Let s Talk About Modifiers! Learning Outcomes

Let’s Talk

About

Modifiers!

Learning Outcomes

• Describe what a modifier is and how it is used

• Identify who is responsible for using correct

modifiers at the correct time

• List the most common modifiers

• Describe the NCCI edits and how they are

used

• Identify the importance of using modifier 59

correctly

A 2-digit alpha or numerical code, added to a CPT or HCPCS code, that further

describes a service or procedure.

An alpha-numeric 5-digit code that describes a service, procedure,

medicine or supply

A 5-digit numerical code that tells the payer What service you provided for the patient

What is a Modifier? What is a CPT Code?

More about

modifiers

Created by the American Medical Association (AMA)

They do not change the basic meaning of the code that they are attached to. The UB 04 claim form allows up to 4 modifiers per line.

Using modifiers can increase or decrease your reimbursement.

Applying modifiers for the sole purpose of bypassing an edit is NOT allowed.

When are modifiers used?

To identify professional or technical services

To designate bilateral or unilateral

To identify a specific body area

To show repeat services

To show a separate service

To show an increased or decreased service

To identify type of service

Who applies modifiers?

hardcoded in your chargemaster

They can be applied by coding staff

They may be applied by billing staff in coordination with

clinical or coding staff.

National Correct Coding Initiative edits were created to control improper reporting of CPT codes. CMS annually

updates the NCCI edits. 2 types of edits.

PTP edits (Procedure to Procedure) MUE edits (Medically unlikely Edits)

NCCI Edits

What edits stop a claim for

modifiers?

Finding the Edits

https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html

They will download in a Zip file Open the xlsx file

Columns A

and B

Column 1 and Column 2 codes

Column 2 codes may be a

component of the Column 1 codes.

The codes may just be pairs that cannot be billed together without a modifier or at all.

They may be mutually exclusive, meaning it’s not reasonable to report them together.

Columns A,

B and F

Column 1 and Column 2 codes

Column 1 codes are the payable codes

Column 2 codes are not paid unless there is a modifier applied.

Column F tells you if a modifier can be used

Column F - Modifiers

• Relates to the two codes in columns A and B • 0 = No modifier allowed

• 1 = Modifier allowed

• 9 = Not applicable this will correspond with Column E that will have the date the edit was inactivated.

Component

Codes

When one code is a component of another code.

Example: A single test in a panel of tests The column 1 code is the code that is the most comprehensive and will pay.

The column 2 code is not paid unless an appropriate modifier is applied.

Documentation must support the application of the modifier.

Example: X-ray of the foot and X-ray of the heel. The most comprehensive is the X-ray of the foot.

Component Codes

• A rhythm strip is considered a component of an EKG.

• 93005 should not be reported with 93041 as a separate part of the EKG interpretation.

• A cardiac stress test – 93017 includes multiple EKGs so they cannot be reported separately. (93005)

Mutually Exclusive

Some CPT codes are considered “mutually exclusive”. They cannot reasonably be performed on the same anatomical site or the same beneficiary the same day. Modifiers are not appropriate.

Example: A laparoscopic gallbladder removal and an open gallbladder removal. Only code the most comprehensive.

EXAMPLE

• 80076 with 82247 Modifier indicator “1” • 80076 Hepatic Function Panel

– ALBUMIN (82040) – BILIRUBIN, TOTAL (82247) – BILIRUBIN, DIRECT (82248) – PHOSPHATASE, ALKALINE (84075) – PROTEIN, TOTAL (84155)

– TRANSFERASE, ALANINE AMINO (ALT) (SGPT) (84460) – TRANSFERASE, ASPARTATE AMINO (AST) (SGOT) (84450) • 82247 Bilirubin Total

• The bilirubin total is being repeated later in the day • Add modifier 91

Modifier

91

Used only for lab CPT codes

Used to identify repeated lab tests

• Running the test to confirm results • Specimen problems (clotting, not enough

etc.)

• When it is run with others in a panel

Not appropriate to use when:

EXAMPLE

• 80061 with 82465 Modifier indicator “0” • 80061 – Lipid Profile

– CHOLESTEROL, SERUM, TOTAL (82465) – LIPOPROTEIN, DIRECT MEASUREMENT

– HIGH DENSITY CHOLESTEROL (HDL CHOLESTEROL) (83718) – TRIGLYCERIDES (84478)

• 82465 – Cholesterol Serum Total

• 82465 – it is not reasonable that this would need to be done more than once per day.

Common

Edits

80305 with 81001 Modifier Indicator “1”

80305 – Drug Screen

81001 – Urinalysis

Drug screens are done using urine. If a urinalysis is done on the same specimen for validity testing do NOT bill 81001 using a modifier.

It must be a completely separate procedure for a medically necessary urinalysis.

CBC Testing

If an automated CBC 85027 is ordered with a manual differential 85007, these can be billed together.

If an automated CBC is ordered with an automated differential WBC count 85025, it cannot be billed with a manual WBC differential 85007 because it will result in an overpayment.

85025 and 85007 cannot be billed even with a modifier

Venipunctures

• “CPT code 36415 describes collection of venous blood by venipuncture. Each unit of service (UOS) of this code includes all collections of venous blood by

venipuncture during a single episode of care regardless of the number of times venipuncture is performed to collect venous blood specimens. Two or more collections of venous blood by

venipuncture during the same episode of

care are not reportable as additional UOS.”

Real World Examples

Column One/Column Two Which code does the modifier apply to?

• 96372– IM/Sq injection with 12001– suture repair

• 12001 is the most comprehensive so modifier 59 would apply to 96372 unless, 96372 is for the injection given to numb the laceration. • 96372with G0463– outpatient clinic visit • 96372 is a column one code so modifier 25

Real World Examples

Which one does the modifier apply to?

96372 – IM/Sq Injection with 96374– IV push injection

96374 is the column one code so apply 59 to 96372

96374 with 71260– CT Chest with contrast 71260 is the most comprehensive so apply

59 to 96374

Common

Edits

If the injection was given through the heplock noted above, only the injection would be charged.

If a second heplock was inserted and never used, you can bill 36000 with a modifier 59.

Included with

Surgical

Procedures

• Foley Catheter insertion CPT codes 51701-51703 • Wound Closure CPT codes 12001-13153 • Control of bleeding in OR or Recovery • Drug Administration

• Radiological guidance integral to the procedure

Blood

Collection

and Irrigation

• Collection of blood from an implanted device – 36591

• Collection of blood from a venous device – 36592

• Cannot be reported with any other service than a lab service.

• Irrigation of implanted device – 96523 • This can only be reported if it is the

ONLY service provided for the patient.

Modifier 59

Distinct service identifies that procedures were done that are not usually reported together but are appropriate under the circumstances. 2 separate procedures done the same day

Done in a separate session, different procedure, different site, or separate area of injury.

Use modifier 59 on the least comprehensive code.

Modifier 59

Do NOT use

modifier 59:

• On an E/M CPT code

(99281-99285 etc.)

• Exact same procedure

done the same day

• Multiple injections of

the same drug

• Without documentation

to support both codes

Modifier 59

Modifier 59 may be used when two timed procedures follow each other sequentially not when they are performed together.

Each timed portion must be separate.

Example: Physical Therapy charges in 15-minute increments.

“X” Modifiers

XE – Separate Encounter – Only used to describe separate encounters on the same day.

XS – Separate Structure – A service that is distinct because it was done on a separate structure.

XP – Separate Practitioner - A service that is distinct because it was done by a different practitioner.

XU – Unusual non-overlapping Service – Service does not overlap usual components of the main service.

Therapy Common Examples

97164– PT Re-evaluation

• If there is documentation that makes it clear that these were done the same day but at different times, you can use the modifier 59.

• 97530 – Therapeutic Activities with

97164 – PT Re-eval

• If there is documentation that makes it clear that these were done the same day but at different times, you can use the modifier 59.

Real World Examples

Which one does the modifier apply to?

97150 – Group therapeutic exercise with 97110 individual therapeutic exercise

Apply 59 to 97150 if the exercise sessions do not have a time overlap.

Modifier 59

Cytopathology Codes

88104-88112, 88142-88143, 88150-88154, 88164-88167, etc When separate specimens from different sites are reported you use modifier 59 instead of modifier 91.

Always check with the lab department before applying modifiers.

Modifier 59

Using modifier 59 routinely is a red flag

for audit.

MACs are reviewing for appropriate use.

NEVER use a modifier 59 to bypass an edit without

knowing if it is appropriate and that documentation supports

Other

Common

Modifiers

25 – Only used on E/M levels

LT and RT – Left and Right

(CDM)

50 - Bilateral

76 – Repeat procedure other

than lab tests

91 – Repeat laboratory testing

Understanding

how and when

to use

modifiers

• Takes time, education and experience.

• Coders should have all 3. • If your coding staff does not understand modifiers that is a problem.

• Billing staff must have someone to turn to with questions.

Always Remember…

Documentation must always support the

use of modifiers.

If you do not have access to the documentation, then

you can’t know if it is sufficient.

MUE Edits

MUE Edits

Medically Unlikely Edits

• The maximum number of units of a service for one patient on one date of service.

• MAI – MUE Adjudication Indicator

1

not date

2

of service

3

Per Day by clinical benchmark Based on medical

necessity

Anatomic Considerations

MUE for knee brace is “2” because there are only 2 knees

MUE for appendectomy is “1” because there is only one appendix

What are MUEs based on?

CPT code descriptions

Code described as initial hour would have an MUE of “1” because of the word “initial”

If the code says “biopsies” the MUE would be “1” because it is a comprehensive plural

If the code is “unilateral” the MUE is “1”

What are MUEs based on?

CMS Policies

If the code descriptor does not specify a unit of service CMS can determine the MUE to be “1”

If a CPT code is non-covered, bundled or not separately payable the MUE may be “0”

What are MUEs based on?

The nature of the equipment

Only one wheelchair can be used per patient at any one time so the MUE is “1”

A specialty bed is used by one patient per day so the MUE is “1”

The nature of the service

If a specimen takes 24 hours to collect the MUE is “1”

If a procedure like a colonoscopy is unlikely to be performed more than once oer day the MUE would be “1”

A sleep study is done over night and there is only one night per date of service the MUE is “1”

What are MUEs based on?

Prescribing Information

If prescribing info has a “maximum” daily dose that is used to determine the MUE. If the dose is “recommended” or “usual” claims data was reviewed to determine the MUE.

For PRN or “as needed” dosages, claims and prescribing data are reviewed.

MUE Denials

MUEs are coding denials not medical

necessity denials.

An ABN would not be appropriate and cannot be used as a

way to exceed the MUE limits. MUE denials can be

appealed if documentation of medical necessity is

shown and proven.

Units of

Service

Always review

the description

of the code that

hits an MUE

edit and look at

the other codes

it is billed with.

Common Labs with MUE of One

80053 Comprehensive Metabolic Profile

(CMP)

80061 Lipid Panel 80069 Renal Function Panel

80074 Acute

Hepatitis Panel 80305-80307 Drug screens Venipuncture36415

J0696

-Rocephin

J0696 - 250mg per unit of

service

MUE – 16 per day based

on prescribing information

Adult daily dose should

not exceed 2 grams

2 grams = 2000 mg ÷ 250 mg = 16

United Healthcare Lab Policies

United Rules

Individual lab codes which together make up a panel, will be denied.

They do NOT follow CPT guidelines for billing lab panels.

Lab panels can be billed without all of the components

Ionized Calcium

– With 4 or more of the following

• CPT 80051 – Electrolyte Panel (82374, 82435, 84132, 84295)

– Plus 82330

– Plus 1 of the following

CPT 80048 – Basic Metabolic Profile

Calcium Total

• With 5 or more of the following

• CPT 80051 – Electrolyte Panel (82374, 82435, 84132, 84295)

Plus 1 or more of the following

Comprehensive Metabolic Panel - 80053

• 80053 cannot be billed the same day as 80048

• 80053 is billed when 10 or more component codes are included

• 80048 plus 2 other codes in 80053 = 80053

https://www.uhcprovider.com/content/provider/en/viewer.html?file=https%3A%2F%2Fwww.uhcprovider.com%2Fcontent%2Fdam%2Fprovider%2Fdo cs%2Fpublic%2Fpolicies%2Fmedicaid-comm-plan-reimbursement%2FUHCCP-Laboratory-Services-Policy-(R0014).pdf

United

Code

Rules

Policy includes many other panel requirements

Modifiers will not lead to

reimbursement for these panels You cannot appeal these denials You may be able to submit corrected claims

Every payer has different rules

Questions?

Learning Outcomes

• Describe what a modifier is and how it is used

• Identify who is responsible for using correct

modifiers at the correct time

• List the most common modifiers

• Describe the NCCI edits and how they are

used

• Identify the importance of using modifier 59

correctly