Wednesday, June 9, 2010

List of Surgical Procedure Modifiers

Surgical Procedure Modifiers

LT Left Side - Used to identify procedures performed on the left side of the body. No effect on payment; however, failure to use when appropriate could result in delay or denial (or partial denial) of the claim.
PA Surgical or other invasive procedure on wrong body part
PB Surgical or other invasive procedure on wrong body patient
PC Wrong surgery or other invasive procedure on patient
RT Right Side - Used to identify procedures performed on the right side of the body. No effect on payment; however, failure to use when appropriate could result in delay or denial (or partial denial) of the claim.
22 Increased procedural services - Used on surgery codes when the work required to provide a service is substantially greater than typically required. Documentation must support the substantial additional work.
50 Bilateral procedure - Unless otherwise identified in the listings, bilateral procedures that are performed at the same operative session should be identified by adding the modifier -50 to the appropriate five digit code.
51 Multiple procedures - When multiple procedures, other than E/M services, Physical Medicine and Rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same provider, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by adding modifier '-51' to the additional procedure or service code(s). MODIFIER 51 IS NOT REQUIRED FOR BILLING PURPOSES: The carrier will assign the multiple procedure modifier if appropriate based on the services billed.
PAYMENT RULES:
We approve 100% of the fee schedule amount for the highest valued procedure, 50% for the 2nd-5th procedures and "by report" for subsequent procedures. Payment determined on a “by report” basis for these codes should never be lower than 50 percent of the full payment amount.
EXCEPTIONS:
Multiple endoscopies:
Special rules for multiple endoscopic procedures apply if the procedure is billed with another endoscopy in the same family. See Pub. 100-04, Chapter 12, Section 40.6 for endoscopy rules.
52 Reduced services - Under certain circumstances a service or procedure is partially reduced or eliminated at the physician's discretion. Under these circumstances the service provided can be identified by its usual procedure number and the addition of the modifier -52, signifying that the service is reduced.This provides a means of reporting reduced services without disturbing the identification of the basic service. Note: For hospital out-patient reporting of a previously scheduled procedure or service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of a patient prior to or after administration of anesthesia, see modifiers -73 and -74 (these modifiers are approved for ASC hospital out-patient use).
53 Discontinued procedure - Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. This circumstance may be reported by adding the modifier '-53' to the code reported by the physician for the discontinued procedure. Note: This modifier is not used to report the elective cancellation of a procedure prior to the patient's anesthesia induction and/or surgical preparation in the operating suite. For outpatient hospital/ambulatory surgery center (ASC) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers -73 and -74 (modifiers approved for ASC and hospital out-patient use).
54 Surgical care only - Use with surgical codes when only the surgical service was performed. Payment will be limited to the amount allotted to the preoperative and intraoperative services only.
55 Postoperative care only - Use with surgical codes only to indicate that only the postoperative care was performed (another physician performed the surgery). Payment will be limited to the amount allotted for postoperative services only.
58 Staged or related procedure or service ny the same physician during the postoperative period - This modifier should be used to permit payment for a surgical procedure during the postoperative period of another surgical procedure when (1) the subsequent procedure was planned prospectively at the time of the original procedure, (2) a less extensive procedure fails and a more extensive procedure is required or (3) a therapeutic surgical procedure follows a diagnostic procedure e.g., a mastectomy follows a breast biopsy. Failure to use modifier when appropriate may result in denial of the subsequent surgery.
62 Two surgeons - When two surgeons work together as primary surgeons performing distinct part(s) of a single reportable procedure, each surgeon should report his/her distinct operative work by adding the modifier -62 to the single distinct procedure code. Each surgeon should report the co-surgery once using the same procedure code. If additional procedure(s) (including add-on procedures) are performed during the same surgical session, separate codes may be reported without the modifier -62 added. Note: 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 modifier -80 or modifier -81 added, as appropriate.
66 Surgical team - The modifier should be used by each participating surgeon to report his services. When team surgery is medically necessary, the carrier will determine the appropriate allowances(s) "by report."
76 Repeat procedure or service by same physician - The physician may need to indicate that a procedure or service was repeated subsequent to the original procedure or service. This circumstance may be reported by adding modifier -76 to the repeated procedure or service.
77 Repeat procedure by another physician - The physician may need to indicate that a basic procedure or service performed by another physician had to be repeated. This situation may be reported by adding modifier -77 to the repeated procedure or service.
78 Unplanned Return to the Operating/Procedure room by the same physician following initial procedure for a related procedure during the postoperative period: - Use on surgical codes only to indicate that another procedure was performed during the postoperative period of the initial procedure, was related to the first, and required the use of the operating room. Payment is limited to the amount allotted for intraoperative services only. Failure to use this modifier when appropriate may result in denial of the subsequent surgery.
79 Unrelated Procedure or Service by the Same Physician during the postoperative - Use on surgical codes only to indicate that the performance of a procedure during the postoperative period of another surgery was unrelated to the original procedure. Failure to use this modifier when appropriate may result in denial of the subsequent surgery.
80 Assistant surgeon - Reimburses the assistant surgeon at 16% of the Medicare Physician Fee Schedule Data Base allowance for the surgical procedure.

 

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