My Coding Connection, LLC Unrelated E/M by the same physician during a postoperative period

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M

ODIFIERS

Rachel Coon, CCS-P, CPC, CPC-P, CPMA, CPC-I, CEMC, ICD-10

My Coding Connection, LLC 618-530-1196

G

LOBAL

P

ACKAGE

M

ODIFIERS

 24 Unrelated E/M by the same physician during a postoperative period

 25 Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service

 57 Decision for surgery

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G

LOBAL

P

ACKAGE

M

ODIFIERS



54 Surgical care only



55 Postoperative management only



56 Preoperative management only

GLOB PRE INTRA POST

HCPCS DESCRIPTION DAYS OP OP OP

22521 Percut vertebroplasty lumb 10 0.1 0.8 0.1

22548 Neck spine fusion 90 0.1 0.69 0.21

G

LOBAL

P

ACKAGE

M

ODIFIERS



58 Staged or related procedure or service by

the same physician during the postoperative

period



78 Unplanned return to the operating/

procedure room by the same physician

following initial procedure for a related

procedure during the postoperative period



79 Unrelated procedure or service by the same

physician during the postoperative period

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G

LOBAL

P

ACKAGE

M

ODIFIERS



78 Unplanned return to the operating/

procedure room by the same physician

following initial procedure for a related

procedure during the postoperative period



Example:

 January – Gastric bypass (90 day global period)  March – Incisional hernia on the bypass incision,

taken back to the operating room for incisional hernia repair.

 Add modifier 78 to the hernia repair

G

LOBAL

P

ACKAGE

M

ODIFIERS



79 Unrelated procedure or service by the same

physician during the postoperative period



Example:

 January – Amputated DIP joint (finger)  March – Below the knee amputation

 Add modifier 79 to the below the knee amputation

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S

URGICAL

M

ODIFIERS



22 – Increased Procedural Service



50 - Bilateral Procedure



51 - Multiple Procedures



52 - Reduced Services



53 - Discontinued Procedure

M

ODIFIER

22 - I

NCREASED

P

ROCEDURAL

S

ERVICE



Services required to perform the procedure are

significantly greater than usually reported

with the procedure



Bill with the operative report

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M

ODIFIER

22 - I

NCREASED

P

ROCEDURAL

S

ERVICE

Example:

A patient has a colonoscopy and a polyp is removed. The removal of the polyp causes excessive bleeding and an extra 30 minutes is spent controlling the bleeding. Modifier 22 would be added to the surgical code and the operative report and/or letter would be sent with the claim to the payer.

M

ODIFIER

50 - B

ILATERAL

P

ROCEDURE

Check with payers on how to submit:

 One line item with modifier 50

Example: 20610-50

 Two line items with modifier 50 on the second code

Example: 20610

20610-50

 Two lines using RT/LT

Example: 20610-RT 20610-LT M yCod in gCon n ec tion .com 10

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M

ODIFIER

50 - B

ILATERAL

P

ROCEDURE



Pay close attention to code descriptions.



Some codes specify ‘unilateral’ and include a

parenthetical statement.

Example: 50592 – Ablation, 1 or more renal

tumor(s), percutaneous, unilateral,

radiofrequency



Some codes say 1 or both.

Example: 69210 – Removal impacted cerumen

(separate procedure), 1 or both ears

M

ODIFIER

51 - M

ULTIPLE

P

ROCEDURES

 More than one procedure performed at the same session by the same provider

 Not used on E/M services, Physical Medicine or

Rehabilitation Services, the provision of supplies such as vaccines or codes designated as ‘add-on’ codes. Example:

An orthopedic surgeon performs a closed treatment of a femoral shaft fracture on the left leg and a closed treatment of a right knee dislocation during the same operative session. It would be coded as 27500-LT and 27552-51-RT. M yCod in gCon n ec tion .com 12

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M

ODIFIER

52 - R

EDUCED

S

ERVICES

Procedure partially reduced at physician discretion

Service not completed in its entirety Example:

43770 Laparoscopy, surgical, gastric restrictive procedure; placement of adjustable gastric restrictive device

(For individual component placement, report 43770 with modifier 52) M yCod in gCon n ec tion .com 13

M

ODIFIER

53 - D

ISCONTINUED

S

ERVICES



Procedure terminated due to:

 Extenuating circumstances

 Circumstances threatening the well-being of the patient



Do not use:

 Elective cancellation prior to induction of anesthesia

Example:

A patient who is having a surgical procedure and after the administration of general anesthetic exhibits unstable vital signs. At the recommendation of the anesthesiologist the surgeon decides to terminate the procedure. M yCod in gCon n ec tion .com 14

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M

ODIFIER

59 - D

ISTINCT

P

ROCEDURAL

S

ERVICE



Procedures not normally reported together



Different Session or Patient Encounter



Different Procedure or Surgery



Different Site or Organ System



Separate Incision/Excision



Separate Lesion

M

ODIFIER

59 - D

ISTINCT

P

ROCEDURAL

S

ERVICE

Example:

A patient had a colonoscopy and a lesion is removed proximal to the splenic flexure. During the same

colonoscopy a biopsy is taken of a different lesion. Both codes are reportable using modifier 59 on the second procedure. M yCod in gCon n ec tion .com 16

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M

ODIFIER

76 - R

EPEAT

P

ROCEDURE

OR

S

ERVICE

BY

S

AME

P

HYSICIAN

Example:

A patient who goes to the Emergency Room with a trauma to the chest. A two-view chest x-ray is taken that shows a pneumothorax. After a chest tube is placed a repeat two-view chest x-ray is taken to verify the placement of the chest tube. You would report 71020 and 71020-76. M yCod in gCon n ec tion .com 17

M

ODIFIER

77 - R

EPEAT

P

ROCEDURE

OR

S

ERVICE

BY

A

NOTHER

P

HYSICIAN

Example:

A patient who sees the family practitioner for chest pain and the physician does an EKG and then refers the patient to a cardiologist. The patient is able to see the cardiologist on the same day and the cardiologist performs a repeat EKG. The second EKG would be reported with modifier 77.

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M

ULTIPLE

S

URGEON

M

ODIFIERS

 62 – Two Surgeons

 Work together as primary surgeons  Perform distinct parts of a procedure  Dictate op report of their distinct part

 Each will submit the same code and append modifier 62  66 – Surgical Team

 Highly complex procedures  Require differently specialties

 Modifier 66 appended to procedures coded by the surgical team

A

SSISTANT

S

URGEON

M

ODIFIERS

 80 – Assistant Surgeon

 Assistant surgeon present for entire or substantial portion of the operation

 Reports the same surgical procedure with modifier 80 appended  81 – Minimum Assistant Surgeon

 Circumstances present that require the services of an asst surgeon for a short time. Minimal assistance.

 Reports the same surgical procedure with modifier 81 appended  82 – Assistant Surgeon (when qualified resident surgeon

not available)

 Used in a teaching hospital that employs residents  No residents available and another surgeon is used

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A

NCILLARY

M

ODIFIERS

 Global – a procedure containing both a technical and a professional component

 Modifier 26 – Professional Component  Modifier TC – Technical Component

A

NCILLARY

M

ODIFIERS

Example:

A patient comes to the office with wheezing and congestion. The physician takes a 2-view chest X-ray using his or her own equipment and sends it out to be read by a radiologist. The office would code 71020-TC for the use of the equipment (technical)

 The radiologist would bill 71020-26 for his/her interpretation

and report (professional service).

 If the office took the X-ray and also did the interpretation and

report, they would code 71020 – without any modifiers – to indicate they did the global service…..both the technical and professional components M yCod in gCon n ec tion .com 22

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L

ABORATORY

M

ODIFIERS

 90 – Reference (Outside) Laboratory

 Used to bill for lab services purchased from an outside lab

 91 – Repeat Clinical Diagnostic Lab Test  Not used to confirm results

 Not used to repeat a test due to equipment malfunction

 92 – Alternative Lab Platform Testing  Single use  HIV testing M yCod in gCon n ec tion .com 23

A

NESTHESIA

M

ODIFIERS

 23 - Unusual Anesthesia  47 - Anesthesia by Surgeon

 AA - Anesthesia services personally performed be an anesthesiologist

 QK – Medical Direction of two, three, or four concurrent anesthesia procedures by an anesthesiologist

 Physical Status Modifiers

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WPS

There are times when the coding and modifier

information issued by the Centers for Medicare & Medicaid Services (CMS) differs from the American Medical Association's (AMA) coding advice regarding the use of modifiers.

A clear understanding of Medicare's rules and regulations is necessary in order to assign the modifier correctly.

• This is particularly true for modifiers 22, 25, 50, 51, 59, 76 and 78.

Please take careful note of the Medicare usage guidance provided in this manual.

WPS

Inappropriate Modifier Usage:

The system used by Part B carriers to process

claims is called the Multi-Carrier System or

MCS.

The MCS system will deny claims as

"unprocessable" for inappropriate modifier use.

If the use of a procedure code/modifier

combination is inappropriate, you will need to

make the necessary corrections and resubmit

the claim

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WPS

 Important Review Facts

Adding modifiers 24, 25, 26, 58, 59, 76, 78, or 79 to a denied service continues to be one of the top reasons for requesting a review. Remember that two different ICD-9-CM codes alone does not justify adding modifier 25.

Calling to add a modifier just because the service was denied is not appropriate.

Having front-end edits in your individual claim processing system can eliminate a delay in payment for you and unnecessary follow-up work for both WPS and your offices.

Be prepared before calling in for a review. We have experienced providers calling and asking to add a modifier.

Then when that modifier did not get the claim paid, they want to try another one. This is inappropriate.

WPS

 Important Documentation Facts

It may be necessary to use the phrase "additional

documentation available upon request" in the narrative field of your claim in order to support the modifier used. It is necessary to indicate you have

documentation with modifier 22, critical care, and co-surgery modifiers for the same specialty.

When documentation is requested because of modifier usage, the number one reason for denial is

because the documentation is not returned in a

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WPS

 Important Miscellaneous Facts

• It is only appropriate to report modifiers 24, 25 and 57 on evaluation and management procedure codes.

• Never report modifier 76 on a surgical procedure code. • When it is necessary to report the following payment

modifiers with another modifier, the payment modifier must be reported in the first modifier field: TC, 26, 52, 53, AA, AD, QK, QW, QY and QZ.

• Report modifiers 54 and 55 on the surgery code only.

 We will review the appropriateness of the use of certain claims modifier codes during the global surgery period and determine whether Medicare payments for claims with modifiers used during the global surgery period were in accordance with Medicare requirements. surgery period resulted in inappropriate payments

 The global surgery payment includes a surgical service and related preoperative and postoperative E/M services provided during the global surgery period. (CMS’s Medicare

Claims Processing Manual, Pub. 100-04, ch. 12, § 40.1.) Guidance

for the use of modifiers for global surgeries is in CMS’s Medicare

Claims Processing Manual, Pub. 100-04, ch. 12, § 30. (OAS;

W-00-12-35607; various reviews; expected issue date: FY 2012; new 30

M yCod in gCon n ec tion .com

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We will determine the extent to which Medicare improperly paid clams for m 2002-2011 in which providers entered GA, GX, GY, or GZ service code modifiers, indicating that Medicare denial was expected.

Providers may us GA or GZ modifiers on claims they expect Medicare to deny as no reasonable and necessary pursuant to CMS’s Claims Processing Manual.

They may us GX or GY modifies for items or services that are statutorily excluded.

A recent OIG review found that Medicare paid for 72%

of pressure-reducing support surface claims with

GA or GZ modifiers, amounting to $4 million in

potentially inappropriate payments. ( FY 2013; work in progress) M yCod in gCon n ec tion .com 31

We will review Medicare Part B claims for personally performed anesthesia services to determine whether they were supported in accordance with Medicare requirements.

We will also determine whether Medicare payments for anesthesiologist services reported on a claim with the “AA” service code modifier met Medicare requirements.

Physicians report the appropriate anesthesia modifier to denote whether the service was personally performed or medically directed. (CMS’s Medicare Claims Processing Manual, Pub. No. 100-04, Ch. 12, ..50)

The service code “AA” modifier is used for anesthesia services personally performed by an anesthesiologist, and the “QK” modifier is used for medical direction of two, three, or four concurrent anesthesia procedures by an anesthesiologist. The QK modifier limits payment at 50% of the Medicare-allowed amount for personally performed services claimed with the AA modifier. Payments to any service provider are precluded unless the provider has furnished the information necessary to

determine the amounts due. ( Social Security Act, 1833 (e).)(FY

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R

EFERENCES

 AAPC  OIG  CPT® Questions Contact: Rachel Coon My Coding Connection, LLC 618-530-1196 MyCodingConnection@gmail.com M yCod in gCon n ec tion .com 33