Showing posts with label ASC modifier. Show all posts
Showing posts with label ASC modifier. Show all posts

Sunday, August 1, 2010

Modifiers - Out-patient Hospital/Ambulatory Surgical Center

Out-patient Hospital/Ambulatory Surgical Center (ASC)

73 Discontinued out-patient hospital/ambulatory surgical 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 (including sedation when provided, and being taken to the room where the procedure is to be performed), but prior to the administration of anesthesia (local, regional block(s), or general). Under these circumstances, the intended service that is prepared for but canceled can be reported by its usual procedure number and the addition of the modifier -73.  Note: the elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. For physician reporting of a discontinued procedure, see modifier -53.
SG Ambulatory Surgical Center (ASC) Facility Service  - This modifier identifies those services performed in the ASC facility that will generate a facility fee allowance. This modifier is NOT used by the performing physician/surgeon.
74 Discontinued out-patient hospital/ambulatory surgery center (ASC) procedure after administration of anesthesia - Due to extenuating circumstances or those that threaten the well being of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia (local, regional block(s), general) or after the procedure was started (incision made, intubation started, scope inserted, etc). Under these circumstances, the procedure started but terminated can be reported by its usual procedure number and the addition of the modifier -74. Note: the elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported for physician reporting of a discontinued procedure, see modifier -53.

Friday, July 30, 2010

Modifier 74 - Discontinued Outpatient Hospital/Ambulatory Surgery Center

Modifier 74 Fact Sheet

Definition:

Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) procedure after administration of Anesthesia

Appropriate Usage:


Due to extenuating circumstances or those that threaten the wellbeing
of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia or after the procedure was started (incision made, intubation started, scope inserted.)

Inappropriate Usage:

• This modifier is not appropriate for the elective cancellation or postponement of a procedure based on the physician or patient’s choice.
• This modifier is not appropriate when the termination of the procedure occurs prior to the beginning of the procedure or the administration of anesthesia.
• This modifier is not for physician use. It is only appropriate for the ASC.

Additional Information:

• Medicare will make the full payment of the surgical procedure if a medical complication arises which causes the procedure to be terminated
• The claim must indicate the ASC has additional
documentation available upon request.
• The operative report and documentation should include the following:
o Reason for termination of the surgery
o Services actually performed
o Supplies actually provided
o Services not performed that would have been performed if surgery had not been terminated
o Supplies not provided that would have been provided if the surgery had not been terminated
o Time actually spent is each stage, e.g., pre-operative, operative, and post-operative,
o Time that would have been spent in each of these stages if the surgery had not been terminated, and
o HCPCS code for procedure had the surgery been performed.

Monday, June 14, 2010

Out - patient ASC modifiers - 73 , 74

Out-patient Hospital/Ambulatory Surgical Center (ASC) Modifiers

73 Discontinued out-patient hospital/ambulatory surgical 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 (including sedation when provided, and being taken to the room where the procedure is to be performed), but prior to the administration of anesthesia (local, regional block(s), or general). Under these circumstances, the intended service that is prepared for but canceled can be reported by its usual procedure number and the addition of the modifier -73. Note: the elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. For physician reporting of a discontinued procedure, see modifier -53.
SG Ambulatory Surgical Center (ASC) modifier - This modifier identifies those services performed in the ASC facility that will generate a facility fee allowance. This modifier is NOT used by the performing physician/surgeon. Beginning January 1, 2008, ASCs no longer are required to include the SG modifier on facility claims to Medicare.
74 Discontinued out-patient hospital/ambulatory surgery center (ASC) procedure after administration of anesthesia - Due to extenuating circumstances or those that threaten the well being of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia (local, regional block(s), general) or after the procedure was started (incision made, intubation started, scope inserted, etc). Under these circumstances, the procedure started but terminated can be reported by its usual procedure number and the addition of the modifier -74. Note: the elective cancellation of a service prior to the administration of anesthesia and/or surgical preparation of the patient should not be reported. For physician reporting of a discontinued procedure, see modifier -53.


Monday, June 7, 2010

Modifier 74: Discontinued Outpatient Hospital/ASC Procedure After Administration of Anesthesi

Some of the most common modifiers used in the ASC are: 


Modifier 74: Discontinued Outpatient Hospital/ASC Procedure After Administration of Anesthesia 

Due to extenuating circumstances or those that threaten the well being of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia (local, regional block(s), general) or after the procedure as started (incision made, intubation started, scope inserted, etc.). This procedure would be reported by its usual CPT code and the addition of modifier 74.

For CMS, when the procedure is reported with modifier 74, there is no payment reduction. This is because the resources of the facility are consumed in essentially the same manner to the same extent as they would have been had the procedure been completed. If this modifier is not used and the patient has to come back for the same procedure, then the subsequent procedure will be denied. You would only get paid for one, whereas the use of the modifier 74 would allow you to be paid for both. The same applies to the modifier 73.

For example: A 65-year-old man was taken to the operating room for a laparoscopic cholecystectomy. After making the portal entry incision, the anesthesiologist noticed the patient having ventricular fibrillation on the cardiac monitor. Defibrillation effort was tried two times, finally the arrhythmia abated. The procedure was cancelled pending further cardiac consultation. CPT code: 47562-74 laparoscopy, surgical: cholecystectomy.

Modifiers 73 and 74 should be used when possible to help streamline revenue. As discussed earlier, modifiers explain to the insurance carrier that the description of the code is the same, but something about the procedure or service was changed.
Some modifiers impact reimbursement, while others are only informational and help get the claim paid without costly delays.

Using a modifier does not guarantee reimbursement, however, if the medical record does not support the modifier billed by the provider, the provider risks denial of the claim and possible penalties for submitting an incorrect claim. The important issue is to understand how to use the modifiers appropriately and which modifier should be appended to the claim appropriately.

Modifier used in ASC - 59

Some of the most common modifiers used in the ASC are: 

Modifier 59: Distinct Procedural Service Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. This may represent a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury not ordinarily encountered or performed on the same day by the same physician. Although the modifier has several different reporting uses, it should only be used if another more descriptive modifier is not available and its use best describes the circumstances.

Caution should be used with modifier 59, as this is one of the most misused modifiers. If this modifier is not used appropriately, the claim will be denied. The denial from the carrier states, “Medicare does not pay for this service because it is part of another service that was performed on the same day.”

For example: A patient presents with a 4.5 malignant lesion on the arm. He also has a sore on his leg. The physician excises the lesion on the arm and does a biopsy on the leg.
CPT codes:
11606 excised lesion over 4 cm on leg
11000-59 biopsy of skin

As coding guidelines state, if a biopsy is performed with an excision on the same site, then you would code the excision only. But in the above example, the excision and biopsy were performed on different sites. Modifier 59 lets the payer know that this service should not be bundled into the excision code because it was performed on a distinctly different site. Normally, a biopsy is considered inherent to an excision procedure.

The best way to know if modifier 59 is the correct modifier is to see if the CMS National Correct Coding Initiative (NCCI) contains an edit that prohibits the two procedure codes from being billed together. If NCCI unbundles the codes, but your services were provided on distinctly different sites, then modifier 59 is appropriate. In the event that a more descriptive modifier is available, it should be used in preference to modifier 59.

Wednesday, June 2, 2010

MODIFIERS APPROVED FOR AMBULATORY SURGERY CENTER (ASC) HOSPITAL OUTPATIENT USE

25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the
Same Day of the Procedure or Other Service
27 Multiple Outpatient Hospital E/M Encounters on the Same Date
50 Bilateral Procedure
52 Reduced Services
58 Staged or Related Procedure or Service by the Same Physician During the Postoperative Period
59 Distinct Procedural Service
73 Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC) Procedure Prior to the
Administration of Anesthesia
74 Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC) Procedure After Administration
of Anesthesia
76 Repeat Procedure by Same Physician
77 Repeat Procedure by Another Physician
78 Return to the Operating Room for a Related Procedure During the Postoperative Period
79 Unrelated Procedure or Service by the Same Physician During the Postoperative Period

Level II (HCPCS/National) Modifiers

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
GA Waiver of Liability on file
GC Resident/Teaching Physician Service
GE Resident Primary Care Exception
GV Attending Physician not hospice
GW Service unrelated to terminal condition
LC Left circumflex coronary artery (Hospitals use with
codes 92980-92984, 92995, 92996)
LD Left anterior descending coronary artery (Hospitals
use with codes 92980-92984, 92995, 92996)
LT Left side (used to identify procedures performed on
the left side of the body)
QM Ambulance service provided under arrangement by
a provider of services
RC Right coronary artery (Hospitals use with codes
92980-92984, 92995, 92996)
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
T8 Right foot, fourth digit
T9 Right foot, fifth digit
TA Left foot, great toe

Sunday, May 30, 2010

Most used modifer in ASC

Tips for Modifiers use in an Ambulatory Surgery Center

Some of the most common modifiers used in the ASC are:

Modifier 50: Bilateral Procedure
Unless otherwise identified in the listings, bilateral procedures that are performed in the same operative session should be identified by adding modifier 50 to the appropriate five-digit CPT code. This modifier is reported for procedures/ services that are performed on both sides of the body at the same operative session (mirror image). The policies each payer has for the use of modifier 50 vary widely, so be sure and check with each carrier before use. The modifier is applied to the CPT code, which is billed once even though the procedure was performed on two sides. For example, a 22-year-old skier injures both right and left knees, with peripheral longitudinal tears of both medial and lateral menisci and underwent arthroscopic meniscus repair of both knees by a suture technique. Appropriate reporting would be 29883-50.

Do not use modifier 50 if the procedure is designated inherent bilateral, which means the code descriptor indicates bilateral in the description. (Example: 58600 ligation or transaction of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral). Determination of pricing for a bilateral procedure would be identical to the determination of pricing in multiple procedures for CMS: 100 percent for the first procedure and 50 percent for the second procedure.

Note that some carriers prefer the use of modifiers LT and RT instead of modifier 50. In this case, the CPT code would be reported twice, as in 29883-LT and 29883-RT. Check with each carrier to ensure you are billing appropriately.
HCPCS Level II Modifier LT and RT: Modifiers LT and RT apply to codes that identify procedures that can be performed on paired organs such as ears, eyes, nostrils, kidneys, lungs, and ovaries. Modifier LT (left) and RT (right) are usually applied when a procedure is performed on only one side. ASCs use the appropriate modifier to identify which one of the paired organs was operated on. CMS requires these modifiers whenever appropriate.

For example: 66984 RT cataract surgery on the right eye. If these modifiers are not used, the carrier may assume that the second procedure done on the opposite eye is a duplicate service and may deny payment.

Saturday, May 29, 2010

Tips for Modifiers use in an Ambulatory Surgery Center




Modifiers have had reporting relevance since the implementation of the Centers for Medicare & Medicaid Services (CMS) payment methodology for procedures performed in ambulatory surgery centers (ASCs), and hospital-based ASCs. On the basis of approval by the National Uniform Billing Committee, CMS instructed its Medicare fiscal intermediaries to accept those approved CPT (HCPCS Level I) and HCPCS (HCPCS Level II) modifiers applicable to outpatient reporting.


A modifier provides the means by which a reporting facility can indicate that the service or procedure represented by a specific code does not exactly meet the standards for that code. A procedural circumstance requires an alteration of the code’s meaning. The individual circumstance depicted by each modifier has reimbursement or tracking relevance to the carrier, and for payment to the provider. The use of the modifier enables the insurance carriers to appropriately pay for the procedure and any associated postoperative services performed within or subsequent to the global period (same day for ASCs). In addition, it allows the carrier to differentiate instances in which duplicate billing or duplicate services may have been reported.


The facility should apply the CMS-endorsed coding policy/instructions when outpatient services are billed, and these should apply to all payers, unless other carrier-specific directives have been received.

Most read cpt modifiers