Showing posts with label cpt modfiers. Show all posts
Showing posts with label cpt modfiers. Show all posts

Wednesday, May 25, 2016

how to use JW modifier

Effective July 1, 2016, providers are required to:


• Use the JW modifier for claims with unused drugs or biologicals from single use vials or single use packages that are appropriately discarded (except those provided
under the Competitive Acquisition Program (CAP) for Part B drugs and biologicals) and

• Document the discarded drug or biological in the patient's medical record when submitting claims with unused Part B drugs or biologicals from single use vials or
single use packages that are appropriately discarded Make sure that your billing staffs are aware of these changes. Remember that the JW modifier is not used on claims for CAP drugs and biologicals

The “Medicare Claims Processing Manual,” Chapter 17, Section 40 provides policy detailing the use of the JW modifier for discarded Part B drugs and biologicals. The current policy allows MACs the discretion to determine whether to require the JW modifier for any claims with discarded drugs or biologicals, and the specific details regarding how the discarded drug or biological information should be documented.


Be aware in order to more effectively identify and monitor billing and payment for discarded drugs and biologicals, CMS is revising this policy to require the uniform use of the JW modifier for all claims with discarded Part B drugs and biologicals

Sunday, May 15, 2016

FQHC and IHC CPT CODES T1015 with POS and Modifier

Clinic/Center-Federally Qualified Health Center (FQHC)

Bill the encounter using procedure code T1015 with the appropriate rate on the first detail line. Providers are required to list all the CPT/HCPCS services provided during the encounter priced at zero dollars on subsequent lines. CPT codes included with the T1015 encounter code must accurately indicate the service(s) provided during the encounter and conform to National Correct Coding Initiative (NCCI) standards. Claims submitted without the corresponding CPT/HCPCS codes will be denied.

Service HCPCS Diagnosis Description Modifier Place of Service 

Clinic/ center -FQHC T1015 Use appropriate diagnosis code for services rendered. (i.e., Well Child Exam, Family Planning) All FQHC clinics must use procedure code T1015 for medical services. 76 (same day/ same provider) 77 (same day/ different provider)  POS 50

Medicaid Guide on CPT T1015 - Physical Therapy and Occupational Therapy

1.      Covered services and authorized procedure codes for physical therapy and occupational therapy are:

Physical Therapy: T1015

Occupational Therapy: T1015 with GO modifier

Rehabilitation Centers: T1015

2.   Limitations for physical therapy and occupational therapy:
a.  Treatment and services must be provided by a licensed physical therapist or occupational therapist.
b.   No prior authorization is required.
c.   Maximum of 10 visits per calendar year in any combination of physical and occupational therapy.


Clinic/Center-Rural Health Clinics (RHC)

Bill the encounter using procedure code T1015 with the appropriate rate on the first detail line. Providers are required to list all the CPT/HCPCS services provided during the encounter priced at zero dollars on subsequent lines. CPT codes included with the T1015 encounter code must accurately indicate the service(s) provided during the encounter and conform to National Correct Coding Initiative (NCCI) standards. Claims submitted without the corresponding CPT/HCPCS codes will be denied.


Service HCPCS Diagnosis Description Modifier Place of Service 

Clinic/ Center -Rural Health Clinics T1015 Use appropriate diagnosis code for services rendered. (i.e., Well Child Exam, Family Planning) All rural health clinics must use procedure code T1015 for medical services. 76 (same day/ same provider)  77 (same day/ different provider) POS 72

Indian Health Center (IHC)

Bill the encounter using procedure code T1015 with the appropriate rate on the first detail line. Providers are required to list all the CPT/HCPCS services provided during the encounter priced at zero dollars on subsequent lines. CPT codes included with the T1015 encounter code must accurately indicate the service(s) provided during the encounter and conform to National Correct Coding Initiative (NCCI) standards. Claims submitted without the corresponding CPT/HCPCS codes will be denied.


Service HCPCS Diagnosis Description Modifier Place of Service

Clinic/ Center -Indian Health Clinics  T1015 Use appropriate diagnosis code for services rendered. (i.e., Well Child Exam, Family Planning) All rural health clinics must use procedure code T1015 for medical services. 76 (same day/ same provider) 77 (same day/ different provider) POS 5

Friday, April 29, 2016

PI and PS Modifier for PET SCAN

B. Modifiers for PET Scans

Effective for claims with dates of service on or after April 3, 2009, the following modifiers have been created for use to inform for the initial treatment strategy of biopsy-proven or strongly suspected tumors or subsequent treatment strategy of cancerous tumors:


PI Positron Emission Tomography (PET) or PET/Computed Tomography (CT) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing.


Short descriptor: PET tumor init tx strat PS Positron Emission Tomography (PET) or PET/Computed Tomography (CT) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treatment physician determines that the PET study is needed to inform subsequent anti-tumor strategy.

Short descriptor: PS - PET tumor subsq tx strategy


Effective for claims with dates of service on or after April 3, 2009, contractors shall accept FDG PET claims billed to inform initial treatment strategy with the following CPT codes AND modifier PI: 78608, 78811, 78812, 78813, 78814, 78815, 78816.

Effective for claims with dates of service on or after April 3, 2009, contractors shall accept FDG PET claims with modifier PS for the subsequent treatment strategy for solid tumors using a CPT code above AND a cancer diagnosis code.



Contractors shall also accept FDG PET claims billed to inform initial treatment strategy or subsequent treatment strategy when performed under CED with one of the PET or PET/CT CPT codes above AND modifier PI OR modifier PS AND a cancer diagnosis code AND modifier Q0/Q1. Effective for services performed on or after June 11, 2013, the CED requirement has ended and modifier Q0/Q1, along with condition code 30 (institutional claims only), or ICD-9 code V70.7, (both institutional and practitioner claims) are no longer required.

Tuesday, April 26, 2016

Using Modifier 59, 76, 91 to prevent Duplicate denials

Preventing duplicate claim denials

Providers are responsible for all claims submitted to Medicare under their provider number. Preventable duplicate claims are counterproductive and costly, and continued submission to Medicare may lead to program integrity action.

Please share this information with your billing companies, vendors and clearing houses: Claim system edits search for duplicate, suspect duplicate and repeat services, procedures and items within paid, finalized, pending and same claim details in history. Duplicate claims and claim lines are automatically denied. Suspect duplicate claims and claim lines are suspended and reviewed by the Medicare administrative contractor (MAC) to make a determination to pay or deny. Click here for additional information.

Medicare correct coding rules include the appropriate use of condition codes and/or modifiers. When you submit a claim for multiple instances of a service, procedure or item, the claim should include an appropriate modifier to indicate that the service, procedure or item is not a duplicate. Note that the modifier should be added to the second through subsequent line items for the repeat service, procedure or item. (An example is listed below.) In many instances, this will allow the claim to process and pay, if applicable.

However, in some instances, even if an appropriate modifier is included, the claim may deny as a duplicate, based on medically unlikely edits (MUEs). MUEs are maximum units of service that are typically reported for a service, medical procedure or item, under most instances, for a beneficiary on a single date of service. Note that these duplicate denials may not always be considered preventable.

However, in some instances, even if an appropriate modifier is included, the claim may deny as a duplicate, based on medically unlikely edits (MUEs). MUEs are maximum units of service that are typically reported for a service, medical procedure or item, under most instances, for a beneficiary on a single date of service. Note that these duplicate denials may not always be considered preventable. Click here for information on MUEs, including appeal rights.

Review your billing procedures and software, and use appropriate modifiers, as applicable. The following are examples of modifiers that may be used on your claim to identify that the service, procedure or item is not a duplicate. Please review the Current Procedural Terminology (CPT®) codebook for a complete list of modifiers.

• Modifier 59: Service or procedure by the same provider, distinct or independent from other services, performed on the same day. Services or procedures that are normally reported together but are appropriate to be billed separately under certain circumstances. Refer to MLN Matters® article SE1418 external pdf file for more details on the use of modifier 59, including numerous coding examples.

• The Centers for Medicare & Medicaid Services (CMS) established four new modifiers, effective January 1, 2015, to define subsets of modifier 59. Refer to MLN Matters® article MM8863 external pdf file for details.

• Modifier 76: Repeat service or procedure by the same provider, subsequent to the original service or procedure.

• Modifier 91: Repeat clinical diagnostic laboratory tests. This modifier is added only when additional test results are medically necessary on the same day.

• Example: Laboratory submits Medicare claim for four glucose; blood, reagent strip tests (CPT® code 82948).
Line 1: 82948
Line 2: 82948 and modifier 91
Line 3: 82948 and modifier 91
Line 4: 82948 and modifier 91

Note: All claims submitted to Medicare should be supported by documentation in the patient’s medical record.

Sunday, April 10, 2016

Surgical Mofiers 50, 52 , 57, 58 When to use

Modifiers

Use the following modifiers, as applicable:

Bill Use Modifier Other Information


Bilateral surgery 50  Refer to the Bilateral Services and CPT Modifier 50 Payment Policy for billing directives


Reduced service 52 Use with CPT code representing the surgery(s) performed


Attempted service (discontinued procedure) 53

Decision for surgery 57 Use with evaluation and management code when appropriate


Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period 58  Use with procedure performed within the global period of another surgery when appropriate


Assistant surgeon 80, 81, 82, or AS • Use with CPT code representing the surgery(s) performed • Bill this modifier in the first modifier field

Co–surgery 62


Team surgery 66 • Use with CPT code representing the surgery(s) performed
• Attach operative notes
• Bill this modifier in the first modifier field


Repeat procedures by the same physician 76 Use with a repeat of a same procedure performed within the global period when appropriate


Return to the operating room for a related procedure during the postoperative period 78   Use when a related procedure requires a return trip to the OR by the same physician within the global period of the first surgery when appropriate


Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period 79 Use when performing an unrelated procedure during the global period of a previous surgery

Wednesday, April 6, 2016

Usage of AT (Active Treatment ) Modifier

The Active Treatment (AT) modifier defines the difference between active treatment and maintenance treatment. Effective October 1, 2004, the AT Modifier is required under Medicare billing to receive reimbursement for CPT codes 98940-98942. For Medicare purposes, the AT modifier is used only when chiropractors bill for active/corrective treatment (acute and chronic care). The policy requires the following:

1. Every chiropractic claim for 98940/98941/98942, with a date of service on or after October 1, 2004, should include the AT modifier if active/corrective treatment is being performed; and 2. The AT modifier should not be used if maintenance therapy is being performed. MACs deny chiropractic claims for 98940/98941/98942, with a date of service on or after October 1, 2004, that does not contain the AT modifier.

The following categories help determine coverage of treatment.


1. Acute subluxation: A patient's condition is considered acute when the patient is being treated for a new injury (identified by x-ray or physical examination). (See SE1601 for details of the x-ray and examination requirements.) The result of chiropractic manipulation is expected to be an improvement in, or arrest of progression of, the patient's condition.

2. Chronic subluxation: A patient's condition is considered chronic when it is not expected to significantly improve or be resolved with further treatment (as is the case with an acute condition); however, the continued therapy can be expected to result in some functional improvement. Once the clinical status has remained stable for a given condition, without expectation of additional objective clinical improvements, further manipulative treatment is considered maintenance therapy
and is not covered.

Both of the above scenarios are covered by CMS as long as there is active treatment which is well documented and improvement is expected.


Maintenance: Maintenance therapy includes services that seek to prevent disease, promote health and prolong and enhance the quality of life, or maintain or prevent  deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy. The AT modifier must not be placed on the claim when
maintenance therapy has been provided. Chiropractors should consider obtaining an Advance Beneficiary Notice (ABN) from beneficiaries in the event of a denial of a claim.

Key Points

For Medicare purposes, a chiropractor must place an AT modifier on a claim when providing active/corrective treatment to treat acute or chronic subluxation. However, the presence of the AT modifier may not in all instances indicate that the service is reasonable and necessary. As always, MACs may deny if appropriate after medical review determines that the medical record does not support active/corrective treatment.

Friday, March 25, 2016

How to use Bilateral Services and CPT Modifier -50 and payment policy

Bilateral Modifier (50)

Modifier 50 identifies the same procedures that are performed as a bilateral service. The procedure should be billed on one line with modifier 50 and one unit with the full charge for both procedures. A procedure code submitted with modifier 50 is a reimbursable service as set forth in this policy only when it is listed on the Oxford Bilateral Eligible Policy List.

When a CPT or HCPCS code is reported with modifier 50 and the code is not listed on the Bilateral Eligible Procedures Policy List, the code will not be reimbursed.

CPT or HCPCS codes with 'bilateral' or 'unilateral or bilateral' written in the description are not on Oxford's Bilateral Eligible Procedures Policy List and will not be reimbursed with modifier 50.

There are  are instances in which a bilateral service may be performed on multiple sites and not just bilaterally. In those instances, use modifier 59 Distinct Procedural Service or XS Separate Structure to report the additional units beyond the bilateral services performed indicating that the services were performed on a different site or organ system. Medical record documentation must support the use of modifier 59 or XS.

Procedure Codes with the Term "Bilateral" in the Description When CPT or HCPCS codes with "bilateral" or "unilateral or bilateral" written in the description are reported, special consideration will be given when reported with modifiers LT or RT.

When a CPT or HCPCS procedure code exists for both a unilateral and a Bilateral Procedure, select the code that best represents the procedure. For example: 40842 Vestibuloplasty; posterior, unilateral and 40843 Vestibuloplasty; posterior, bilateral.

Codes with "Bilateral" in the Description Policy List

Consistent with CPT guidelines, if a unilateral procedure has not been defined by CPT or HCPCS and only a bilateral description of a procedure exists, report the code with "bilateral" in the description with modifier 52 (reduced services)  when the procedure is performed unilaterally. For more information on reimbursement for reduced services, see Oxford's Reduced Services policy.

For Oxford purposes, when both modifiers LT and RT are reported separately for codes with "bilateral" in the description, only one charge will be eligible for reimbursement up to the respective Maximum Frequency per Day (MFD) value as the procedure is inherently bilateral. For additional information, refer to the Questions and Answers section, Q&A3. For more information on maximum frequency per day values, see Oxford's Maximum Frequency Per Day policy.

When a procedure with "unilateral or bilateral" written in the description is performed unilaterally, then the CPT or HCPCS procedure code need not be reported with modifier 52 since the procedure description already indicates that the service can be performed either unilaterally or bilaterally. For example: 31231 Nasal endoscopy, diagnostic, unilateral or bilateral (separate procedure).

Codes with "Unilateral or Bilateral" in the Description Policy List

The use of modifiers LT or RT will be recognized as informational only when the procedure with "unilateral or bilateral" in description is performed on only one side. Consistent with CMS guidelines, when both modifiers LT and RT are reported separately on the same day by the same individual physician, hospital, ambulatory surgical center or other health care professional, only one charge will be eligible for reimbursement up to the maximum frequency per day limit.


For maximum frequency per day limits, see Oxford's Maximum Frequency Per Day policy. Modifier Definitions Modifier Description 50 Bilateral Procedure Unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate five digit code.

Description

Bilateral services are procedures performed on both sides of the body during the same session or on the same day.

The HCPCS modifiers -LT and -RT are used when the procedure is valid for a modifier -50 procedure but the procedure is only performed on one side.

• As defined in the CPT, Modifier 50 “Bilateral Procedure: Unless otherwise identified in the listings, bilateral procedures that are performed at the same session should be identified by adding modifier 50 to the appropriate five digit code.”

• Modifier 50 is used to report diagnostic, radiology and surgical procedures. Modifier 50 applies to any bilateral procedure performed on both sides at the same session.

• Do not use Modifiers RT and LT when modifier 50 applies. A bilateral procedure is reported on one line, using modifier 50.

• Modifier 50 eligibility is based on procedure description, CPT guidelines, CMS directives and nationally recognized sources (e.g., Journal of AHIMA, CPT Assistant).

The modifier “50” is not applicable to:
• Procedures that are bilateral by definition.
• Procedures with descriptions including the terminology as “bilateral” or “unilateral.”


Harvard Pilgrim Reimburses1

Bilateral services performed on both sides of the body during the same session or on the same day at 150% of the fee schedule allowed amount.

• Bilateral payment adjustment applies to all providers except for those providers contracted as facility surgery case rate and percent of charge reimbursement methods.


Bilateral Service Billing

Bilateral services performed on both sides of the body during the same session or on the same day must be billed on a single detail line with CPT and modifier 50 appended.


Multiple Modifiers Billing

Modifier that reduces the fee schedule/allowable amount must be billed in the primary modifier position, and modifier 50 in the secondary position.


REIMBURSEMENT GUIDELINES

Bilateral Eligible List

The Oxford Bilateral Eligible Procedures Policy List is developed based on the Centers for Medicare and Medicaid Services (CMS) National Physician Fee Schedule (NPFS) Relative Value File status indicators.

All codes in the NPFS with the "bilateral" status indicators "1" or "3" are considered by Oxford to be eligible for bilateral services as indicated by the bilateral modifier 50.

When a bilateral eligible code with a bilateral indicator of "1" is reported with modifier 50 and is subject to reductions under the Multiple Procedures policy, the code will be eligible for reimbursement at 150% of the allowable amount not to exceed billed charges for a single procedure code, with one side reimbursed at 100% and the other side reimbursed at 50%. When other reducible procedure codes are reported on the same date of service, an additional multiple procedure reduction may or may not be applied to the line paid at 100% depending on whether another procedure code is ranked as primary or not.

When a bilateral eligible code with a bilateral indicator of "3" is reported with modifier 50 and is not subject to reductions under the Multiple Procedure Policy, the code will be eligible for reimbursement at 100% of the allowable amount for each side for a sum of 200% of the allowable amount not to exceed billed charges.


Multiple Procedure Reduction

Eligible Bilateral Procedures on the Oxford Bilateral Eligible Procedures Policy List may be subject to multiple procedure reductions as defined in Oxford's Multiple Procedures policy. In order to fully understand Oxford's reimbursement rules for eligible Bilateral Procedures, refer to the Multiple Procedures policy in conjunction with this policy.


Wednesday, March 23, 2016

Documentation is required when billing modifier 24

Based on widespread probes of office evaluation and management (E/M) services, First Coast has discovered that the 24 modifier for E/M services, when billing within a global surgery period, has been billed incorrectly at least 60 percent of the time. Clinical review of documentation demonstrates that modifier 24 was either not supported for the encounter, or was improperly applied (i.e., a different modifier should have been submitted).

To address this widespread improper billing, First Coast implemented a pre-payment edit on April 16, 2012, applicable to office visit E/M claims (codes 99201-99205 and 99212-99215) billed with the 24 modifier.

Claims
For claims containing modifier 24 received on or after April 16, 2012, First Coast began developing to the provider to provide supporting documentation that justifies the use of the 24 modifier. Providers must respond within the specified timeframe included in the development letter. Failure to submit the documentation timely may result in a claim denial.

Reopenings

Also effective April 16, 2012, First Coast no longer accepts:

• Telephone requests via the interactive voice response or a customer service representative to add or change the 24 modifier on a previously denied claim.
• Written or fax requests (processed on or after April 16) to add or change the 24 modifier without supporting documentation. The provider will be sent a written notification that their request could not be completed.

Thursday, February 18, 2016

Telehealth services with GT modifier

All reimbursable telehealth services must be provided and billed in accordance with appropriate licensure standards, Idaho Medicaid Telehealth Policy, Information Release MA15-11, and applicable handbooks. Codes covered by telemedicine must always be billed with the GT modifier. The procedure codes listed below are the ONLY services that can receive Medicaid reimbursement when delivered via telehealth


CPT/HCPS Description Modifier

90791 Psychiatric Diagnostic Evaluation GT
90792 Psychiatric Diagnostic Eval W/Medical Services GT
90832 Psychotherapy Patient & / Family 30 Minutes GT
90833 Psychotherapy Pt & /Family W/E & M Srvcs 30 Min GT
90834 Psychotherapy Patient & / Family 45 Minutes GT
90836 Psychotherapy Pt & /Family W/E & M Srvcs 45 Min GT
90837 Psychotherapy Patient & / Family 60 Minutes GT
90838 Psychotherapy Pt & /Family W/E & M Srvcs 60 Min GT
96150 Hlth & Behavior Assmt Ea 15 Min W/Pt 1st Assmt GT
96151 Hlth & Behavior Assmt Ea 15 Min W/Pt Re-Assmt GT
96152 Hlth & Behavior Ivntj Ea 15 Min Indiv GT
96153 Hlth & Behavior Ivntj Ea 15 Min Grp 2/Gt Pts GT
96154  Hlth & Behavior Ivntj Ea 15 Min Fam W/Pt GT
99354 Prolng Svc Office O/P Dir Contact 1st Hr GT
99355 Prolng Svc Office O/P Dir Contact Ea 30 Min GT
99406 Tobacco Use Cessation Intermediate 3-10 Minutes GT
99407 Tobacco Use Cessation Intensive Gt10 Minutes GT
99495 Transitional Care Manage Service 14 Day Discharge GT
99496 Transitional Care Manage Service 7 Day Discharge GT
99201 Office Outpatient New 10 Minutes GT
99202 Office Outpatient New 20 Minutes GT
99203 Office Outpatient New 30 Minutes GT
99204 Office Outpatient New 45 Minutes GT
99205 Office Outpatient New 60 Minutes GT
99211 Office Outpatient Visit 5 Minutes GT
99212 Office Outpatient Visit 10 Minutes GT
99213 Office Outpatient Visit 15 Minutes GT
99214 Office Outpatient Visit 25 Minutes GT
99215 Office Outpatient Visit 40 Minutes GT
H2011 Therapeutic consultation GT
H2019 Crisis intervention GT

Thursday, January 7, 2016

Appropriate use of assistant at surgery modifiers and payment indicators



An assistant at surgery is a provider who actively assists the physician in charge of a case in performing a surgical procedure. A physician, nurse practitioner, physician assistant or clinical nurse specialist who is authorized to provide such services under state law can serve as an assistant at surgery.

Medicare considers advanced registered nurse practitioner (ARNP), physician assistant (PA), and clinical nurse specialist (CNS) as non-physician practitioners. Medicare does not recognize a registered nurse first assistant (RNFA) as a qualified Medicare provider.

To report services of an assistant surgeon, the following surgical modifiers should be appended:

• 80 -- Assistant Surgeon: This modifier pertains to physician’s services only. A physician’s surgical assistant services may be identified by adding the modifier 80 to the usual procedure code. This modifier describes an assistant surgeon providing full assistance to the primary surgeon, and is not intended for use by non-physician providers.
• 81 -- Assistant Surgeon: This modifier pertains to physician’s services only. Minimal surgical assistance may be identified by adding the modifier 81 to the usual procedure code, and describes an assistant surgeon providing minimal assistance to the primary surgeon. This modifier is not intended for use by non-physician providers.
Note: This modifier is used in the private insurance industry and is not commonly used in Medicare billing.
• 82 -- Assistant surgeon (when a qualified resident surgeon is not available in a teaching facility): This modifier applies to physician’s services only. The unavailability of a qualified resident surgeon is a prerequisite for use of this modifier and the service must have been performed in a teaching facility. The circumstance explaining that a resident surgeon was not available must be documented in the medical record. This modifier is not intended for use by non-physician providers.
• AS -- Non-physician provider as assistant at surgery: This modifier applies when the assistant at surgery services are provided by a PA, ARNP, or CNS.
Payment information
Medicare reimburses services rendered for assistant at surgery by a physician performing as a surgical assistant at 16 percent of the MPFS amount. Services rendered for assistant at surgery by non-physician providers are reimbursed at 85 percent of 16 percent (i.e., 13.6 percent) of the MPFS amount.
When reporting services provided by non-physician practitioners acting as assistants at surgery, append modifier AS to the procedure code used to report the surgeon’s service.
If a physician appends modifier AS to procedure codes for which he/she acted as assistant at surgery, these codes will be denied (see above for modifiers that should be used by physicians).

Medicare physician fee schedule database (MPFSDB) assistant at surgery payment indicators
The MPFSDB is a file layout that carriers and A/B MACs use to display the total fee schedule amount, related component parts, and payment policy indicators. The assistant at surgery payment indicator describes when assistant at surgery may be paid or not. Valid indicators are:

• 0 = Payment restriction for assistants at surgery applies 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.
• 9 = Concept does not apply.
If multiple services are submitted with modifiers indicating assistants at surgery, each service is independently reviewed (based on the above-listed indicators) to determine payment.

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.

Sunday, December 20, 2015

HPSA And PSA Modifiers -AQ, AR, PQRS Modifiers - 1P, 2P,3P,8P, Ambulance Modifiers - QM,QN,QL

Health Professional Shortage Area (HPSA) and Physician Scarcity Area (PSA) Modifiers

Modifier    Description
AQ    Service performed in a Health Professional Shortage Area. This modifier is used by physicians to indicate the services reported were rendered in a qualified Health Professional Shortage Area (HPSA) and are eligible for the 10% incentive payment.
AR    Physician providing services in a physician scarcity area.

Provider Quality Reporting Initiative (PQRI) Modifiers


These modifiers are only to be used for PQRI, no other modifiers should be used when reporting PQRI.

Modifier    Description
1P    Performance Measure Exclusion Modifier Due to Medical Reasons
2P    Performance Measure Exclusion Modifier Due to Patient Choic    
3P    Performance Measure Exclusion Modifier Due to System Reasons
8P    Performance Measure Reporting Modifier - Action Not Performed, Reason Not Otherwise Specified

Ambulance Modifiers
For ambulance service claims, institutional-based providers and suppliers must report an origin and destination modifier for each ambulance trip provided in HCPCS/Rates.
Origin and destination modifiers used for ambulance services are created by combining two alpha characters. The first position alpha code equals origin; the second position alpha code equals destination.  

Origin/Destination    Description
D    Diagnostic or therapeutic site other than P or H when these are used as origin codes
E    Residential, domiciliary, custodial facility (other than 1819 facility)
G    Hospital based ESRD facility
H    Hospital
I    Site of transfer (e.g. airport or helicopter pad) between modes of ambulance transport
J    Freestanding ESRD facility
N    Skilled nursing facility
P    Physician’s office
R    Residence
S    Scene of accident or acute event
X    Intermediate stop at physician’s office on way to hospital
Note: This is a destination code only

In addition, institutional-based providers must report one of the following modifiers with every HCPCS code to describe whether the service was provided under arrangement or directly. 

Modifier    Description
QM    Ambulance service provided under arrangement by a provider of services
QN    Ambulance service furnished directly by a provider of services
QL    Patient pronounced dead after ambulance called

Wednesday, December 9, 2015

Surgical Modifiers - 51, 53, 54, 55, 56, 62, 66, 73, 74, 80,81,82


Modifier    Description

50    Bilateral Procedure: Unless otherwise identified in the listings, bilateral procedures that are performed at the same operative session should be identified by adding the modifier 50 to the appropriate five digit code.

Report such procedures as a single line item with a unit of 1. For example, when procedure code

19303 (Mastectomy, simple, complete) is performed bilaterally, report the service as 1930350.
If a procedure is identified by the terminology as bilateral ( or unilateral or bilateral), do NOT report the procedure code with modifier 50. For example, procedure code 68810 to 68815, (probing of nasolacrimal duct, with or without irrigation, unilateral or bilateral) includes terminology which indicates the procedure is performed either unilaterally or bilaterally. Therefore it’s not appropriate to report this modifier with this code.

Additionally some procedure codes, i.e., 52000

(Cystourethroscopy, separate procedure) should NOT be reported with the 50 modifier since anatomy does not permit this procedure to be performed bilaterally.

51    Multiple Procedures: When multiple procedures, other than E/M services, physical medicine and rehabilitation services or provision of supplies (eg, vaccines), are performed at the same session by the same provider, the primary procedure or service may be reported as listed. The additional procedure(s) or service(s) may be identified by appending the modifier 51 to the additional procedure or service code(s).

Note: This modifier should not be appended to designated "add-on" codes.

53    Discontinued Procedure: Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. This circumstance may be reported by adding the modifier 53 to the code reported by the physician for the discontinued procedure.

Modifier 53 is used for “unusual (discontinued) circumstances”. Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure due to extenuating circumstances that may threaten the well being of the patient. In many instances, attachments, medical records, etc are not required to be sent in if an explanation for the discontinuation is in the narrative field of the claim. For example, submit “discontinued due to elevated blood pressure”. When additional information to support the use of the 53 modifier cannot be contained in the narrative of the claim, additional documentation may be submitted.

Note: This modifier is not used to report the elective cancellation of a procedure prior to the patient’s anesthesia induction and/or surgical preparation in the operating suite. For outpatient hospital/ambulatory surgery center (ASC) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use)

54    Surgical Care Only: When one physician performs a surgical procedure and another provides preoperative and/or postoperative management, surgical services may be identified by adding the modifier 54 to the usual procedure code.

Services billed with a 54 modifier will be reimbursed at the intraoperative allowance for the surgical procedure. The intraoperative allowance includes the one day preoperative care, the intraoperative service, as well as any in-hospital visits that are performed.

55    Postoperative Management Only: When one physician performs the postoperative management and another physician has performed the surgical procedure, the postoperative component may be identified by adding the modifier 55 to the usual procedure number.

This modifier is used to identify postoperative, out of hospital medical care associated with a given surgical procedure. When billing for postoperative care only, report the original date of surgery as your date of service and the procedure code for the surgical procedure followed by the 55 modifier. In rare situations where the out of hospital postoperative care is split between physicians, each physician must also indicate the period of his/her responsibility for the patient’s postoperative care by reporting the appropriate range of dates. Where a transfer of postoperative care occurs, the receiving physician cannot bill for any part of the global services until he/she has provided at least one service.

62    Two surgeons: When two surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier

62 to the procedure code and any associated add-on code(s) for that procedure as long as both surgeons continue to work together as primary surgeons. Each surgeon should report the co-surgery once using the same procedure code. If additional procedure(s) (including add-on procedure(s) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added.

Note: If a co-surgeon acts as an assistant in the performance of additional procedure(s) during the same surgical session, those services may be reported using separate procedure code(s) with modifier 80 or modifier 82 added, as appropriate.

66    Surgical Team: Under some circumstances, highly complex procedures (requiring the concomitant services of several physicians, often of different specialties, plus other highly skilled, specially trained personnel and various types of complex equipment) are carried out under the "surgical team" concept. Such circumstances may be identified by each participating physician with the addition of the modifier 66 to the basic procedure number used for reporting services.

Documentation establishing that a surgical team was medically necessary is required for certain services identified by Centers for Medicare & Medicaid Services (CMS). All claims for team surgeons must contain sufficient information i.e., operative reports, to allow pricing "by report".

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 preformed), but prior to the administration of anesthesia (local, regional block(s) or general). 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.

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.

74    Discontinued Out-patient Hospital/Ambulatory Surgical 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) or 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.

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 item 24D for paper claims.

81    Minimum Assistant Surgeon: Minimum surgical assistant services are identified by adding modifier 81 to the usual procedure number.

82    Assistant Surgeon (when qualified resident surgeon not available): The unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code number(s).

This modifier is used in teaching hospitals if there is no approved training program related to the medical specialty required for the surgical procedure or no qualified resident was available.

Wednesday, November 25, 2015

Global Surgery Modifiers - 24, 25, 57,58,59,78,79


The following modifiers are used by physicians to indicate a billed service is not part of a global surgical package and is eligible for separate reimbursement: 

Modifier    Description
24    Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period: The physician may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. This circumstance may be reported by adding the modifier 24 to the appropriate level of E/M service.

An excision of a malignant lesion on the left arm is performed in the office on January 10, 2009. The ICD-9-CM diagnosis code reported is 171.2. The post-operative period designated for excision code 11606 is 10 days.

The patient returns to the office on January 15, 2009 and is treated for contact dermatitis, ICD-9-CM code 692.0. The physician should report the appropriate evaluation and management code followed by the 24 modifier, e.g., 9921224.

In order for the evaluation and management service to be payable in the post-operative period with the 24 modifier, the diagnosis code supporting the E/M service must be different from the diagnosis code reported for the previously performed surgery.

Modifier 24 should not be used for the medical management of a patient by the surgeon following surgery. Medicare recognizes modifier 24 only for the care following a discharge under these circumstances:

The care is for immunotherapy management furnished by the transplant surgeon;
The care is for critical care (99291, 99292) for a burn or trauma patient under diagnosis codes 800.0-929.9, 940.0-959.9; or

The documentation demonstrates that the visit occurred during a subsequent hospitalization and the diagnosis supports the fact that it is unrelated to the original surgery.

25    Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Day of a Procedure or Other Service: It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or be beyond the usual preoperative and postoperative care associated with the procedure that was performed. A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service.

Note: This modifier is not used to report an E/M service that resulted in a decision to perform major surgery. See modifier 57. For significant, separately identifiable non-E/M services, see modifier 59.

57    Decision for Surgery: An evaluation and management service that resulted in the initial decision to perform the surgery may be identified by adding modifier 57 to the appropriate level of E/M service.

E/M services on the day before or on the day of major surgery ( 90 day global period) which result in the initial decision to perform the surgery are not included in the global surgery payment. These E/M services may be billed separately and identified with the 57 modifier.

This modifier should not be used for visits furnished during the global period of minor procedures (0 or 10 day global period ) unless the purpose of the visit is a decision for major surgery. This modifier is not used with minor surgeries because the global period for minor surgeries does not include the day prior to the surgery. When the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine preoperative service and a visit or consultation is not billed in addition to the procedure. See modifier 25.

58    Staged or Related Procedure or Service by the Same Physician During the Postoperative Period: It may be necessary to indicate that the performance of a procedure or service during the postoperative period was (a) planned or anticipated (staged); (b) more extensive than the original procedure; or (c) for therapy following a surgical procedure. This circumstance may be reported by adding the modifier 58 to the staged or related procedure.

Note: For treatment of a problem that required a return to the operating or procedure room (e.g., unanticipated clinical condition), see modifier 78.

59    Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures or services, other than E/M services, that are not normally reported together but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, or separate injury (or area in injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than modifier 59. Modifier 59 should only be used if there is no other more descriptive modifier available and the use of modifier 59 best explains the circumstances. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25.

78    Unplanned Return to the Operating/Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure During the Postoperative Period: It may be necessary to indicate that another procedure was performed during the postoperative period of the initial procedure (unplanned procedure following initial procedure). When this procedure is related to the first and requires the use of an operating room, it may be reported by adding modifier 78 to the related procedure. (For repeat procedures, see modifier 76).

79    Unrelated Procedure by the Same Physician During the Postoperative Period: The physician may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. This circumstance may be reported by using the modifier 79. (For repeat procedures on the same day, see modifier 76).

Friday, October 16, 2015

Specific Modifiers for Distinct Procedural Services

Provider Types Affected

This MLN Matters Article is intended for physicians, providers and suppliers submitting claim to Medicare Administrative Contractors (MACs) and Durable Medical Equipment (DME) MACs for services provided to Medicare beneficiaries.

Provider Action Needed
STOP-Impact to You

New coding requirement related to Healthcare Common Procedure Coding System (HCPCS) modifier - 59 could impact your reimbursement.

CAUTION-What You Need to Know

Change Request (CR) 8863 notifies MACs and providers that the Centers for Medicare & Medicaid Services (CMS) is establishing four new HCPCS modifiers to define subsets of the - 59 modifiers, a modifier used to define a "Distinct Procedural Service".

GO-What You Need to Do

Make sure your billing staffs are aware of the coding modifier changes.

Background

The Medicare National Correct Coding Initiative (NCCI) has Procedure to Procedure (PTP) edits to prevent unbundling of services, and the consequent overpayment to physicians and outpatient facilities. The underlying principle is that the second code defines a subset of the work of the first code. Reporting the codes separately is inappropriate. Separate reporting would trigger a separate payment and would constitute double billing.

CR8863 discussed changes to HCPCS modifier-59, a modifier which is used to define a "Distinct Procedural Service". Modifier - 59 indicates that a code represents a service that is separate and distinct from another service with which it would usually be considered to be bundled.

The - 59 modifier is the most widely used HCPSC modifier. Modifier - 59 can be broadly applied. Some providers incorrectly consider it to be the "modifier to use to bypass (NCCI)." This modifier is associated with considerable abuse and high levels of manual audit activity; leading to reviews, appeals and even civil fraud and abuse cases.

The primary issue associated with the - 59 modifier is that it is defined for use in a wide variety of circumstances, such as to identify:

•    Different encounters;
•    Different anatomic sites; and
•    Distinct services.

The - 59 modifier is

•    Infrequently (and usually correctly) used to identify a separate encounter;
•    Less commonly (and less correctly) used to define a separate anatomic site; and
•    More common only (and frequently incorrectly) used to define a distinct service.

The - 59 modifier often overrides the edit in the exact circumstance for which CMS created it in the first place. CMS believes that more precise coding options coupled with increased education and selective editing is needed to reduce the errors associated with this overpayment.

CR8863 provides that CMS is establishing the following four new HCPCS modifiers (referred to collectively as - X{EPSU}modifiers) to define specific subsets of the 59-modifiers:

•    XE Separate Encounter, A Service That us Distinct Because It Occurred During A Separate Encounter,

•    XS Separate Structure, A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure,

•    XP Separate Practitioner, A Service That Is Distinct Because It Was Performed By A Different Practitioner, and

•    XU Unusual Non-Overlapping Service, The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of the Main Services.

CMS will continue to recognize the 59 modifier, but notes that Current Procedural Terminology (CPT) instructions state that the 59 modifier should not be used when a more descriptive modifier is available. While CMS will continue to recognize the - 59 modifier in many instances, it may selectively require a more specific - X{EPSU} modifier for billing certain codes at high risk for incorrect billing. For example, a particular NCCI PTP code pair may be identified as payable only the - XR separate encounter modifier but not the - 59 or other - X{EPSU} modifier are more elective versions of the 59 modifier so it would be incorrect to include both modifiers on the same line.

The combination of alternative specific modifiers with a general less specific modifier creates additional discrimination in both reporting and editing. As a default, at this time CMS will initially accept either a - 59 modifier or a more selective - X{EPSU} modifier as correct coding, although the rapid migration of providers to the more selective modifiers is encouraged.

However, please note that the modifiers are valid even before national edits are in place. MACs are not prohibited from requiring the use of selective modifiers in lieu of the general - 59 modifier, when necessitated by local program integrity and compliance needs.


Wednesday, September 2, 2015

CPT modifier GT, HT, HQ, GQ, T1016, H2011

Modifier   Description

GQ Via Asynchronous Telecommunications systems


GT Via Interactive Audio and Video Telecommunications systems


Modifier GT BILLING AND PAYMENT FOR PROFESSIONAL SERVICES FURNISHED VIA TELEHEALTH


Submit claims for telehealth services using the appropriate CPT or HCPCS code for the professional service along with the telehealth modifier GT, “via interactive audio and video telecommunications systems” (for example, 99201 GT). By coding and billing the GT modifier with a covered telehealth procedure code, you are certifying that the beneficiary was present at an eligible originating site when you furnished the telehealth service. By coding and billing the GT modifier with a covered ESRD-related service telehealth code, you are certifying that you furnished one “hands on” visit per month to examine the vascular access site.

For Federal telemedicine demonstration programs in Alaska or Hawaii, submit claims using the appropriate CPT or HCPCS code for the professional service along with the telehealth modifier GQ if you performed telehealth services “via an asynchronous telecommunications system” (for example, 99201 GQ). By coding and billing the GQ modifier, you are certifying that the asynchronous medical file was collected and transmitted to you at the distant site from a Federal telemedicine demonstration project conducted in Alaska or Hawaii.

You should bill the Medicare Administrative Contractor (MAC) for covered telehealth services. Medicare pays you the appropriate amount under the Medicare Physician Fee Schedule (PFS) for telehealth services. When you are located in a CAH and reassigned your billing rights to a CAH that elected the Optional Payment Method, the CAH bills the MAC for telehealth services and the payment amount is 80 percent of the Medicare PFS for telehealth services.


CODING

The following list of codes is provided as an informational tool only, to help identify some of the applicable Current Procedural Terminology (CPT®)' codes/code ranges and Healthcare Common Procedure Coding System Level II (HCPCS)  codes/modifiers that may be utilized in reporting telemedicine/telehealth services. The inclusion or exclusion of a specific code does not indicate eligibility for reimbursement and/or coverage in all situations.

CPT codes that ordinarily describe direct face-to-face services, but signify telemedicine services

when used with modifier GT:

• 99201-99215 -- Office or other outpatient Evaluation and management services

• 99241-99245 -- Office or other outpatient consultations

• 90791-90792 -- Psychiatric diagnostic evaluation

• 90832-90838 -- Individual psychotherapy services

• 90863 ----------- Pharmacologic management service (List separately in addition to the code for primary procedure)


Category III CPT codes specific to telemedicine/telehealth:

• 0188T---------- Remote real-time interactive video-conferenced critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes

• 0189T---------- Remote real-time interactive video-conferenced critical care, evaluation and management of the critically ill or critically injured patient; each additional 30 minutes (List  separately in addition to code for primary list)


HCPCS codes/modifiers:

• G0406 -- Follow-up inpatient consultation, limited, physicians typically spend 15 minutes communicating with the patient via telehealth

• G0407 -- follow-up inpatient consultation, intermediate, physicians typically spend 25 minutes communicating with the patient via telehealth.

• G0408 -- Follow-up inpatient consultation, complex, physicians typically spend 35 minutes or more communicating with the patient via telehealth

• G0425 -- Telehealth consultation, emergency department or initial inpatient, typically 30 minutes communicating with the patient via telehealth

• G0426 -- Telehealth consultation, emergency department or initial inpatient, typically 50 minutes communicating with the patient via telehealth

• G0427 -- Telehealth consultation, emergency department or initial inpatient, typically 70 minutes or more communicating with the patient via telehealth

• G0459 -- Inpatient telehealth pharmacologic management, including prescription, use, and review of medication with no more than minimal medical psychotherapy.

• GT ------ Modifier signifying: Via interactive audio and video telecommunications HCPCS codes/modifiers that are not eligible for separate reimbursement:

• Q3014 -- Telehealth originating site facility fee

• T1014 -- Telehealth transmission, per minute, professional services bill separately

• GQ ------ Modifier signifying: Via asynchronous telecommunications system

CPT codes that are not eligible for reimbursement in accordance with the Health Plan’s Bundled Services and Supplies Reimbursement Policy:

• 98966-98968 -- Telephone assessment and management service provided by a qualified nonphysician health care professional to an established patient, parent, or guardian

• 98969 -- Online assessment and management service provided by a qualified non-physician health care professional to an established patient or guardian, using the Internet or similar electronic communications network.

• 99441-99443 --Telephone evaluation and management service provided by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian

Crisis Intervention and Case Management (non-targeted Levels I and II)


Case Management T1016

One (1) unit equals 15 minutes. Billing Instructions: This service is covered for children and adults that meet Levels I and II in the Intensity of Needs Grid only. For Levels III-VI, Targeted Case Management (code T1017) is billed under provider type 54. See MSM Chapter 2500 for service limitations and criteria.

Crisis Intervention H2011 Crisis intervention service, per 15 minutes

H2011 GT Crisis intervention service, per 15 minutes
Modifier GT indicates telephonic services.

H2011 HT Crisis intervention service, per 15 minutes Modifier HT indicates team services.

Rehabilitative Mental Health Services

H0038 Self-help/peer services, per 15 minutes (Peer-to-Peer Services)
H0038 HQ Self-help/peer services, per 15 minutes (Peer-to-Peer Services)
Modifier HQ indicates group services.

H2012 Behavioral health day treatment, per hour Prior Authorization and Billing Instructions: Only Provider Type 14 Behavioral Health Community Network groups that have an approved Day Treatment Model and Specialty 308 Enrollment Checklist can request prior authorization for Day Treatment and bill code H2012. Prior authorization is required and authorization requests for Day Treatment services must be submitted via the Provider Web Portal effective April 1, 2015. Please be advised: No retroactive authorizations will be permitted for Day Treatment services. The provider must first enroll as a provider type 14 and will then be eligible to apply for the Day Treatment Specialty.

H2014 Skills training and development, per 15 minutes (Basic Skills Training)

H2014 HQ
Skills training and development, per 15 minutes (Basic Skills Training)
Modifier HQ indicates group services.

H2017 Psychosocial rehabilitation services, per 15 minutes
H2017 HQ

Psychosocial rehabilitation services, per 15 minutes
Modifier HQ indicates group services.



Q: If a provider renders the professional component for a diagnostic service, at a distant site from the patient, should modifier GT be reported?

A: No. Modifier GT indicates a face-to-face encounter utilizing interactive audio-visual communication technology. Therefore, it is not appropriate to report modifier GT in this scenario since this does not represent a face-to-face encounter. However, use of modifier 26 would be appropriate to designate that the professional component of the diagnostic service was provided.

Modifier Guidelines

Modifier GT designates services performed via interactive audio and video telecommunication systems and will be allowed with codes specified in the Corporate Reimbursement Policy titled, “Telehealth.”


9/10/07 Modifier GT - Via interactive audio and video telecommunication systems will be allowed with code 99201 - 99205, 99212 - 99215(Office or Other Outpatient Services) and 99241 - 99245 (Office or Other Outpatient Consultations) added to “When a Modifier may be covered”. Modifier GQ - Via asynchronous telecommunications system will not be allowed specifically with code 99201 - 99215(Office or Other Outpatient Services) and 99241 - 99245(Office or Other Outpatient Consultations) and Modifier GT - will not be recognized with a minimal office visit for an established patient (99211) added to “When a modifier may not be covered”. Modifier GT - will not be recognized with a minimal office visit for an established patient (99211) added to “When a modifier may not be covered.” Added to Policy Guidelines: BCBSNC does not reimburse for evaluation and management and consultation services provided via telephone, Internet, or other communication network or devices that do not involve direct, in-person patient contact. Revised wording related to modifier 57 from “Modifier - 57 designates the decision to do surgery. It is accepted only with inpatient and observation E&M codes when the decision is made to do a major surgical procedure. A major surgical procedure is defined as one with a 90 day global period. The global period starts the day prior to surgery. The modifier is appropriate to signify that the decision was made to do a major surgery procedure within the global period.” to “Modifier 57 - is an evaluation and management service that results in the initial decision to perform surgery.” from “When a modifier may be covered.” Statement “Modifier -57 will not be recognized with any E&M code other than inpatient or observation” removed from “When a modifier may not be covered”. Medical Policy reviewed 08/17/07 by Senior Medical Director of Provider Partnerships, Medical and Reimbursement Policy.

Wednesday, August 26, 2015

Modifier 59 and New Modifiers XE, XS, XP, XU with example

The Medicare National Correct Coding Initiative (NCCI) * includes edits that define when two Healthcare Common Procedure Coding System (HCPCS)/ Current Procedural Terminology (CPT) codes should not be reported together.

 A Correct Coding Modifier Indicator (CCMI) of “0,” indicates the codes should never be reported together by the same provider for the same beneficiary on the same date of service. If they are reported on the same date of service, the column one code is eligible for payment and the column two code is denied.

A CCMI of “1,” indicates the codes may be reported together only in defined circumstances, which are identified on the claim by the use of specific NCCI-associated modifiers.

One function of these edits is to prevent payment for codes that report overlapping services except in instances where the services are “separate and distinct.” Modifier 59 is an important NCCI-associated modifier that is often used incorrectly.

The CPT Manual defines modifier 59 as a Distinct Procedural Service. Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-Evaluation and Management (E/M) services performed on the same day.

 Modifier 59 identifies procedures/services, other than E/M services and radiation treatment management, which are not normally reported together, but are appropriate under the circumstances.

Documentation must support:
a different session,
different procedure or surgery,
different site or organ system,
separate incision/excision,
separate lesion,
or separate injury (or area of injury in extensive injuries)

Note: When another already established modifier is appropriate, report it instead of modifier 59. Use modifier 59 only if no other descriptive modifier is available.

Do not report modifier 59 or other NCCI-associated modifiers to bypass an edit unless documentation in the medical record supports its use.

The Centers for Medicare & Medicaid Services (CMS) established four (4) new HCPCS modifiers (XE, XS, XP, and XU) to provide greater reporting specificity in situations where modifier 59 was previously reported.



Modifiers (collectively referred to as -X {EPSU} modifiers) are defined as follows:


XE – “Separate encounter, A service that is distinct because it occurred during a separate encounter” This modifier should only be used to describe separate encounters on the same date of service.

XS – “Separate Structure, A service that is distinct because it was performed on a separate organ/structure”

XP – “Separate Practitioner, A service that is distinct because it was performed by a different practitioner”

XU – “Unusual Non-Overlapping Service, The use of a service that is distinct because it does not overlap usual components of the main service”


Although NCCI will eventually require use of these modifiers rather than modifier 59 with certain edits, you may begin using them for claims with dates of service on or after January 1, 2015.

Note: You have the option to continue using modifier 59 in any instance in which it was correctly used prior to January 1, 2015. CMS' additional guidance and education as to the appropriate use of the new -X {EPSU} modifiers is forthcoming.

Until CMS provides official guidance, Novitas offers the following suggestions for the use of the -X {EPSU} modifiers, should you decide to use them.

As a reminder, your medical documentation must support the use of modifiers.


Examples

The examples below are from the Centers for Medicare & Medicaid Services (CMS) Modifier 59 article * along with Novitas Solutions' suggestions for the optional use of modifiers XE, XS, XP, and XU beginning January 1, 2015.

Common uses of modifier 59 is for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures performed at different anatomic sites not ordinarily performed or encountered on the same day, and cannot be described by one of the more specific anatomic modifiers, such as RT, LT, E1-E4, FA, F1-F9, TA, T1-T9, LC, LD, RC, LM, or RI.



Example 1
17000 – Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), all benign or premalignant lesions (e.g., actinic keratosis) other than skin tags or cutaneous vascular proliferative lesions; first lesion

11100 – Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed; single lesion

Modifier 59 may be reported with 11100 if the procedures are performed at different anatomic sites on the same side of the body and a specific anatomic modifier does not apply.

If the procedures are performed on different sides of the body, modifiers RT and LT or another pair of anatomic modifiers should be used.


Modifier 59 is reported for different anatomic sites during the same encounter only when procedures, not ordinarily performed or encountered on the same day, are performed on different organs, different anatomic regions, or in limited situations on different, non-contiguous lesions in different anatomic regions of the same organ.

Example 2

47370 – Laparoscopy, surgical, ablation of one or more liver tumor(s); radiofrequency

76942 – Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation

Modifier 59 should not be reported with 76942 if the ultrasonic guidance is for needle placement for the laparoscopic liver tumor ablation procedure.

Modifier 59 may be reported with 76942 if the ultrasonic guidance for needle placement is unrelated to the laparoscopic liver tumor ablation procedure




Wednesday, July 29, 2015

Physician supervision of diagnostic procedures


This field provides levels of physician supervision required for diagnostic tests payable under the physician fee schedule.

General supervision means the procedure is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure. Under general supervision, the training of the nonphysician personnel who actually performs the diagnostic procedure and the maintenance of the necessary equipment and supplies are the continuing responsibility of the physician.

Direct supervision in the office setting means the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed.

Personal supervision means a physician must be in attendance in the room during the performance of the procedure.

01 -- Procedure must be performed under the general supervision of a physician.
02 -- Procedure must be performed under the direct supervision of a physician.
03 -- Procedure must be performed under the personal supervision of a physician.
04 -- Physician supervision policy does not apply when procedure is furnished by a qualified, independent psychologist or a clinical psychologist; otherwise must be performed under the general supervision of a physician.

05 -- Not subject to supervision when furnished personally by a qualified audiologist, physician or nonphysician practitioner. Direct supervision by a physician is required for those parts of the test that may be furnished by a qualified technician when appropriate to the circumstances of the test.
06 -- Procedure must be performed by a physician or a physical therapist (PT) who is certified by the American Board of Physical Therapy Specialties (ABPTS) as a qualified electrophysiologic clinical specialist and is permitted to provide the procedure under state law.
21 -- Procedure may be performed by a technician with certification under general supervision of a physician; otherwise must be performed under direct supervision of a physician.
22 -- May be performed by a technician with on-line real-time contact with physician.
66 -- May be performed by a physician or by a physical therapist with ABPTS certification and certification in this specific procedure.
6A -- Supervision standards for level 66 apply; in addition, the PT with ABPTS certification may supervise another PT, but only the PT with ABPTS certification may bill.
77 -- Procedure must be performed by a PT with ABPTS certification or by a PT without certification under direct supervision of a physician, or by a technician with certification under general supervision of a physician.
7A -- Supervision standards for level 77 apply; in addition, the PT with ABPTS certification may supervise another PT, but only the PT with ABPTS certification may bill.
09 -- Concept does not apply.

Facility pricing
Facility fees are calculated at a national level with a reduced practice expense because of reduced physician overhead associated with services provided in a facility.

Place of service (POS) codes to be used to identify facilities are:
21-- Inpatient hospital
22 -- Outpatient hospital
23 -- Emergency room-hospital
24 -- Ambulatory surgical center - In a Medicare approved ASC, for an approved procedure on the ASC list, Medicare pays the lower facility fee to physicians. Beginning with dates of service January 1, 2008, in a Medicare approved ASC, for procedures NOT on the ASC list of approved procedures, contractors will also pay the lower facility fee to physicians.
26 -- Military treatment facility
31 -- Skilled nursing facility
34 – Hospice
41 -- Ambulance -- land
42 -- Ambulance air or water
51 -- Inpatient psychiatric facility
52 -- Psychiatric facility partial hospitalization
53 -- Community mental health center
56 -- Psychiatric residential treatment facility
61 -- Comprehensive inpatient rehabilitation facility

Monday, June 22, 2015

Medicare physician fee schedule payment policy indicators - Modifier 50, 62, 66

Bilateral surgery - modifier 50

This field provides an indicator for services subject to a payment adjustment.
0 -- 150 percent payment adjustment for bilateral procedures does not apply. If procedure is reported with modifier -50 or with modifiers RT and LT, base payment for the two sides on the lower of: (a) the total actual charge for both sides or (b) 100 percent of the fee schedule amount for a single code.
Example: The fee schedule amount for code XXXXX is $125. The physician reports code XXXXX-LT with an actual charge of $100 and XXXXX-RT with an actual charge of $100. Payment would be based on the fee schedule amount ($125) since it is lower than the total actual charges for the left and right sides ($200).

The bilateral adjustment is inappropriate for codes in this category because of (a) physiology or anatomy or (b) because the code descriptor specifically states that it is a unilateral procedure and there is an existing code for the bilateral procedure.

1 -- 150 percent payment adjustment for bilateral procedures applies. If code is billed with the bilateral modifier or is reported twice on the same day by any other means (e.g., with RT and LT modifiers or with a 2 in the units field), contractors base payment for these codes when reported as bilateral procedures on the lower of: (a) the total actual charge for both sides or (b) 150 percent of the fee schedule amount for a single code

If code is reported as a bilateral procedure and is reported with other procedure codes on the same day, apply the bilateral adjustment before applying any applicable multiple procedure rules.
2 -- 150 percent payment adjustment for bilateral procedure does not apply. RVUs are already based on the procedure being performed as a bilateral procedure. If procedure is reported with modifier -50 or is reported twice on the same day by any other means (e.g., with RT and LT modifiers with a 2 in the units field), contractors base payment for both sides on the lower of (a) the total actual charges by the physician for both sides or (b) 100 percent of the fee schedule amount for a single code.

Example: The fee schedule amount for code YYYYY is $125. The physician reports code YYYYY-LT with an actual charge of $100 and YYYYY-RT with an actual charge of $100. Payment would be based on the fee schedule amount ($125) since it is lower than the total actual charges for the left and right sides ($200).

The RVUs are based on a bilateral procedure because: (a) the code descriptor specifically states that the procedure is bilateral; (b) the code descriptor states that the procedure may be performed either unilaterally or bilaterally; or (c) the procedure is usually performed as a bilateral procedure.
3 -- The usual payment adjustment for bilateral procedures does not apply. If procedure is reported with modifier -50 or is reported for both sides on the same day by any other means (e.g., with RT and LT modifiers or with a 2 in the units field), contractors base payment for each side or organ or site of a paired organ on the lower of: (a) the actual charge for each side or (b) 100% of the fee schedule amount for each side. If procedure is reported as a bilateral procedure and with other procedure codes on the same day, contractors determine the fee schedule amount for a bilateral procedure before applying any applicable multiple procedure rules.

Services in this category are generally radiology procedures or other diagnostic tests which are not subject to the special payment rules for other bilateral procedures.
9 -- Concept does not apply.

Assistant at surgery
This field provides an indicator for services where an assistant at surgery is never paid for per the CMS Internet-only manual.

0 -- Payment restriction for assistants at surgery applies 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.
9 -- Concept does not apply.

Co-surgeons - modifier 62
This field provides an indicator for services for which two surgeons, each in a different specialty, may be paid.
0 -- Co-surgeons not permitted for this procedure.
1 -- Co-surgeons could be paid; supporting documentation required to establish medical necessity of two surgeons for the procedure.
2 -- Co-surgeons permitted; no documentation required if two specialty requirements are met.
9 -- Concept does not apply.

Team surgeons - modifier 66
This field provides an indicator for services for which team surgeons may be paid.
0 -- Team surgeons not permitted for this procedure.
1 -- Team surgeons could be paid; supporting documentation required to establish medical necessity of a team; pay by report.
2 -- Team surgeons permitted; pay by report.
9 -- Concept does not apply.

Sunday, January 11, 2015

Other specific appropriate uses of modifier 59


There are three other limited situations in which two services may be reported as separate and distinct because they are separated in time and describe non-overlapping services even though they may occur during the same encounter.

a. Modifier 59 is used appropriately for two services described by timed codes provided during the same encounter only when they are performed sequentially.

There is an appropriate use for modifier 59 that is applicable only to codes for which the unit of service is a measure of time (e.g., per 15 minutes, per hour). If two timed services are provided in time periods that are separate and distinct and not interspersed with each other(i.e., one service is completed before the subsequent service begins), modifier 59 may be used to identify the services.(See example below)

Example : Column 1 Code/Column 2 Code - 97140/97530

>CPT Code 97140 – Manual therapytechniques (eg, mobilization/manipulation, manually mphatic drainage, manual traction), one or more regions, each 15 minutes

>CPT Code 97530 –Therapeutic activities, direct (one-on-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes Modifier 59may be reported if the two procedures are performed in distinctly different 15 minute intervals.

CPT code 97530 should not be reported and modifier 59 should not be used if the two procedures are performed during the same 15 minute time interval.

b.Modifier 59 is used appropriately for a diagnostic procedure which precedes a therapeutic procedure only when the diagnostic procedure is the basis for performing the therapeutic procedure.

When a diagnostic procedure precedes a surgical procedure or non-surgical therapeutic procedure and is the basis on which the decision to perform the surgical procedure is made, that diagnostic test may be considered to be a separate and distinct procedure as long as (a) it occurs before the therapeutic procedure and is not interspersed with services that are required for the therapeutic intervention;(b) it clearly provides the information needed to decide whether to proceed with the therapeutic procedure; and(c) it does not constitute a service that would have otherwise been required during the therapeutic intervention.(See example below)If the diagnostic procedure is an inherent component of the surgical procedure, it should not be reported separately.

Example : Column 1 Code / Column 2 Code - 37220/75710

>CPT Code 37220 – Revascularization, endovascular, open or percutaneous, iliac artery, unilateral, initial vessel; with transluminal angioplasty

>CPT Code 75710 – Angiography, extremity, unilateral, radiological supervision and interpretation Modifier 59 may be reported with CPT code 75710 if a diagnostic angiography has not been previously performed and the decision to perform the revascularization is based on the result of the diagnostic angiography. The CPT Manual defines additional circumstances under which diagnostic angiography may be reported with an interventional vascular procedure on the same artery.

c. Modifier 59 is used appropriately for a diagnostic procedure which occurs subsequent to a completed therapeutic procedure only when the diagnostic procedure is not a common, expected, or necessary follow-up to the therapeutic procedure.

When a diagnostic procedure follows the surgical procedure or non-surgical therapeutic procedure, that diagnostic procedure may be considered to be a separate and distinct procedure as long as (a) it occurs after the completion of the therapeutic procedure and is not interspersed with or otherwise commingled with services that are only required for the therapeutic intervention, and (b) it does not constitute a service that would have otherwise been required during the therapeutic intervention. (See example below)If the post-procedure diagnostic procedure is an inherent component or otherwise included (or not separately payable) post-procedure service of the surgical procedure or non-surgical therapeutic procedure, it should not be reported separately.

Use of modifier 59 does not require a different diagnosis for each CPCS/CPT coded procedure. Conversely, different diagnoses are not adequate criteria for use of modifier 59. The HCPCS/CPT codes remain bundled unless the procedures are performed at different anatomic sites or separate patient encounters or meet one of the other three scenarios described above.

Example : Column 1 Code / Column 2 Code – 32551/71020

>CPT Code 32551 – Tube thoracostomy, includes connection to drainage system (eg, water seal), when performed, open

>CPT Code 71020 – Radiologic examination, chest, 2 views, frontal and lateral Modifier 59 may be reported if, later in the day following the insertion of a chest tube, the patient develops a high fever and a chest x-ray is performed to rule out pneumonia. CPT code 71020 should not be reported and modifier 59 should not be used for a chest x-ray that is performed
following insertion of a chest tube in order to verify correct placement of the
tube.



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