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traight Talk XXII
November 11, 2013
Sandy Steele, CPC, CPMA, CEDC, CAC
Applying Modifiers
What is a Modifier?
A modifier added to a CPT code will help provide additional
information on the claim. A modifier can help answer questions such as:
Which one
Which side
Indicate repeat or multiple procedures
Explain special circumstances or conditions of patient care
Indicate that a service has been modified from the CPT description but the core procedure or service has not changed.
Steps to take to apply the correct modifier:
Review CPT (AMA) Guidelines
Review individual carrier guidelines (CMS for example)
Apply only 2 digit modifiers
Review the entire medical record before assigning modifiers
Two or more modifiers may be assigned to one CPT code to give the most accurate description possible
Applying Modifiers
Most common Emergency Department Modifier
MODIFIER 25
Significant Separately Identifiable E/M Service by the Same Physician on the Same Day of the Procedure or Other Service
The patient has a complete E/M service and a procedure performed during the same visit.
Add additional ICD-9 codes to describe the circumstances
The medical record should have a history, physical exam and medical decision making documented to justify the E/M code being assigned.
Example – a patient presents with a 2.0 cm laceration to the scalp. The 2 y/o patient was running and tripped and struck the brick around the fireplace. A history and exam was performed to check for additional injuries and the wound was evaluated and sutured. The documentation has a history, physical exam, medical decision making and a procedure note. 9928X-25 and 120XX would be
Modifier 26
Professional Component
Modifier 26 indicates that only the physician’s (professional) component of the procedure was performed.
Example – Coding for the interpretation and report of an x-ray. The physician does not own the equipment or employ the staff that took the x-ray. The 26 modifier indicates that the billing is only for the professional component – the technical component will be billed separately.
Applying Modifiers
MODIFIER 50
Bilateral Procedure
Modifier 50 will be added when bilateral procedures are performed during the same operative session.
Example: The patient tripped while running down a hill injuring both wrists. Bilateral short arm splints were applied. 29125-50
MODIFIER 51
Multiple Procedures
This modifier will indicate that multiple procedures (other than
the E/M) were performed during the same session by the same
provider. The primary procedure would not have a modifier, the
additional procedure may be identified by attaching modifier 51.
Example – two lacerations repaired during the same visit; 12051 &
12001-51. The E/M would have modifier 25 assigned if
appropriate.
Applying Modifiers
Modifier 53
Discontinued Procedure
Indicates that the physician elected to terminate a surgical or
diagnostic procedure that was started but discontinued due to
extenuating circumstances or circumstances that threaten the
well-being of the patient.
Lumbar puncture discontinued due to the patient have difficulty lying still. Check with the physician, many providers do not want to bill for
MODIFIER 54
Surgical Care Only
This modifier indicates that the physician has performed the surgical portion of a procedure only. Another physician will provide
postoperative management.
Example: The emergency physician provides manipulation of a closed distal radial fracture. The patient will follow-up with another
physician for postoperative care. The physician providing the post-op care would apply modifier 55.
Applying Modifiers
Modifier 57
Decision for Surgery
Modifier 57 indicates that the decision for surgery was
made during the E/M service.
Example – The patient presents to the emergency
department with shoulder pain. The physician provides
the E/M service, finds that the patient had dislocated his
shoulder. The shoulder is then reduced by the physician.
9928X-57 & 23650-54
Modifier 59
Distinct Procedural Service
Modifier 59 indicates that a non-E/M procedure or service was distinct or independent from other non-E/M services performed on the same day. This modifier is used to identify procedures and/or services that are not normally reported together, but are appropriate under the circumstances.
Documentation should be very clear to support that separate services were provided. Examples would be separate incisions, separate injuries, different or separate procedures. If a more descriptive modifier is available, modifier 59 should not be chosen.
Example: Patient has a repair of a laceration to the hand and also has an abscess that is incised and drained on the back. 10060 & 12001-59
Modifier 59 will allow most claims to process, be very careful that procedures are fully documented and code selection is not unbundling procedure codes. Excessive use of modifier 59 can be a red-flag to the carrier and possibly prompt an audit.
Applying Modifiers
Modifier 76
Repeat Procedure or Service by Same Physician
Indicates that a procedure or service was repeated
subsequent to the original procedure or service.
Example – Second ECG interpretation and report on the
same day. WPS Medicare prefers that the units or quantity
be used to report multiple ECG interpretations. Example
93010 & 93010-76 WPS Medicare 93010 – quantity 2
Modifier 77
Repeat Procedure by Another Physician
Modifier 77 indicates that a procedure or service performed
by another physician had to be repeated.
Example: The physician at hospital A sutures the patient’s
scalp wound. A few hours later the patient falls and goes to
hospital B were it is found the sutures need to be replaced.
12001-77 (billed by the physician at hospital B)
Applying Modifiers
Additional Modifiers
These are just a few of many, many modifiers available
F1 left hand, second digit F2 left hand, third digit T8 Right foot, fourth digit
1P PQRS modifier to indicate that measure was not performed due to medical reasons
8P PQRS modifier to indicate that the measure was not performed, reason not specified
GC Service has been performed in part by a resident under the direction of a teaching physician. Reporting this modifier certifies that the teaching physician was present during the key portion of the service and were immediately available during other parts of the service.
When hospice coverage is elected, the beneficiary waives all rights to Medicare Part B payments for professional services that are related to the treatment and management of his/her terminal illness during any period his/her hospice benefit election is in force. Professional services of an independent attending physician, who is not an employee of the designated hospice nor receives compensation from the hospice for those services may be paid by Medicare Part B. Apply this modifier when service
is received for an unrelated illness or injury.
GW - service not related to the hospice patient’s terminal condition
Providers that render services to a prisoner or patient in a jurisdiction that meets the conditions of 42 CFR 411.4(b) should indicate this fact with the use of modifier
QJ – Services provided to a prisoner or patient in State or local custody Additional information on applying modifier QJ can be found at this address:
http://wpsmedicare.com/j8macpartb/claims/submission/b_statelocal.shtml
Applying Modifiers
Michigan Medicaid FFS & Managed Care
E/M codes 99281 – 99285 are reimbursed based on the disposition of the patient. Additional procedures will be reimbursed separately. Critical care services (99291-99292) do not require the UD/UA modifier.
UA - Admitted or transferred - Required for ED case rate to be paid to the attending ED physician when beneficiary is admitted or transferred - $96.43
UD - Released/Discharged from Emergency Department - Required for ED case rate to be paid to the attending ED physician when beneficiary is treated and released/discharged from the ED. – $41.94
Reimbursement without the UD/UA modifier: 99282 - $14.46
99283 - $32.49 99284 - $50.71 99285 - $79.44
