Wednesday, July 28, 2010

Modifier 22, 25, 47 - When to use

When a Modifier may not be covered - BCBS of  North Carolina

• Modifier -22 will not affect claims processing adjudication. In general, BCBSNC does not allow a
severity adjustment to fee allowances. Payment for new technologies is based on the outcome of the treatment rather than the "technology" involved in the procedure.

The modifier -25 will not be recognized with a minimal office visit for an established patient (99211) performed on the same date as a preventative medicine visit (99391 - 99397).

• Modifier -47 is used to report anesthesia by the attending or assistant surgeon. No additional benefits are allowed above the total allowed for the surgical procedure if the anesthesia services are not administered by, or under the supervision of, a doctor other than the attending surgeon or assistant surgeon.


Modifier 47 Anesthesia by Surgeon

Instructions

    Surgical allowable based on 50 percent of Medicare Physician Fee Schedule (MPFS)

Correct Use

    Regional/general anesthesia provided by surgeon/attending surgeon only
    Append 47 modifier to basic surgical service/procedure only

Incorrect Use

    Surgeon performs both surgery/anesthesia, separate payment not allowed
    Anesthesiologist not covered with 47 modifier
    Not appropriate with anesthesia codes or local anesthesia
    Not appropriate with moderate sedation (99143 – 99145)
    Not appropriate for monitoring general anesthesia provided by
        Certified Registered Nurse Anesthetist (CRNA), intern, anesthesiologist or resident

• Modifier -50 designates the performance of a bilateral procedure. Clinical consultant review may determine these services will not be allowed.

• Modifier -51 will not be accepted with evaluation and management services. If used, the claim for services will not be allowed. Response will be; “Invalid Modifier/Procedure Combination.”

• Modifiers -80, -81, and -82 for assistant surgeon services will not be allowed if they do not meet BCBSNC guidelines for appropriateness, Blue Cross and Blue Shield of North Carolina uses Claim Check as its primary source for determining those procedures available for assistant surgeon benefits. Claims will be denied if the assistant surgeon is not board-certified or otherwise highly qualified as a skilled surgeon. Claims with procedures determined not to require an assistant surgeon will be denied as; “Does Not Require An Assistant Surgeon.”

• Modifier GQ - Via asynchronous telecommunications system will not be allowed specifically with code 99201 - 99215(Office or Other Outpatient Services) and 99241 - 99245(Office or Other Outpatient Consultations).

• Modifier GT - will not be recognized with a minimal office visit for an established patient (99211).

• Modifier PA - Surgical or other invasive procedure on wrong body part. Refer to Corporate Medical Policy titled “Nonpayment for Serious Adverse Events”

• Modifier PB - Surgical or other invasive procedure on wrong patient. Refer to Corporate Medical Policy titled “Nonpayment for Serious Adverse Events”

• Modifier PC - Wrong surgery or other invasive procedure on patient. Refer to Corporate Medical Policy titled “Nonpayment for Serious Adverse Events”

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