Showing posts with label Modifier 22. Show all posts
Showing posts with label Modifier 22. Show all posts

Monday, July 18, 2016

Payment Guide for Modifier 20, 52 and 22



Allowable Adjustments


Effective January 1, 2000, the replacement code (CPT 69990) for modifier -20 - microsurgical techniques requiring the use of operating microscopes may be paid separately only when submitted with CPT codes:


61304 through 61546

61550 through 61711

62010 through 62100

63081 through 63308

63704 through 63710

64831

64834 through 64836

64840 through 64858

64861 through 64871

64885 through 64891

64905 through 64907.


Payment Due to Unusual Circumstances (Modifiers “-22” and “-52”)


The fees for services represent the average work effort and practice expenses required to provide a service. For any given procedure code, there could typically be a range of work effort or practice expense required to provide the service. Thus, carriers may increase or decrease the payment for a service only under very unusual circumstances based upon review of medical records and other documentation.

Wednesday, December 30, 2015

Other CPT Modifiers- 22. 26. 32. 52, 76, 77,90, 91, 92


Modifier    Description
22    Increased Procedural Services: When the work required to provide a service is substantially is greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. Documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time, technical difficulty of procedure, severity of patient’s condition, physical and mental effort required).

Note: This modifier should not be appended to an E/M service. It should only be reported with procedure codes that have a global period of 0, 10, or 90 days.

26    Professional Component: Certain procedures are a combination of a physician component and a technical component. When the physician component is reported separately, the service may be identified by adding the modifier 26 to the usual procedure number. This modifier must be reported in the first modifier field.

32    Mandated Services: Services related to mandated consultation and/or related services (e.g., third-party payer governmental, legislative or regulatory requirement) may be identified by adding modifier 32 to the basic procedure.

52    Reduced Services: Under certain circumstances a service or procedure is partially reduced or eliminated at the physician’s discretion. Under these circumstances the service provided can be identified by its usual procedure number and the addition of the modifier 52, signifying that the service is reduced. This provides a means of reporting reduced services without disturbing the identification of the basic service.

Modifier 52 is used for “unusual (reduced) circumstances.” It designates that the service performed was significantly less than usually required. In many instances, attachments, medical records, etc. are not required to be sent in if an explanation for the reduction is in the narrative field of the claim. For example, submit “one view only” in the narrative when only one view of a two view study is performed. Similarly “right side only” may be submitted when a procedure code that is bilateral by definition is not performed bilaterally. When additional information to support the use of the 52 modifier cannot be contained in the narrative of the claim, additional documentation may be submitted.

76    Repeat Procedure or Service by Same Physician: It may be necessary to indicate that a procedure or service was repeated subsequent to the original procedure or service. This circumstance may be reported by adding the modifier 76 to the repeated procedure or service.
Note:  Do not report this modifier with 'add-on' codes denoted in CPT with a “+” sign. If a service defined as an 'add-on' code is repeated or provided more than once (based on description) on the same day by the same provider, report the 'add-on' code on one line with a multiplier in the unit field to indicate how many times that service was performed. For example, CPT 64636 (each additional facet joint) (billed in addition to primary/principle code 64635) is reported on one line as: 64636, units equal 3 (or the total number of additional facet joints (not bilateral) in addition to the initial/single facet joint billed under CPT code 64635). In this example, follow CPT instruction if provided bilaterally.

77    Repeat Procedure by Another Physician: The physician may need to indicate that a basic procedure or service performed by another physician had to be repeated. This situation may be reported by adding modifier 77 to the repeated procedure or service.

90    Reference (Outside) Laboratory: When laboratory procedures are performed by a party other than the treating or reporting physician, the procedure may be identified by adding the modifier 90 to the usual procedure number.

For the Medicare program, this modifier is used by independent clinical laboratories when referring tests to a reference laboratory for analysis.

91    Repeat Clinical Diagnostic Laboratory Test: In the same course of treatment of the patient, it may be necessary to repeat the same laboratory test on the same day to obtain subsequent (multiple) test results. Under these circumstances, the laboratory test performed can be identified by its usual procedure number and the addition of the modifier 91.

Note: This modifier may not be used when tests are rerun to confirm initial results; due to testing problems with specimens or equipment; or for any other reason when a normal, one-time, reportable result is all that is required. This modifier may not be used when other code(s) describe a series of test results (e.g., glucose tolerance tests, evocative/suppression testing). This modifier may only be used for laboratory test(s) performed more than once on the same day on the same patient.

92    Alternative Laboratory Platform Testing: When laboratory testing is being performed using a kit or transportable instrument that wholly or in part consists of a single use, disposable analytical chamber, the service may be identified by adding modifier 92 to the usual laboratory procedure code (HIV testing 86701-86703). The test does not require permanent dedicated space; hence by its design it may be hand carried or transported to the vicinity of the patient for immediate testing at that site, although location of the testing is not in itself determinative of the use of this modifier.

Tuesday, November 16, 2010

If claim goes with modifier 22, how much payment will get?

Modifier 22: Denotes an unusual procedural service. Should only be submitted on surgical procedure codes along with supporting documentation to justify the unusual service:

* If documentation supports sufficient difficulty/complexity to warrant additional payment for a procedure submitted with Modifier -22, then 25% of the eligible amount is allowed as an additional payment.
*  Otherwise, no additional payment is allowed.
*  A provider is allowed one appeal if the initial request for recognition of Modifier - 22 is denied.


Modifier 25: Denotes a significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service. Should only be submitted on an evaluation and management code, and medical records should reflect the significant, separately identifiable service.

Friday, July 30, 2010

Usage of Modifier 22 - increased Procedural Service

Modifier 22 Fact Sheet

Definition:

• Increased Procedural Service requiring work substantially greater than typically required.

Appropriate Usage:

• Surgeries where services performed are significantly greater than usual.
• Anatomical variants could be an appropriate use of the modifier.
• Assistant at surgery claims where a procedure is significantly greater than usual.
• Procedures having a global surgery indicator of 000, 010, or 090 on the
Medicare Physician Fee Schedule Database (MPFSDB).
• Procedures having a global period but not surgical services (i.e. 77761,
77777, 77782).

Inappropriate Usage:

• Additional time alone does not justify the use of this modifier.
• Do not use when there is an existing code to describe the service.
• We may deny the claim when the documentation supports another
existing code.
• Do not use to indicate a specialist performed the service.
• Not appropriate for an Evaluation and Management (E/M) service.
Documentation:
• Indicate “additional information available upon request” in field 19 of the 1500 form or loop 2300 NTE for the claim level or loop 2400 NTE segment for the line level in your electronic claim. We will send a development letter asking for the additional information.
• Supply an operative/procedure report along with a short, concise statement describing the way the service was unusual and the increased physician work.
• If we do not receive documentation, the claim will process based on normal Medicare guidelines and fee schedule.
• Carrier Medical Review staff determine the amount of reimbursement based on the information in the documentation.

Unassigned Claim:

• For unassigned claims, an increase in the limiting charge is allowed only when a charge above the fee schedule amount is justified.

Tuesday, July 27, 2010

Billing modifier 22 - Usage and coding tips

Modifier 22 INCREASED PROCEDURAL SERVICES

When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code.

Documentation must support the substantial additional work and the reason for the additional work (i.e., increased intensity, time, technical difficulty of procedure, severity of patient's condition, physical and mental effort required). Note: This modifier should not be appended to an E/M service.

Modifier Use/Example Special Billing Instructions Reimbursement 22 – Unusual Service Service provided is greater than that which is usually required (e.g., delivery of twins); not to be used with visit or lab codes Attach supporting documentation which clearly describes the extent of the service 125% of the fee on file.

Using the Modifier Correctly

Modifier 22 is appended to the basic CPT® procedure code when the service(s) provided is greater than usually required for the listed procedure. Use of modifier 22 allows the claim to undergo individual consideration.

• Modifier 22 is used to identify an increment of work that is infrequently encountered with a particular procedure and is not described by another code.

• Modifier 22 is generally not appended to a radiology code. If a rare circumstance does occur, submit detailed documentation with a cover letter from the radiologist or other provider.

• The frequent reporting of modifier 22 has prompted many payers to simply ignore it.

• Modifier 22 is used with computerized tomography (CT) numbers when additional slices are required or a more detailed examination is necessary. However, this is subject to payer discretion. Many payers will not allow additional reimbursement for additional CT slices.

Incorrect Use of the Modifier

• Appending this modifier to a radiology code without justification in the medical record documenting an unusual occurrence. Because of its overuse, many payers do not acknowledge this modifier.

• Using this modifier on a routine basis; to do so will cause scrutiny of submitted claims and may result in an audit.

• Using modifier 22 to indicate that the radiology procedure was performed by a specialist; specialty designation does not warrant use of modifier 22.

• Using modifier 22 when more x-rays views are taken than actually specified by the CPT code description. This is incorrect, especially when the code descriptor reads “complete” (e.g., 70130, 70321, 73110, etc.). Complete means any number of views taken of the body site.

Coding Tips

• Using modifier 22 identifies the service as one that requires individual consideration and manual review.

• Overuse of modifier 22 could trigger a payer audit. Payers monitor the use of this modifier very carefully. Modifier 22 should be used only when sufficient documentation is present in the medical record.

• A Medicare claim submitted with modifier 22 is forwarded to the payer medical review staff for review and pricing. With sufficient documentation of medical necessity, increased payment may result.


Modifier 22 (Unusual Procedural Services)

Tufts Health Plan requires documentation when claims are submitted with modifier 22 (unusual procedural services). Claims submitted without additional documentation are not considered for additional compensation. Clinical documentation must indicate one of the following:

** Excessive blood loss for the particular procedure performed

** Extensive, well-documented adhesions present with an abdominal surgery and requiring minimum of 45 minutes to lyse

** Presence of an excessively large surgical specimen (tumor)

** Trauma so extensive that the particular procedure and complication is not billed as separate and distinct procedures themselves

** Other pathologies, tumors and malformations that increase the complexity of the procedure

** Extended anesthesia is identified (anesthesia record must be submitted)

Do not submit modifier 22 if you are reporting any of the following:

** Increased complexity due to a surgeon’s choice of approach

** Describing a re-operation

** Describing a weight reduction surgery

** Describing the use of robotic assistance

** An unspecified procedure code

Modifier 22 - Increased Procedural Services 

In order to be considered for additional reimbursement when reporting Modifier 22, thorough medical records or reports and a separate document containing a concise statement about how the service differed from the usual service or procedure is required. The documents must indicate the substantial additional work performed and the reason for the additional work which may include, but not be limited to, increased intensity or time, technical difficulty of procedure that is not described by a more comprehensive procedure code, severity of the patient’s condition, or increased physical and mental effort required.

Additional reimbursement will only be considered for services appended with Modifier 22 that are assigned a global period of 0, 10, 42 or 90 days. Modifier 22 should not be appended to an evaluation and management service. Refer to the “Global Days Policy” for a listing of those codes with a global day period.

Modifier 63 - Procedure Performed on Infants Less Than 4 kg

In order to be considered for additional reimbursement when reporting Modifier 63, thorough medical record(s) or report(s) that support the use of the modifier is required. The document(s) must indicate the substantial additional work performed and the reason for the additional work which may include, but not be limited to, increased intensity or time, technical difficulty of procedure that is not described by a more comprehensive procedure code, severity of the patient’s condition, or increased physical and mental effort required.

Unless otherwise designated, this modifier may only be appended to procedures/services listed in the 20005-69990 code series. Modifier 63 should not be appended to any CPT code listed in the Evaluation and Management Services,Anesthesia, Radiology, Pathology/Laboratory, or Medicine sections.


DEFINITIONS

Allowable Amount: The dollar amount eligible for reimbursement to the physician or health care professional on the claim.

Contracted rate, reasonable charge, or billed charges are examples of allowable amounts.

Modifier 22: Increased Procedural Services: When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. Documentation must support the substantial additional work and the reason for the additional work (i.e., increased intensity, time, technical difficulty of procedure, severity of patient's condition, physician and mental effort required).

Note: This modifier should not be appended to an E/M service.

Modifier 63: Procedures performed on neonates and infants up to a present body weight of 4 kg may involve significantly increased complexity and physician or other qualified health care professional work commonly associated with these patients. This circumstance may be reported by adding the modifier 63 to the procedure number.

Note: Unless otherwise designated, this modifier may only be appended to procedures/services listed in the 20005- 69990 code series. Modifier 63 should not be appended to any CPT code listed in the Evaluation and Management Services, Anesthesia, Radiology, Pathology/Laboratory, or Medicine sections.



QUESTIONS AND ANSWERS

1 Q: Do the American Medical Association (AMA), the Centers for Medicare and Medicaid Services (CMS) or other national professional organizations recommend a specific reimbursement amount for use of Modifiers 22 or 63?

A: No. Therefore, Oxford has made the determination to reimburse in total an additional 20% of the Allowable Amount of the unmodified procedure, not to exceed the billed charges, provided the documentation supports use of either Modifier 22 or Modifier 63.

2 Q: Can the concise statement required for modifier 22 substantiating how a service differs from the usual service performed be included within the operative report?

A: No. In alignment with CMS, two separate documents will be required. One required document is eitherthe operative report or medical record. The other required document is a concise statement supporting the substantial additional work and the reason for the additional work.

Modifier 22: Denotes an unusual procedural service. Should only be submitted on surgical procedure codes along with supporting documentation to justify the unusual service:

If documentation supports sufficient difficulty/complexity to warrant additional payment for a procedure submitted with Modifier -22, then 25% of the eligible amount is allowed as an additional payment.

Otherwise, no additional payment is allowed.

A provider is allowed one appeal if the initial request for recognition of Modifier -22 is denied



Modifier Modifier Definition Cross reference Guidelines

Modifier 22 - Increased Procedural Services

Description: When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code. Documentation must support the substantial additional work and the reason for the additional work (i.e., increased intensity, time, technical difficulty of procedure, severity of patient’s condition, physical and mental effort required). Note: This modifier should not be appended to an E/M service.

This modifier can be located in the following rule(s):

* Anesthesia
* Global Maternity
* This modifier is not utilized to override any edits.
* Modifier should be appended to the procedure when the provider is seeking additional compensation for the procedure due to the increased service.
* This modifier can be appended to surgical and non-surgical procedures.
* This modifier cannot be appended to an E/M service.
* Documentation of the unusual circumstances must accompany the claim (e.g., a copy of the operative report and a separate statement written by the physician explaining the unusual amount of work required).

• 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.


Modifier 22 can be used on any procedure within the Anesthesia, Surgery, Radiology, Laboratory/Pathology and Medicine series of codes. However, this modifier should not be used on E&M services. E&M codes like CPT 99211, 99213 with a modifier 22 will be denied. If modifier 22 is used on any surgical procedure, then it must only be used on surgeries which have a global period of  000, 010, 090, or YYY identified on the Medicare Physician Fee Schedule Relative Value File

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