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Coding with Modifiers

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  1. Coding with Modifiers Oregon Medical Association October 29, 2009 Frann M. Britton, RN, CCS,CCS-P

  2. 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

  3. 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

  4. 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

  5. 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.

  6. CPT Categories • Category II Performance Measurement • The use of these codes is optional and is not required for correct coding.

  7. 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.

  8. 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

  9. 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

  10. 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

  11. 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.

  12. 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

  13. 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”.

  14. 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.

  15. 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.

  16. National Correct Coding Initiative • NCCI is used by all practioners, hospitals, providers or suppliers eligible to bill Medicare.

  17. 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

  18. 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.

  19. 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.

  20. 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.

  21. 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.

  22. 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”.

  23. 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.

  24. 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

  25. NCCI Modifiers Important to use NCCI-associated modifiers only when appropriate • Separate patient encounter • Separate anatomic sites • Separate specimens • Paired organs

  26. Modifiers Evaluation and Management Only -24 Unrelated E/M Unrelated E/M during the postoperative period . -25 Separate E/M -57 Decision for Surgery

  27. 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.

  28. 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.

  29. 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.

  30. 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.

  31. 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

  32. 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

  33. 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.

  34. 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.

  35. 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.

  36. 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 -TC

  37. 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%

  38. 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

  39. 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.

  40. 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

  41. 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

  42. 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

  43. 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

  44. 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

  45. 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

  46. 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.

  47. 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

  48. 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

  49. Modifiers -54 Surgical Care Only -55 Postoperative Management Only -56 Preoperative Management Only

  50. 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