does Modifiers affecting payment and reimbusement

• Payment modifiers:  Payment modifiers are accounted for in the creation of the file consistent with current payment policy as implemented in claims processing. For example, services billed with the assistant at surgery modifier are paid 16 percent of the PFS amount for that service; therefore, the utilization file is modified to only account for 16 percent of any service that contains the assistant at surgery modifier. Similarly, for those services to which volume adjustments are made to account for the payment modifiers, time adjustments are applied as well. For time adjustments to surgical services, the intraoperative portion in the work time file is used; where it is not present, the intraoperative percentage from the payment files used by contractors to process Medicare claims is used instead. Where neither is available, we use the payment adjustment ratio to adjust the time accordingly. Table 2 details the manner in which the modifiers are applied.


APPLICATION OF PAYMENT MODIFIERS TO UTILIZATION FILES

Modifier        Description         Volume adjustment               Time adjustment

80, 81, 82 ... Assistant at Surgery ........ 16%   ............. Intraoperative portion.

AS ...... Assistant at Surgery—Physician Assistant.... . 14% (85% * 16%) ............................. Intraoperative portion.

50 or LT and RT ... Bilateral Surgery .....................150% ...............................  150% of work time.

51 ............... Multiple Procedure .................... 50%   ............................ Intraoperative portion.

52 ........... Reduced Services .................... 50%   ................................................... 50%.

53 .......... .. Discontinued Procedure ................... 50%  .............................................. 50%.


54 .......................... Intraoperative Care only ................... Preoperative + Intraoperative Percentages
on the payment files used by Medicare contractors to process Medicare claims.  Preoperative + Intraoperative portion.

55 .......................... Postoperative Care only ................... Postoperative Percentage on the payment files used by Medicare contractors to process Medicare claims.  Postoperative portion.

62 .......................... Co-surgeons .................... 62.5%  .......................................... 50%.


66 .......................... Team Surgeons ............. 33%  ......................................... 33%.


Q: What are modifiers and how are they used?

What are modifiers?

For Medicare purposes, modifiers are two-digit codes that may consist of alpha and/or numeric characters, which may be appended to procedure codes and/or HCPCS codes, to provide additional information needed to process a claim. This includes both HCPCS Level 1 (CPT) and HCPCS Level II codes. Modifiers answer the questions such as, which one, how many, what kind, and when?


Definition

*A two-digit code appended to procedure codes

*May affect reimbursement

*May be informational only

*Updated annually


What is the purpose of using a modifier?

The use of a modifier on a Medicare claim provides additional information for the code that is being billed and, if approved, may determine the payment for the code.

Why is the correct use of a modifier important?

Several of the top billing errors involve the incorrect use of modifiers. Correct modifier use is an important part of avoiding fraud and abuse or noncompliance issues, especially in coding and billing processes involving government programs.

How does a modifier affect payment?

In some cases, addition of a modifier may directly affect payment. Placement of a modifier after a CPT or HCPCS code does not insure reimbursement. Medical documentation may be requested to support the use of the assigned modifier. If the service is not documented or the documentation does not contain all pertinent information and an adequate definition of the procedure or service, it may not be considered appropriate to report the modifier.

What should be understood about modifiers?

The critical thing to remember is that, just because a service is “covered”, it does not necessarily mean that service is “reimbursable” A clear understanding of Medicare’s rules is necessary to assign modifiers correctly. It is the responsibility of any provider submitting claims to keep abreast of Medicare program requirements.


Q: Where can I find information pertaining to the use of common modifiers?

A: First Coast University external link has several free online learning courses that focus on modifiers:

Modifier 24

• Defined as “Unrelated E/M service by the same physician during a post-op period.”

Modifier 25

• Defined as “Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service.”

Modifier 58

• Defined as “Staged or related procedure or service by the same physician during the post-op period.”

Modifier 78

• Defined as “Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the post-op period.”

Modifier 79

• Defined as “Unrelated procedure or service by the same physician during the post-op period.”


MPFS Modifiers

The Medicare Physician Fee Schedule (MPFS) modifiers may be used to indicate that:

*A service or procedure has both a professional and technical component

*A service or procedure was performed by more than one physician

*An assistant-at-surgery service was performed

*A bilateral procedure was performed

*Unusual events occurred

Let’s Review the MPFS Modifiers

*Modifier 54 – Surgical Care

*Modifier 55 – Postoperative Care

*Modifier 26 – Professional Component

*Modifier TC – Technical Component

*Modifier 51 – Multiple Procedure

*Modifier 50 – Bilateral Procedure

*Modifier 80 – Assistant-at-Surgery (Physician)

*Modifier AS – Assistant-at-Surgery (Non-Physician Practitioner)

*Modifier 62 – Co-Surgery

*Modifier 66 – Team Surgery



Following are some general guidelines for using modifiers. They are in the form of questions to be considered. If the answer to any of the following questions is yes, it is appropriate to use the applicable modifier.


1. Will the modifier add more information regarding the anatomic site of the procedure?

EXAMPLE: Cataract surgery on the right or left eye.

2. Will the modifier help to eliminate the appearance of duplicate billing?

EXAMPLES: Use modifier 77 to report the same procedure performed more than once on the same date of service but at different encounters.

Use modifier 25 to report significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service.

Use modifier 58 to report staged or related procedure or service by the same physician during the postoperative period.

Use modifier 78 to report a return to the operating room for a related procedure during the postoperative period.

Use modifier 79 to report an unrelated procedure or service by the same physician during the postoperative period.

3. Would a modifier help to eliminate the appearance of unbundling?

EXAMPLE: CPT codes 90765 (Intravenous infusion, for therapy, prophylaxis, or diagnosis (specify substance or drug); initial, up to 1 hour) and 36000 (Introduction of needle or intra catheter, vein): If procedure 36000 was performed for a reason other than as part of the IV infusion, modifier -59 would be appropriate.




http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c12.pdf

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