Saturday, March 6, 2010

Medical billing modifiers 80, 81 and 82, 62

Medicare Part B modifiers - 80

Assistant Surgeon: Surgical assistant services may be identified by adding the modifier 80 to the usual procedure number(s).

Modifier 80 Assistant Surgeon

Instructions

Modifier 80 is appended to the surgical code when another surgeon is assisting at surgery. Check Medicare Physician Fee Schedule (MPFS) Indicator/Descriptor Lists. See Column A indicates if assistant at surgery allowed/not allowed.
Correct Use

    Physician:
        Assist-at-surgery allowed with appended modifiers 80, 81 or 82
        Allowed = 16% of surgery fee schedule allowable
    Note: Non Physician Practitioner (NPP) or mid-level practitioner (PA, NP, CNS):
        Append AS modifier only
        Allowed equals 85% of surgical assist or 16% allowable

Incorrect Use

    Inappropriate to bill AS modifier for physician surgical services
    Inappropriate to append modifier 58 (staging) with assistant surgery

Claim Coding Example

    Per fee schedule indicator, descriptor 2 = payment restriction for assistants at surgery does not apply to this procedure. Assistant surgeon may be paid.

Treatment Description  CPT/Modifier

Gastric Bypass for Morbid Obesity 43846 80

This modifier should be reported to identify surgical assistant services performed in a non-teaching setting or in a teaching setting when a resident was available but the surgeon opted not to use the resident. In the latter case, the service is generally not covered by Medicare. When the surgical services are performed in a non-teaching setting, report “Non-teaching” in the narrative section of an electronic claim submission, or in Block 24D for paper claims.

This modifier is not intended for use by non-physicians assisting at surgery (e.g. Nurse Practitioners, Physician Assistants, Registered Nurse First Assistants, etc.).

• The purpose of this modifier is to report services when one physician assists another physician during a surgical procedure.

• This modifier is not intended for use by non-physician providers (i.e., registered nurse first assistants (RNFA) with a CNOR certification in addition to our current providers; physician assistants (PA), certified registered nurse first assistants (CRNFA) and nurse practitioners (NP),, modifier AS must be used.

• Multiple surgery reduction applies if more than one procedure is performed during the same operative session

• The primary surgeon cannot append this modifier to the procedure code.

• If the procedure requires a co-surgeon, modifier 62 must be used.

• Modifier 80 will price the procedure at 20% ofthe allowable charge.


Payment Guidelines.

Medicare pays for a surgical assistant when the procedure is authorized for an assistant and the person performing the service is a physician, physician assistant (PA), nurse practitioner (NP) or a clinical nurse specialist (CNS).

To facilitate payment, CMS (under authority of 42 CFR Section 414.40) has established uniform national definitions of services, codes to represent services, and payment modifiers to the codes, to include the use of payment modifiers for
assistant at surgery services.

To bill for these services, you should use Modifier 80 (assistant surgeon), 81 (minimum assistant surgeon), or 82 (when qualified resident surgeon not available). You should also use Modifier AS when you need to indicate that a PA, NP or CNS served as the assistant at surgery. Be aware that when you use Modifier AS, you must also use Modifier 80, 81, or 82 because using these modifiers without modifier AS indicates that a physician served as the surgical assistant. Claims that you submit with modifier AS and without modifier 80, 81 or 82 will be returned to you.


Exemptions

* Amerigroup in Florida requires the primary surgeon and assistant surgeon to bill the same procedure code in all cases, in compliance with Florida’s Agency for Health Care Administration (AHCA) Medicaid Services Coverage and Limitations handbook.

* Amerigroup Louisiana, Inc. does not apply multiple-procedure fee  reductions to the assistant surgeon in accordance with Louisiana Department of Health and Hospitals (DHH).

* Amerigroup Community Care in Texas and Amerigroup Insurance Company in accordance with Texas Medicaid & Healthcare Partnership (THMP) allows:

* Assistant at surgery reimbursement in a teaching facility when Modifier 80 and KX are used together; Modifier AS is used when the physician assistant is not enrolled as an individual provider and provides assistant at surgery.

* The use of two assistant surgeons for liver transplant surgery only when billed with appropriate modifiers


Medicare Part B modifiers - 82


Assistant Surgeon ( when qualified resident surgeon not available): The unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s).

This modifier is used in teaching hospitals if there is no approved training program related to the medical specialty required for the surgical procedure or no qualified resident was available.

Modifier 82 Assistant Surgeon – when qualified resident surgeon not available

Instructions

This modifier is used when minimal surgical assistance is needed, but a qualified resident was not available (documentation required). First, check Medicare Physician Fee Schedule (MPFS) Indicator/Descriptor List. Column A indicates if assistant at surgery allowed/not allowed.

Correct Use

    Physician:
        Assist-at-surgery allowed with appended modifiers 80, 81 or 82
        Allowed = 16% of surgery fee schedule allowable
    Modifier 82 needs a statement that "no qualified resident surgeon was available"
        Indicates exceptional medical circumstances exist
        Primary surgeon must have a policy of never involving residents in preoperative, operative or postoperative care of his/her patients
    Non Physician Practitioner (NPP) or mid-level practitioner (PA, NP, CNS):
        Append AS modifier only
        Allowed equals 85% of surgical assist or 16% allowable

Incorrect Use

    Inappropriate to bill physician assistant surgical services with AS modifier
    Inappropriate to append modifier 58 (staging) with any assistant surgery

Claim Coding Example

    Per fee schedule indicator descriptor 2 = payment restriction for assistants at surgery does not apply to this procedure. Assistant surgeon may be paid.

Treatment Description


CPT/Modifier

Laparoscopy, surgical prostatectomy 55866 82



Medicare Part B modifiers - 81

Minimum Assistant Surgeon: Minimum surgical assistant services are identified by adding modifier 81 to the usual procedure number.

Modifier 81 Minimum assistant surgeon

Instructions

Modifier 81 is appended to the procedure code for an assistant surgeon who assists an operating or principal surgeon during part of a procedure. Check the Medicare Physician Fee Schedule (MPFS) Indicator/Descriptor Lists. Column A indicates if assistant at surgery is allowed.

Correct Use

    Append to appropriate code when more than one assistant is involved or if one person assists during a portion of surgery. Includes physicians providing minimal assistance to primary surgeon. Must be used with Type of Service 8 codes.

This modifier identifies surgical assistant services

    Indicates exceptional medical circumstances exist
    Indicates primary surgeon has policy of never involving residents in preoperative, operative or postoperative care of his/her patients

Claim Coding Example

    Fee Schedule Indicator Descriptor 2 = Payment restriction for assistants at surgery does not apply to this procedure. Assistant surgeon may be paid.

Treatment Description  CPT/Modifier

Gastric Bypass for Morbid Obesity



Assistant Surgeon Modifiers

Modifier 80, 81, 82: Denote assistant surgeons. Should be submitted on those surgical procedures where an assistant surgeon is warranted. NOTE: Physicians acting as assistants cannot bill as co-surgeons.


Modifier         Description         Adjustment Rate

Modifier 80

Assistant Surgeon

20% of Fee Schedule Allowance/Contracted Rate for MD
10% of Fee Schedule Allowance/Contracted Rate for PA


Modifier 62 - Two Surgeons

• The purpose of this modifier is to report when two surgeons work together as primary surgeons performing distinct part(s) of a procedure.

• Each surgeon must report his/her distinct operative work by adding the modifier 62 to the procedure code and any associated add-on codes(s) for that procedure as long as both surgeons continue to work together as primary surgeons.

• Each surgeon must report the co-surgery once using the same procedure code. If additional procedure(s), including add-on procedures(s) are performed during the same surgical session, separate code(s) may also be reported without the modifier 62 added.

• If a co-surgeon acts as an assistant in the performance of additional procedure(s) during the same surgical session, those services may be reported using separate procedure code(s) with the modifier 80 or 82 added, as appropriate.


Billing/Coding Guidelines

All claims must be billed according to CMS guidelines. Practitioner credentials with the appropriate corresponding modifier must be on the claim.

Physician providers billing for assistant surgeon services should use modifier 80, 81, or 82 for both Medicare and commercial plans. Non-physician providers should use modifier AS for both Medicare and commercial plans.

Non-physician providers billing for assistant surgeon services that qualify for reimbursement with modifier AS are: Medicare Plans

Physician assistant (PA), nurse practitioner (NP), advanced registered nurse practitioner (ARNP), and clinical nurse specialist (CNS) Commercial Plans

Physician assistant (PA), nurse practitioner (NP), advanced registered nurse practitioner (ARNP), clinical nurse specialist (CNS), registered nurse first assist (RNFA), certified registered nurse first assist (CRNFA), and certified nurse midwife (CNM)


Q1: A Medicare member had a surgery that qualified for an assistant surgeon per CMS guidelines. The physician was a MD that performed the assistant surgeon duties. The provider coded the same CPT as the surgeon and modifier 80. Will the service be reimbursed?


A1: Yes. Group Health will reimburse Medicare assistant surgeon fees at 16 percent of the allowable when billed with modifier 80.


Assistant Surgeon Modifier usage Guide

The American College of Surgeons (ACS) has determined that assistant surgeon services are required for the successful completion of certain surgical procedures that have been identified as sufficiently complex or intensive. Providers rendering assistance at surgery (“Assistant Surgeon services”) should report such services by appending the modifier 80, 81, 82, or HCPCs Level II modifier AS, as appropriate, to a specific Current Procedural Terminology  code. Each modifier identifies a
unique situation.

• 80 - Physician providing assistance in surgery
• 81 - Physician providing minimum assistance in surgery
• 82 - Physician providing assistance in surgery when qualified resident not available
• AS – Non-physician providing assistance in surgery (e.g., Registered Nurse First Assist (RNFA) or Physician Assistant (PA) or other non-physician provider as required by state licensure)

POLICY

The Health Plan considers the following points to be important considerations in the adjudication of an Assistant Surgeon claim:

1. The provider of service must be a licensed or certified practicing Medical Doctor (M.D.), Doctor of Podiatric Medicine (D.P.M.), Doctor of Dental Surgery (D.D.S.), Doctor of Ostepathy (D.O.), PA , RNFA , Clinical Nurse Specialist (CNS), or any other provider with equal state licensure or certification and recognized by the Health Plan to be eligible for reimbursement as an Assistant Surgeon for a covered procedure.

2. Only one Assistant Surgeon is eligible for reimbursement per covered surgical procedure.

3. Procedure  codes reported with an Assistant Surgeon modifier are subject to multiple surgery reimbursement rules, if applicable. Assistant Surgeon services are eligible for reimbursement as follows:

• Assistant Surgeon services reported with modifiers 80, 81, and 82 will be eligible for reimbursement at 16% of the allowed amount for the primary procedure. Multiple
surgery reimbursement rules are applied to subsequent procedures, if applicable.

• Assistant Surgeon services reported with modifier AS will be eligible for reimbursement at 14% of the allowed amount for the primary procedure. Multiple surgery reimbursement rules are applied to subsequent procedures, if applicable.

4. Procedures reported with an unlisted Procedure  code will be retrospectively reviewed for pricing and eligibility for reimbursement for an Assistant Surgeon.

5. Assistant Surgeon claim editing is administered by the ClaimsXten® software package from McKesson, Inc.. ClaimsXten uses edit designations that are tailored to physicians. However, the Health Plan applies the same edit designations to non-physician assistants.

6. Some procedures may require assistance for positioning, and retraction for maintaining visualization. However, this type of assistance can usually be performed by a surgical technician and does not require Assistant Surgeon services. 

No comments:

Post a Comment

Most read cpt modifiers