Showing posts with label CPT modifer 80. Show all posts
Showing posts with label CPT modifer 80. Show all posts

Friday, April 1, 2011

CPT CODE G0431 WITH MODIFIER QW

Qualitative Drug Testing G0431 & G0431 QW

G0431 – Drug screen, qualitative; single drug class method (e.g., immunoassay, enzyme assay), each drug class

This HCPCS code must be used when reporting any qualitative single drug or drug class assay. This includes individual drug or drug class assays performed using CLIA moderate or high complexity instruments as well as point of care devices which produce results for only one drug or class of drugs.

Medicare reimbursement for G0431 will continue to be $19.72.

G0431QW – Drug screen, qualitative; single drug class method (e.g., immunoassay,
enzyme assay), each drug class, CLIA waived test

This new HCPCS code will become effective April 1, 2010, and must be used when reporting qualitative, single drug class assays classified as “CLIA waived” by the
FDA.

Medicare reimbursement for G0431QW will be $19.72 after April 1, 2010. A key difference between codes G0430 and G0431 is that G0430 is reported per procedure, while G0431 is reported for each drug class. Also, G0430 applies only to non-chromatographic methods, while G0431 can be used for any method.

The definition of a procedure is typically a single device (such as a test cup, test strip or card) or a separate set of reagents used with an instrument to produce one or more test results. Thus, G0431 would be used to report individual drugs or drug classes determined using immunoassay instruments employing discrete reagent sets. The code would be reported once for each drug or drug class determined.

Likewise, if more than one point-of-care test device for a single drug or single drug class is employed, the test results from each device would be separately reported using G0431. At present CMS has assigned no frequency limits for G0430 and G0431. Since these are new codes, they have not yet been assigned Correct Coding Initiative frequency limits (MUEs). It is expected that, in the near future, G0430 will be assigned an MUE value of 1 since CMS would not expect the code to be reported more than one time for each date of service. G0431 will probably be assigned a higher, but unpublished, frequency limit. It is CMS policy to keep frequency limits they believe may be abused confidential. Medically necessary services that exceed MUE frequency limits may be reported as
separate line items using an appropriate modifier such as 59 (separate and distinct service) or 91 (repeat clinical test) to identify them as medically necessary. Since each line of a claim is individually adjudicated, this allows the MUE edit to be bypassed and all medically necessary codes to be paid. However, excessive use of the 59 modifier to bypass MUE edits has been targeted by the Office of Inspector General as a possibly abusive practice. Thus, care should be taken to document medical necessity of such tests in the patient record.

HCPCS codes G0430QW and G0431QW may be used to report any test cleared by the FDA as “waived”. Any correctly coded, medically necessary assay currently cleared by  the FDA should be reimbursed by Medicare/Medicaid contractors after April 1, 2010. The following table summarizes the use of qualitative drug testing codes for Medicare claims submitted after April 1, 2010.

CLIA Waived Modifier QW
CLIA Non-waived
Chromatography:
Multiple drug classes N/A* 80100
Single drug or drug class G0431QW G0431

Other methods:

Multiple drug classes G0430QW G0430
Single drug or drug class G0431QW G0431

*there are no CLIA waived, chromatographic, qualitative drug procedures, thus 80100QW is not included on the Medicare Laboratory Fee Schedule.

Monday, November 15, 2010

Modifier SA, AS & 80 - payment rate for physician assistant and advanced nurse practitioner modifier

Supervision of Physician Assistant, Advanced Nurse Practitioner or Certified Registered Nurse First Assistant

The following modifiers should be used by the supervising physician when he/she is billing for services rendered by a Physician Assistant, (PA), Advanced Nurse Practitioner (APN) or Certified Registered Nurse First Assistant (CRNFA):

AS Modifier: A physician should use this modifier when billing on behalf of a PA, ANP or CRNFA for services provided when the aforementioned providers are acting as an assistant during surgery. (Modifier AS to be used ONLY if they assist at surgery)

Modifier AS Physician Assistant (PA), Nurse Practitioner (NP) or Clinical Nurse Specialist (CNS) assistant at surgery services.

Instructions

Append this modifier to appropriate procedure codes when Non-Physician Practitioners (NPPs) are assisting a principal surgeon as an assistant surgeon. The assistant at surgery provides more than ancillary services. NPPs include a CNS, NP and PA.

Correct Use

    The Medicare Physician Fee Schedule (MPFS) Indicator/Descriptor lists under column A will confirm if assistant at surgery is allowed.
        2 = payment restriction for assistants at surgery does not apply to this procedure. Assistant surgeon may be paid).
    NPP, mid-level practitioner or advance practice practitioner (APP)
        Append this modifier only
    NPP must accept assignment
    NPPs are allowed 85% of 16% physician fee allowable or 14% of surgery

Incorrect Use

    Inappropriate for NPPs to use modifiers 80, 81 or 82 (physician only modifiers)
    Modifier 80 (assistant surgeon), 81 (minimum assistant surgeon) or 82 (qualified resident surgeon not available) with physician (MD/DO) assisting at surgery


SA Modifier: A supervising physician should use this modifier when billing on behalf of a PA, ANP, of CRNFA for non-surgical services. (Modifier SA is used when the PA, ANP, or CRNFA is assisting with any other procedure that DOES NOT include surgery.)


Assistant Surgeon Modifiers

Modifier 80, 81, 82: Denote assistant surgeons. Should be submitted on those surgical procedures where an assistant surgeon is warranted. NOTE: Physicians acting as assistants cannot bill as co-surgeons. Benefits will be derived based on CMS designation for Assistant Surgeon.

-80 Modifier: PA’s, ANP’s, and CRNFA’s who are billing with their own provider number will not need to bill a modifier, unless they are billing as an Assistant Surgeon, then they must use the –80 modifier.


Billing and Coding Guidelines

A non-physician assistant-at-surgery is required to actively assist the surgeon and participate in the actual performance of the procedure. The operative report documents  the specific service(s) the non-physician assistant surgeon rendered.

Modifier AS should not be used if the Physician Assistant, Nurse Practitioner or Clinical Nurse Specialist is acting as an “extra” pair of hands and not a surgical assistant in place of another surgeon.

Codes that are eligible for multiple surgical reductions will be adjusted when multiple surgical procedures are performed at the same surgical session.



Billing Reminder for Mid-level Practitioners


A nurse practitioner (NP), physician assistant (PA), and certified nurse midwife (CNM) must have his/her own provider identification number with BlueCross BlueShield of Western New York.

Direct services furnished by a NP, PA, or CNM are reimbursed at 80 percent of the physician fee schedule and must be billed by the mid-level practitioner using his/her own provider number. For a mid-level provider to receive reimbursement for services directly, the requirements are:

The services must be services that could be furnished by a doctor of medicine or osteopathy. The services must be within the New York state defined scope of practice for NP, PA, and CNM. NP services must be provided in collaboration with a physician. PA services must be supervised by a physician.


Examples to help determine who should bill for services rendered: Encounter Who Should Bill? Reimbursement Rate Physician performs service Physician 100 percent of fee schedule

NP/PA/CNM performs service NP/PA/CNM 80 percent of fee schedule NP sees patient but medical record clearly demonstrates significant physician input for patient encounter, including face-to-face contact Physician

100 percent of fee schedule NP/PA sees patient, physician co-signs note or states "concur with treatment plan" NP/PA/CNM

80 percent of fee schedule

Note: only one provider may bill for an individual patient encounter/service.


Coding Assistant at Surgery Services Rendered in a Method II CAH

An assistant at surgery is a physician or non-physician practitioner who actively assists the physician in charge of the case in performing a surgical procedure.
Medicare makes payment for an assistant at surgery when the procedure is authorized for an assistant and the person performing the service is a physician, physician assistant (PA), nurse practitioner (NP) or a clinical nurse specialist (CNS).

Assistant at surgery services rendered by a physician or non-physician practitioner that has reassigned their billing rights to a Method II CAH are payable by Medicare when the procedure is billed on type of bill 85X with revenue code (RC) 96X, 97X or 98X and an appropriate assistant at surgery modifier.

Under authority of 42 CFR 414.40, CMS establishes uniform national definitions of services, codes to represent services, and payment modifiers to the codes. This includes the use of payment modifiers for assistant at surgery services.

Modifier 80 (assistant surgeon), 81 (minimum assistant surgeon), or 82 (when qualified resident surgeon not available) is used to bill for assistant at surgery services. When billed without modifier AS (PA, NP or CNS services for assistant at surgery) the use of these modifiers indicate that a physician served as an assistant at surgery.

Modifier AS is billed to indicate that a PA, NP or CNS served as the assistant at surgery.

Modifier 80, 81 or 82 must also be billed when modifier AS is billed. Claims submitted with modifier AS and without modifier 80, 81 or 82 are returned to the provider



Provider Types Eligible for Reimbursement for Assistant at Surgery Services

Moda Health considers the following provider types eligible for reimbursement for assistant at surgery services:

• MD (Medical Doctor)
• DO (Doctor of Osteopathic Medicine)
• PA (Physician’s Assistant)
• NP (Nurse Practitioner)
• RNFA (Registered Nurse First Assistant)



Provider Types Not Eligible for Reimbursement for Assistant at Surgery Services

The following provider types are not eligible for reimbursement of assistant at surgery service. Moda Health does not credential these provider types, and they are not eligible providers under our member plan language.

• Certified First Assistant (CFA)
• Certified Surgical First Assistant (CSFA)
• Certified Surgical Assistant (CSA)

These provider types are also not recognized by Medicare as eligible to bill or be reimbursed for assistant at surgery services.

Claims for services of CFAs, CSAs, or CSFAs, will be printed and returned to the billing office.

Contracted participating providers and groups are expected to not submit claims for assistant at surgery services performed by CFAs, CSAs, or CSFAs. Members may not be balance-billed for CFA services.



Assistant Surgeon Payment Adjustments

Procedure codes eligible for assistant at surgery reimbursement:

• Reported with modifier -80 or -82 appended will be reimbursed at 20% of the established fee.

• Reported by physician providers with modifier -81 appended will be reimbursed at 20% of the established fee.

• Reported by a non-physician provider with modifier -81 appended will be reimbursed at 10% of the established fee.

• Reported with modifier –AS appended, will be reimbursed at 10% of the established fee

PHYSICIAN ASSISTANTS

Louisiana Medicaid enrolls and issues individual Medicaid provider numbers to Physician Assistants (PA). Medicaid requires that all services provided by the PA be billed identifying the physician assistant as the attending provider.

Unless otherwise excluded by Louisiana Medicaid, the services covered are determined by individual licensure, scope of practice, and supervising physician delegation. The supervising physician must be a Medicaid enrolled physician. Clinical practice guidelines and protocols shall be available for review upon request by authorized representatives of Louisiana Medicaid.


Services  provided by a physician assistant shall not be billed when he/she is employed by or under contract with providers whose reimbursement is based on costs that include these salaries.

The reimbursement for services rendered by a physician assistant shall be 80% of the professional services fee schedule and 100% for KIDMED medical, vision, and hearing screens and immunizations.

Billing Information

Please note the following billing instructions and enrollment requirements regarding PA services

• PA services are billed on the CMS 1500/837P form.

• Services provided by the PA must be identified by entering the provider number of the PA in block 24J, and the group number must be entered in block 33B.

• Physicians who employ or contract with PAs must obtain a group provider number and link the PAs individual provider number to the group number. Physician groups must notify Provider Enrollment of such employment or contracts when PAs are added or
removed from the group.

• Qualified PAs who perform as first assistant in surgery should use the “-AS” modifier to identify these services.

Services rendered by the physician assistant that are billed and paid by Medicaid using a physician’s number as the attending provider are subject to post payment review and recovery.

First Assistant in Surgery

Louisiana Medicaid will reimburse for only one first assistant in surgery. Ideally, the first assistant to the surgeon should be a qualified physician. However, in those situations when a physician does not serve as the first assistant; qualified, enrolled, advanced practice registered nurses and physician assistants may function in the role of a surgical first assistant and submit claims for their services under their Medicaid provider number. The reimbursement of claims for more than one first assistant is subject to recoupment.


General reimbursement guide for NP and PA

A nurse practitioner (NP), physician assistant (PA), and certified nurse midwife (CNM) must have his/her own provider identification number with BlueCross BlueShield of Western New York. Direct services furnished by a NP, PA, or CNM are reimbursed at 80 percent of the physician fee schedule and must be billed by the mid-level practitioner using his/her own provider number. For a mid-level provider to receive reimbursement for services directly, the requirements are:

The services must be services that could be furnished by a doctor of medicine or osteopathy. The services must be within the New York state defined scope of practice for NP, PA, and CNM. NP services must be provided in collaboration with a physician. PA services must be supervised by a physician.


Encounter Who Should Bill? Reimbursement Rate


Physician performs service Physician 100 percent of fee schedule

NP/PA/CNM performs service NP/PA/CNM 80 percent of fee schedule

NP sees patient but medical record clearly demonstrates significant physician input for patient encounter, including face-to-face contact Physician 100 percent of fee schedule

NP/PA sees patient, physician co-signs note or states "concur with treatment plan" NP/PA/CNM 80 percent of fee schedule

Friday, April 30, 2010

Assitant sugeon Modifier 80

Surgical - 80 Modifier

80    Assistant Surgeon: Surgical assistant services may be identified by adding the modifier 80 to the usual procedure number(s).

This modifier should be reported to identify surgical assistant services performed in a non-teaching setting or in a teaching setting when a resident was available but the surgeon opted not to use the resident. In the latter case, the service is generally not covered by Medicare. When the surgical services are performed in a non-teaching setting, report “Non-teaching” in the narrative section of an electronic claim submission, or in Block 24D for paper claims.

Reimbursement 80 – Assistant Surgeon MD’s = 20% of the full service physician fee on file. Certified Nurse Midwives = 80% of MD’s ‘Assistant Surgeon’ fee. AS – First Assistant in Surgery: Qualified Phys. Assistant, Nurse Practitioner, or Clinical Nurse Specialist 80% of MD’s ‘Assistant Surgeon’ fee AT – Acute Treatment Chiropractors use this modifier when reporting service 98940, 98941 Fee on file

Surgical Assistant Guidelines

Payment is made only if an assistant surgeon is allowed on the Federal Register.

Modifier 80—Assistant Surgeon (MD, DMD, DDS, DO)]

• The allowance for modifier 80 is 20 percent of the surgery Procedure  allowance.

Modifier 81—Minimum Assistant Surgeon (MD, DMD, DDS, DO)

• The allowance for modifier 81 is ten percent of the surgery Procedure  allowance.

• This modifier is used when the doctor performed minimal assistance.

Modifier AS—Non-physician Assistant (PA, RN, CRNFA, CST, CNM, SA)

• The allowance for modifier AS is ten percent of the surgery Procedure  allowance.

To ensure accurate payment, please make sure when you are billing assistant surgeon claims that you submit the full billed amount, rather than the pre-cut amount. Our system will not recognize that the claim has been pre-cut (adjusted to show the assistant surgeon payment percentage), and it will be cut again according to the assistant surgeon guidelines.




Assistant-at-Surgery

*Assists the physician in charge of surgical procedure

*Modifier 80 used when the assistant at surgery service provided by a medical doctor

*Allowable based on 16% of MPFS

*Modifier AS used when the assistant at surgery service provided by a non-physician practitioner

*Examples include Physician Assistant and Nurse Practitioner

*Allowable based on 85% of 16% of MPFS

*MPFS Indicators for services where assistant at surgery allowed:

*0 = Payment restrictions for assistants at surgery applies to this procedure unless supporting documentation

*2 = Assistant at Surgery may be paid



Category         Indicator        Indicator Description

0
Payment restrictions for assistants at surgery apply to this procedure unless supporting documentation is submitted to establish medical necessity.

1
Statutory payment restriction for assistants at surgery applies to this procedure. Assistant at surgery may not be paid.

2
Payment restriction for assistants at surgery does not apply to this procedure. Assistant at surgery may be paid.


common Billing Errors (Mod 80 & AS)

*Claims for physician billed with modifier “AS”

*Claims for non-physician practitioner billed with modifier “80)

*Billed inappropriately with codes that have an Assistant-at-Surgery indicator of “1” (Assist at surgery may not be paid)



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