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.




General Coding Modifier policy

Modifiers are two-digit codes that are appended to a service as a means to indicate that the service/procedure is affected or altered by a specific circumstance and to add specificity, but not changed in its definition.



CPT codes are not limited to CPT modifiers. HCPCS codes are not limited to HCPCS modifiers. HCPCS modifiers may also be used with CPT codes and/or in combination with CPT modifiers. CPT modifiers may also be used with HCPCS codes and/or in combination with HCPCS modifiers. For example, -TC and –76 can be appended to a radiology procedure to indicate the technical component of the services was repeated.

Modifiers may be used to indicate:

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

** A service or procedure was performed by more than one physician and/or in more than one location.

** A service or procedure has been increased or reduced.

** Only part of a service was performed.

** A bilateral procedure was performed.

** A service or procedure was provided more than once.

** Unusual events occurred.

** A DME item is purchased or rented.


It is important to append all appropriate modifiers the first time the claim is submitted.


Definitions:

The following list is not all-inclusive. All valid modifiers will be accepted; however, the modifiers listed below impact payment.


Mod. Definition Submission Guidelines Impact to Payment -22

Increased Procedural Services

See Modifier 22 Policy

See Modifier 22 Policy -24

Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional

During a Postoperative Period.

Blue Cross defines the “same physician” as the same physician(s) or qualified health care practitioner(s) of the same or similar specialty within the same clinical practice.

By appending the -24 modifier to an unrelated evaluation and management

(E/M) service you are indicating that the patient’s condition requires a significant, separately identifiable E/M service above and beyond the other service provided, or beyond the usual pre-operative and postoperative care associated with the procedure that was performed. Services appended with a –24 modifier must be sufficiently documented in the patient’s medical record that the visit was unrelated to the post-operative care of the procedure.

An ICD that clearly indicates that the Separate payment of the E/M may be allowed.


-25 Significant Separately  Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service

Use the –25 modifier when an E/M service is rendered on the same d ay as a minor surgical procedure (0 or 10 day global period).

The use of –25 is appropriate only when the E/M service provided is above and beyond the usual pre and post-operative service associated with a procedure.

No documentation needs to be submitted with the initial claim. However, E/M services submitted with a –25 modifier are subject to review. Furthermore, medical documentation, when requested,needs to support the significant, separately identifiable E/M service.

Note: Requests to add a modifier -25 to a denied service must follow the replacement claim process. An adjustment request will not be allowed.


Separate payment of the E/M may be allowed.


-26 Professional Component

See Professional and Technical Component Policy

See Professional and Technical Component Policy


-50 Bilateral Procedure

Surgical procedures performed on bilateral pieces of anatomy should be billed on one line. The –50 modifier should be appended to the submitted lines of service.

The CPT descriptors for some procedures specify that the procedure is bilateral. In such cases, the bilateral modifier should not be used.

Payment is made at 150% of the allowed amount for the procedure.

Multiple surgery pricing logic also applies to bilateral procedures.

If -50 is submitted on a CPT defined bilateral procedure that service will be denied based on submission of an incorrect procedure/modifier combination.


-51 Multiple Procedures

When more than one service is performed during the same operative session, the –51 modifier may be appended to all secondary surgical procedures.

It is not necessary to append the –51 modifier to “add on” or to exempt codes.

Applicable code edits will be applied to services submitted.

The -51 modifier itself does not affect payment. Multiple surgical payment is based on whether the surgical procedure may be subject to a multiple surgery.

Then the reduction would be based on the allowed amount. The lowest valued procedure(s) will have the multiple surgical reduction applied. When covered, payment is made at 50% of the allowed amount for all allowable secondary procedures.

Multiple surgery pricing logic also applies to bilateral procedures.


-52  Reduced Services

Append the –52 modifier to indicate that a service or procedure is partially reduced or eliminated at the physician’s discretion.

This provides a means of reporting reduced services without disturbing the identification of the basic service.

The normal full charge billed or a reduced charge for the procedure may be submitted. Blue Cross will pay the lesser of either 90% of the physician fee schedule allowance for the procedure or the charge submitted.


-53 DiscontinuedProcedure

Append –53 when the physician elects to terminate the procedure.

The normal full charge or reduced charge should be submitted.

-54 Surgical Care

Only

Append –54 when one physician performs the intraoperative portion of a surgical procedure while another practitioner(s) from a different practice provides preoperative and/or post-operative management.

Surgery should be billed globally (no modifier) if the pre-, intra-, and postoperative services are rendered by the same provider or other practitioners who are employed by the same clinic (same tax ID number).

Payment is made at 80% of the allowed amount.



-55 Post-operative Management Only

Append –55 to the surgical procedure code only when post-operative services are provided by a different clinic than performed the surgery.

Append the –55 to the surgical procedure code.

Separate payment may be allowed.

Services will be denied if the –55 modifier is billed by a practitioner who is employed by the same clinic (same tax ID number) as the surgeon.



-56 Pre-operative Management Only

Append –56 to the surgical procedure code only when pre-operative services are provided by a different clinic than performed the surgery.

Append the –56 to the surgical procedure code.

Separate payment may be allowed.

Services will be denied if the –56

modifier is billed by a practitioner who is employed by the same clinic (same tax ID number) as the surgeon.

-57 Decision for Surgery

The –57 modifier is appended to indicate that the E/M service resulted in the initial decision to perform surgery either the day before or the day of a major surgical procedure (90-day global period).

Do not append this modifier when a minor surgical procedure (0-, 10-day global period) is performed.

The –57 should not be used to report an E/M service that was pre-planned or prescheduled the day before or the day of surgery, as the E/M would be included as part of the global surgical package.

Patients are normally reevaluated on the date of the actual surgery to assure the service can be performed. That clearance would be included in the global period and should not be reported separately.

Note: Requests to add a modifier -57 to a denied service must follow the replacement claim process. An adjustment request will not be allowed.

Services denied may be considered on subsequent appeal.

Modifer-57 may not affect edits or payment. However, if applicable, the modifier should be appended to the E/M.




-59 DistinctProcedural Service

Modifier –59 may be appended to identify non-E/M procedures/services that are not

Modifer-59 may not affect edits or payment. However, if applicable, the normally reported together, but are appropriate under the circumstances.

However, when another already established modifier is appropriate it should be used rather than modifier –59.

Only if no more descriptive modifier is available, and the use of modifier –59 best explains the circumstances, should modifier –59 be used. Modifier –59 is always appended to the component or lesser procedure code. Documentation supporting the separate and distinct status must be present in the patient’s medical record.

Note: Requests to add a modifier -59 to a denied service must follow the replacement claim process. An adjustment request will not be allowed.

modifier should be appended to the service. Generally,the –59 modifier is only applicable to those code

combinations noted in the Correct Coding Initiative (CCI) code list with a modifier indicator of “1” which specifies the services are distinct and separate and thus allowed. Services denied may be considered on subsequent appeal.


-62 Two Surgeons

See Co-Surgeon/Team Surgeon Policy

See Co-Surgeon/Team Surgeon Policy


-66 Surgical Team

See Co-Surgeon/Team Surgeon Policy

See Co-Surgeon/Team Surgeon Policy


-73 Discontinued Out-patient Hospital/ Ambulatory Surgery Center (ASC) Procedure Prior to the Administration of Anesthesia

Due to extenuating circumstances or those that threaten the well-being of the patient, the physician may cancel a surgical or diagnostic procedure subsequent to the patient's surgical preparation, but prior to the administration of anesthesia. Under these circumstances, the intended service that is prepared for but cancelled can be reported by its usual procedure number and the addition of the modifier -73.


Payment is made at 50% of the allowed amount.


-76 Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional

The practitioner may need to indicate that a procedure or service was repeated subsequent to the original procedure or service on the same day. This circumstance may be reported by adding modifier –76 to the repeated procedure/service.

Note: In situations warranting the use of both the –26 and –76 modifier (for example., reading multiple chest X-rays of a patient performed on the same day), submit the –26 modifier in the first position with the initial procedure and the
–76 in the first position for the repeat procedure.

Separate payment of the service may be made.

-77 Repeat Procedure by Another Physician or Other Qualified Health Care Professional

The practitioner may need to indicate that a procedure or service was repeated subsequent to the original procedure or service on the same day. This circumstance may be reported by adding modifier –77 to the repeated procedure/service.

Note: In situations warranting the use of both the –26 and –77 modifier (for example, reading multiple chest Xrays of a patient performed on the same day), submit the –26 modifier in the first position with the initial procedure and the –77 in the first position for the repeat procedure. Separate payment of the service may be made.


XU Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service

The modifier may be appended to identify a distinct service that does not overlap the usual components of the main service.

Note: Requests to add a modifier -XU to a denied service must follow the replacement claim process. An adjustment request will not be allowed.


Modifer-XU may not affect edits or payment. However, if applicable, the modifier should be appended to the service. Services
denied may be considered on subsequent appeal.


Anatomical Modifiers

The following modifiers indicate a specific anatomic site. Because these modifiers affect edits and payment we suggest they be submitted in the first modifier position, if applicable. Appropriate use of these modifiers may assure correct claims adjudication.

E1 Upper left, eyelid

E2 Lower left, eyelid

E3 Upper right, eyelid

E4 Lower right, eyelid

F1 Left hand, second digit

F2 Left hand, third digit

F3 Left hand, fourth digit

F4 Left hand, fifth digit

F5 Right hand, thumb

F6 Right hand, second digit

F7 Right hand, third digit

F8 Right hand, fourth digit

F9 Right hand, fifth digit

FA Left hand, thumb

LC Left circumflex coronary artery

LD Left anterior descending coronary artery

LT Left side (used to identify procedures performed on the left side of the body)

RC Right coronary artery

RT Right side (used to identify procedures performed on the right side of the body)

T1 Left foot, second digit

T2 Left foot, third digit

T3 Left foot, fourth digit

T4 Left foot, fifth digit

T5 Right foot, great toe

T6 Right foot, second digit

T7 Right foot, third digit


Modifiers Defined by DHS


The national HCPCS Panel developed several modifiers (U1-U9, UA-UD) that could be defined by the various state Medicaid agencies. The Minnesota Department of Human Services (DHS) has specifically defined these codes for their various programs. Refer to the DHS provider manual for detailed definitions.

Each modifier has more than one definition dependent on what service it is appended to or the program affected. The modifiers are generally informational only and, with the exception of –U7, applicable primarily to services for our PMAP and MNCare subscribers. The –U7 definitions are as follows: Mod. Definitions Usage -U7

Definition 1 = Physician extender (medical services)

Definition 2 = IEP assistive technology device (T1018)

Definition 3 = NET bus/train, monthly pass (A0110)

Definition 4 = Oximeter for intermittent use (E0445)

Append this modifier to services by non-credentialed or non-enrolled practitioners when performing incident to services under the direct supervision. The services would be reported under the directing physician’s provider number. The modifier does not impact payment.

Append the modifier if directed to in guidelines that may be found elsewhere in the Provider Policy and Procedure Manual.


Policy:

Modifiers are also subject to compatibility edits with the procedure to which they are appended. For example, an Evaluation and Management (E/M) service appended with a -59 modifier will be denied.

Note: If your claim is denied due to lack of documentation to support the use of a specific modifier or an invalid modifier/procedure combination, you may submit a claim payment appeal or replacement claim. Your appeal must be in writing and accompanied by the necessary documentation. Replacement claims must include an attachment with supporting documentation.


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

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