficult surgical approach
•Revisions or removals of prior operative work that are unusually
complex or difficult
Other Modifiers
Other valid uses of modifier 22
•Modifier 22 may also be given individual consideration in other
situations. For example, if access to the primary operative site is
difficult and time‐consuming, additional payment may be warranted
for the primary procedure. However:
•Secondary procedures performed through the same incision may not
meet the same criteria.
•Reductions for multiple procedures will still apply.
•This process does not exempt claims from clinical code edits relative
to bundled services and other code edits
More Modifiers
Surgical Modifiers
•When reporting services performed bilaterally, identify the procedure
code with modifier 50 and a count of 1 on the claim line. For example,
using modifier 50 would be an appropriate way to report a procedure
done on the right wrist and the left wrist at the same setting, each
with a count of 1. This is different than advice from some payers who
request that a bilateral procedure be reported with one line with a
modifier 50 and a second line with the same procedure code but
without a modifier 50. Only if the procedure was performed twice on
each wrist would it be appropriate to report the procedure code with
a modifier 50 and a count of 2.
Surgical Modifiers
•When modifier 52 is reported with
a procedure code, reimbursement
will be adjusted to 50 percent of
the fee schedule. When modifier
52 is reported with a procedure
code, reimbursement will be
adjusted to 50 percent of the
allowed amount. Note: This applies
to BCN Advantage SM and BCN
commercial products as well as
many of the other third party
payers.
Surgical Modifiers
•Modifier 53 Discontinued services: Under certain circumstances, the
physicians may elect to terminate a surgical or diagnostic procedure.
Due to extenuating circumstances or those that threaten the well
being of the patient, it may be necessary to indicate that a surgical or
diagnostic procedure was started but discontinued.
•Note: The modifier is not used to report the elective cancellation of a
procedure “PRIOR to the anesthesia induction and/or surgical
preparation in the operating suite.” (Per CPT 2015).
Surgical Modifiers
•Modifier 54: Surgical care only
•Modifier 55: Postoperative Management
•Modifier 56: Preoperative Management
Surgical Modifiers
•A follow‐up surgical procedure performed by an emergency room
physician within 90 days of a surgical procedure done in an
emergency room is typically reported with modifier 54, indicating that
only preoperative and surgical care were provided. The patient’s own
physician would be expected to assume the care of the patient
postoperatively.
• Claims for these follow‐up surgical procedures will be sent back to
the provider with instructions to resubmit.
Surgical Modifiers
•If surgical care is split between providers, the claims submitted should
identify the care provided by use of the appropriate modifiers. The
surgical care modifiers include modifiers 54, 55 and 56. Claim lines
reported with these modifiers will be reimbursed according to the
percentages from the national (CMS) Physician Fee Schedule Relative
Value Files. Modifier 54 is reimbursed by CMS at the combined
preoperative and intraoperative percentages.
Surgical Modifiers
•Modifier 58 is used to indicate that a subsequent procedure
performed during the global surgery period was anticipated. The
global surgery period is defined according to CMS guidelines and
incorporates the postoperative time frames of 0, 10 and 90 days.
Medical services performed in the postoperative period that are
associated with an earlier surgery must be appropriately coded with
modifier 58 to avoid unnecessary editing.
Surgical Modifiers
•Modifier 62: Two surgeons work together as primary surgeons
perfuming DISTINCT part(s) of a procedure, each surgeon should
report his/her own work. Each surgeon should report the co‐surgery
once using the same procedure code. If additional procedure(s) are
performed during the same surgical session, separate code(s) may
also be reported.
DOCUMENATION! DOCUMENTATION! DOCUMENTATION!
Surgical Modifiers
•Modifier 63: Procedures performed on infants less than 4kg that may
involve significantly increase complexity on work normally associated
with these patients.
•Modifier 66 Surgical Team: Under certain circumstances, highly
complex procedures are carried out under the “surgical team”
concept. These circumstances may be identified by each participating
individual with the addition of modifier 66. Documentation has to
clearly support the individual surgeon as to their involvement in the
OR.
Surgical Modifiers
•
Modifier 76 Repeat procedure or service by same physician or other
qualified Health Care Professional: It may be necessary to indicate
that a procedure or service was repeated by the same physician
subsequent to the original procedure or service.
•
Modifier 77 Repeat procedure or service by ANOTHER physician or
other qualified Health Care Professional: It may be necessary to
indicate that a basic procedure or service was repeated by another
physician subsequent to the original procedure or service.
These modifiers should never be appended to an E/M service.
Surgical Modifiers
•Modifier 78 is used to indicate return trips to the operating room
during the global surgery period for complications related to an
earlier procedure. The global surgery period is defined according to
CMS guidelines, incorporating the postoperative time frames of 0, 10
and 90 days. Medical services performed after an earlier surgery that
are unintended or unexpected must be appropriately coded using
modifier 78 to avoid unnecessary editing. For procedures with a 10‐
or 90‐day global period, the procedure reported with modifier 78 is
reimbursed on the value of the intraoperative care, as noted in the
Medicare Fee Schedule. Procedures that have a 0‐day global period
reported with modifier 78 are not subject to this adjustment.
Surgical Modifiers
•Modifier 79 is used to indicate that a subsequent procedure
performed during the global surgery period should be evaluated
separately. The global surgery period is defined according to CMS
guidelines, incorporating the postoperative time frames of 0, 10 and
90 days. Medical services performed during the postoperative period
that are not associated with the earlier surgery must be appropriately
coded using modifier 79 to avoid unnecessary editing.
Surgical Modifiers
Using modifiers 80, 81, 82: Assistant at surgery:
•Modifier ‐80, assistant at surgery. This includes MD, DO, and DPM provider types
and is an assistant surgeon providing full assist to the primary surgeon.
•Modifier ‐81, minimal assistant at surgery. This includes MD, DO, and DPM
provider types and is an assistant surgeon providing minimal assistance to the
primary surgeon. This modifier may be used when more than one assistant is
involved or if one person assists during a portion of the surgery. This modifier is
not intended for use by non‐physician assistants (e.g., RN, PA).
• Modifier ‐82, assistant at surgery when a qualified resident surgeon is not
available to assist the primary surgeon. This includes MD, DO, and DPM provider
types.
•HCPCS Level II modifier ‐AS, a non‐physician assistant at surgery. This would
include PA, CNS, CRNFA, RNFA, NP, LPN, DDS, DMD, and surgical technician
provider types, subject to contract eligibility.
Modifier 59
•Modifier 59 may be appended when
procedures not typically reported
together needed to be performed on a
patient on the same day by the same
physician, such as separate incisions or
procedures done on different organ
systems. Modifier 59 should not be
used unless other modifiers do not
apply.
Modifier 59
•MLN Matters number MM8863 (included in your handouts):
“The Medicare National Correct Coding Initiative (NCCI) has Procedure to
Procedure (PTP) edits to prevent unbundling of services, and the consequent
overpayment to physicians and outpatient facilities. The underlying principle is
that the second code defines a subset of the work of the first code. Reporting
the codes separately is inappropriate. Separate reporting would trigger a
separate payment and would constitute double billing. “
Modifier 59
CMS has established 4 new HCPCS to define specific subsets of the
Modifier 59 which were effective 1‐1‐2015:
•XE Separate Encounter, A Service That Is Distinct Because It Occurred
During A Separate Encounter,
•XS Separate Structure, A Service That Is Distinct Because It Was
Performed On A Separate Organ/Structure,
•XP Separate Practitioner, A Service That Is Distinct Because It Was
Performed By A Different Practitioner, and
•XU Unusual Non‐Overlapping Service, The Use Of A Service That Is
Distinct Because It Does Not Overlap Usual Components Of The Main
Service.
Modifier 59
While CMS will continue to recognize the ‐59 modifier in many
instances, it may selectively require a more specific ‐ X{EPSU} modifier
for billing certain codes at high risk for incorrect billing. For example, a
particular NCCI PTP code pair may be identified as payable only with
the ‐XE separate encounter modifier but not the ‐59 or other ‐X{EPSU}
modifiers. The ‐X{EPSU} modifiers are more selective versions of the ‐
59 modifier so it would be incorrect to include both modifiers on the
same line.
Modifier 59
However, please note that
these modifiers are valid
even before national edits
are in place. MACs are not
prohibited from requiring the
use of selective modifiers in
lieu of the general ‐59
modifier, when necessitated
by local program integrity
and compliance needs.
Modifier 59
Use of these modifiers vs. modifier 59
•Do not use one of these modifiers with modifier 59 on the same claim
line. According to CPT guidelines, modifier 59 should be used only
when no other descriptive modifier explains why distinct procedural
circumstances exist. Therefore, these new modifiers should be used
instead of modifier 59 to describe why a service is distinct.
•The CPT definition for modifier 59 has also been revised with a
notation that references using these new Level II HCPCS modifiers
Modifier 59
•Medical Affairs Response: BCBSM will be accepting the new modifiers
indicated below for the same procedures currently eligible for
modifier 59. We do expect to receive additional CMS program
guidance in the future, regarding the Distinct Procedural Services, at
which time we will discuss further with our physician staff to
determine if additional changes would be required. However, unless
or until CMS provides additional guidance on selective editing or any
guidance wherein modifier ‐59 is given additional restrictions for its
use, we will continue to edit the same as ‐59 currently does in CXT
today. ”
Modifier 59
BCN take on changes to utilization of Modifier 59:
•Modifier 59 is not required to override the edit between procedure
code *11100 and any of the following codes: *11040‐*11042,
*11055‐*11057, *11200, *11300‐*11301, *11305, *11307, *11310,
*16000, *16020, *17000, *17250 and *17260. Reporting modifier 59
with *11100 and any of these codes could result in an incorrect
reduction in reimbursement. Procedure code *11100 and any of the
listed codes will process without a modifier. (This applies to all BCN
products except BCN Advantage and BCN 65.)
Modifier 59 for BCN continued
•When reporting another injection along with an immunization, you must
report modifier 59 on the injection procedure. If both services are provided
and modifier 59 is not indicated, an edit may occur between the injection
administration code and the immunization administration code.
•For its commercial membership, BCN recognizes modifier 59 as valid but
does not allow it to automatically override all edits allowed in the National
Correct Coding Initiative Manual. The codes for which modifier 59 will
override appropriate edits and increase payment are listed in the
Addendum in this document. (The Addendum applies to all BCN products
except BCN Advantage and BCN 65. For BCN Advantage, the CMS listing is
followed.)
Modifier 59 insight from Priority Health
•Effective Jan. 1, 2015, four new modifiers will more effectively identify
distinct services that are typically considered inclusive to another
service. Utilizing these modifiers will assist in more accurate coding
that better describes the procedural encounter.
•These modifiers, collectively known as ‐X {ESPU}, will be accepted for
all lines of business on both professional and facility claims.
•‐ See more at:
http://www.priorityhealth.com/provider/manual/billing‐and‐
payment/modifiers/xe‐xs‐xp‐xu#sthash.Mxm30Ofu.dpuf
Modifier 59 insight from Priority Health
Documentation requirements:
As always, providers must maintain adequate documentation in the
medical record. Documentation must support the modifier use for
separate services. Although one of these modifiers may be appended
to a claim line on first submission, this does not guarantee
reimbursement for these services. Medical records may be required to
validate use of modifier. Addenda or amendments to the
documentation will not be accepted after a claim has been denied. If a
claim line is denied due to a clinical edit and you submit a corrected
claim using modifier XU, XS, XP, or XU for that claim line, we will require
medical records in order to process the corrected claim.
Modifier 59 insight from Priority Health
CPT codes that require medical records when submitted with X
modifiers:
•Cardiovascular system 36215‐36218, 38220
•Digestive system 44005, 45378, 45380, 45381, 49000, 49320
•Integumentary system 11055‐11057, 19120, 19125, 19260, 19290,
19291, 19295, 19301, 19303, 19307, 19316, 19318, 19325, 19328,
19330, 19340, 19357, 19361, 19370, 19371, 19380
•Urinary/reproductive systems 52000, 52310, 57100, 57268, 58555,
58660
Modifier 59 insight from Priority Health
CPT codes that require medical records when submitted with X modifiers:
•Musculoskeletal system 20600, 20604‐20606, 20610, 20650, 20670, 20680,
22214, 22224, 22425, 22505, 22520, 22521‐22524, 22551, 22552, 22554,
22585, 22600, 22610, 22612, 22614, 22630, 22633, 22634, 22800, 22802‐
22804, 22830, 22842, 22845, 22846, 22848, 22850‐22852, 22855, 23700,
24300, 25259, 26340, 27570, 27860, 28110, 28230, 28232, 28310, 28725,
29805‐29807, 29821‐29824, 29870, 29884
•Nervous and ENT systems 63005, 63012, 63030, 63035, 63042, 63045‐
63048, 63055‐63057, 63075, 63076, 63081, 63082, 69210, 69990
Surgical Modifiers
These are for the ASC reporting only:
•When a surgical or diagnostic procedure is discontinued, modifier 73
or 74 is required in order to administer payment appropriately.
•Modifier 73 is reported when the surgical or diagnostic procedure
was discontinued before the anesthesia was administered.
•Modifier 74 is reported when the surgical or diagnostic procedure
was discontinued after the anesthesia was administered.
Who am I?
Kathy Jo Uecker
CMPE, EFPM, NCP, CPC, COC
AHIMA trained for ICD‐10CM/PCS
AHIMA Ambassador
Medical Informatics Solutions, LLC
Phone 248/851‐3124 Ext 109
Mobile 269/420‐9404
Kuecker@mis‐llc.com
