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

Saturday, August 13, 2016

Modifier “-91 with how to use example



Definition - The “-91” modifier is used to indicate a repeat laboratory procedural service on the same day to obtain subsequent reportable test values. The physician may need to indicate that a lab procedure or service was distinct or separate from other lab services performed on the same day. This may indicate that a repeat clinical diagnostic laboratory test was distinct or separate from a lab panel or other lab services performed on the same day, and was performed to obtain subsequent reportable test values.


Rationale - Multiple laboratory services provided to a patient on one day by the same provider may appear to be incorrectly coded, when in fact the services may have been performed as reported. Because these circumstances cannot be easily identified, a modifier “-91” was established to permit claims of such a nature to bypass correct coding edits. The addition of this modifier to a laboratory procedure code indicates a repeat test or procedure on the same day.


Instruction - The additional or repeat laboratory procedure(s) or service(s) must be identified by adding the modifier “-91”.



EXAMPLE 1:

When cytopathology codes are billed, the appropriate CPT code to bill is that which describes, to the highest level of specificity, what services were rendered. Accordingly, for a given specimen, only one code from a family of progressive codes (subsequent codes include services described in the previous CPT code, e.g., 88104-88107, 88160-88162) is to be billed. If multiple services on different specimens are billed, the “-91” modifier should be used to indicate that different levels of service were provided for different specimens. This should be reflected in the cytopathologic reports.

Thursday, August 4, 2016

CPT modifiers KB, QL, TQ AND GX

KB Beneficiary Requested Upgrade for ABN, more than 4 Modifiers on a Claim

ABN Required; if service denied in development, beneficiary assumed liable
Use only on line items requiring more than [2 or ] 4* modifiers on home health DME claims (TOBs 32x, 33x, 34x)
Line item submitted as covered, claim must suspend for development

QL Patient pronounced dead after ambulance called

None, recommend documenting records; provider liable
Use only for ambulance services (TOBs: 12x, 13x, 22x, 23x, 83x, 85x)
Mileage lines submitted as non-covered and will be denied; base rate line submitted covered

TQ Basic life support transport by a volunteer ambulance provider

Not payable by Medicare
None, recommend documenting records; provider liable
Use only for ambulance services (TOBs: 12x, 13x, 22x, 23x, 83x, 85x)
Lines submitted as non-covered and will be denied

GX Notice of Liability Issued, Voluntary Under Payer Policy

Used when a provider issued an ABN on a voluntary basis; beneficiary liable
Use on all types of provider claims when a voluntary notice has been issued. May be used in association with modifiers –GY or used separately.
Lines submitted as non-covered and will be denied

Wednesday, July 27, 2016

Non covered Modifier list


HCPCS Modifiers Not Covered or Not Payable by Medicare by HCPCS Definition


-A1 through -A9,
-GY, -GZ, -H9,
-HA through -HZ,
-SA through -SE,
-SH, -SJ, -SK, -SL,
-ST, -SU, -SV, -SY, -TD through -TR, -TT through -TW, -U1 through -U9, -UA through –UD, –UF through -UK

Institutional standard systems will deny all line items on all TOBs using these modifiers in all cases as part of processing claims; provider liability is assumed EXCEPT when noted as beneficiary liable in accordance with the chart below (of the total set to the left:-GY)




Modifiers Used in Billing Ambulance Non-covered Charges

-GY, -QL, -QM* or -QN*, -TQ, alpha origin/destination modifiers*

Applicable TOBs for ambulance billing: 12x, 13x, 22x, 23x, 83x, 85x



Specific HCPCS Modifiers to Consider Related to Non-covered Charges or ABNs

-EY, -GA, -GK, -GL, -GY, -GZ, -KB,

Institutional standard systems accept some of these modifiers for processing as specified on the chart below

Friday, July 22, 2016

Medicare part B modifiers full list

Modifiers to be used for Part B


Program Category Modifier Code Description
PART - B Physician Quality Reporting 1P Physician Quality Reporting System – Performance measure exclusion modifier due to medical reasons.
PART - B Surgical 22 Unusual procedural services.
PART - B E/M 24 Evaluation and Management (E/M) – Unrelated E/M service by the same physician during a postoperative period.
PART - B E/M 25 Significant, separately identifiable Evaluation and Management (E/M) service by the same physician on the same day of the procedure or other service.
PART - B Radiology/Pathology 26 Professional component.
PART - B Physician Quality Reporting 2P Physician Quality Reporting System  – Performance measure exclusion modifier due to patient reasons.
PART - B Physician Quality Reporting 3P Physician Quality Reporting System  – Performance measure exclusion modifier due to system reasons.
PART - B Coding 50 Bilateral procedure.
PART - B Surgical 51 Multiple procedures.
PART - B Coding 52 Reduced services.
PART - B Coding 53 Discontinued procedure. 
PART - B Surgical 54 Surgical care only.
PART - B Surgical 55 Postoperative management only.
PART - B Surgical 56 Preoperative management only.
PART - B E/M 57 Evaluation and Management (E/M) – Decision for surgery.
PART - B Surgical 58 Staged or related procedure or service by the same physician during the postoperative period.
PART - B Coding 59 National Correct Coding Initiative (NCCI) – Distinct procedural service.
PART - B Surgical 62 Two surgeons.
PART - B Surgical 66 Surgical team.
PART - B ASC 73 Ambulatory Surgical Center (ASC) – Discontinued procedure prior to administration of anesthesia.
PART - B ASC 74 Ambulatory Surgical Center (ASC) – Discontinued procedure after administration of anesthesia.
PART - B Coding 76 Repeat procedure by same physician. 
PART - B Coding 77 Repeat procedure by another physician. 
PART - B Surgical 78 Return to the operative room for a related procedure during the postoperative period.
PART - B Surgical 79 Unrelated procedure or service by the same physician during the postoperative period.
PART - B Surgical 80 Assistant surgeon.
PART - B Surgical 81 Minimum assistant surgeon.
PART - B Surgical 82 Assistant surgeon (when qualified resident surgeon not available).
PART - B Physician Quality Reporting  8P Physician Quality Reporting System – Performance measure reporting modifier – action not performed, reason not otherwise specified.
PART - B Laboratory 90 Referenced (outside) laboratory.
PART - B Laboratory 91 Repeat clinical diagnostic laboratory test.
PART - B Coding 99 Multiple modifiers.
PART - B Anesthesia AA Services performed personally by an anesthesiologist.
PART - B Anesthesia AD Medical supervision by a physician, more than four concurrent procedures.
PART - B Psychiatric  AH Clinical psychologist.
PART - B E/M AI Principal physician of record.
PART - B Psychiatric  AJ Clinical social worker.
PART - B HPSA/PSA AQ Physician providing a service in a Health Professional Shortage Area (HPSA).
PART - B HPSA/PSA AR Physician provided service in a Physician Scarcity Area (PSA).
PART - B Surgical AS Physician Assistant (PA), Clinical Nurse Specialist (CNS) or Nurse Practitioner (NP) services for assistant-at-surgery.
PART - B Chiropractic AT Acute treatment.
PART - B Outpatient Hospital AY Item or service furnished to an ESRD patient that is not for the treatment of ESRD.
PART - B Health Professional Shortage Area (HPSA) AZ Physician providing a service in a dental health professional shortage area for the purpose of an Electronic Health Record (EHR) incentive payment.
PART - B ESRD CB Service ordered by a RDF physician as part End Stage Renal Disease (ESRD) beneficiary’s dialysis benefit.
PART - B Coding CC Procedure code change.
PART - B Catastrophe/Disaster CR Catastrophe/Disaster-related claims.
PART - B Disaster-related claims CS Gulf oil spill 2010 related.
PART - B Anatomical E1 Upper left eyelid.
PART - B Anatomical E2 Lower left eyelid.
PART - B Anatomical E3 Upper right eyelid.
PART - B Anatomical E4 Lower right eyelid.
PART - B Drugs EA Erythropoiesis Stimulating Agent (ESA) – Anemia, chemo-induced.
PART - B Drugs EB Erythropoiesis Stimulating Agent (ESA) – Anemia, radio-induced.
PART - B Drugs EC Erythropoiesis Stimulating Agent (ESA) – Anemia, non-chemo/radio.
PART - B Anatomical F1 Left hand, second digit.
PART - B Anatomical F2 Left hand, third digit.
PART - B Anatomical F3 Left hand, fourth digit.
PART - B Anatomical F4 Left hand, fifth digit.
PART - B Anatomical F5 Right hand, thumb.
PART - B Anatomical F6 Right hand, second digit.
PART - B Anatomical F7 Right hand, third digit.
PART - B Anatomical F8 Right hand, fourth digit.
PART - B Anatomical F9 Right hand, fifth digit.
PART - B Anatomical FA Left hand, thumb.
PART - B ASC FB Ambulatory Surgical Center (ASC) – Item provided without cost to provider, supplier or practitioner, or full credit received for replaced device.
PART - B ASC FC Ambulatory Surgical Center (ASC) – Partial credit received for replaced device.
PART - B Anesthesia G8 Monitored Anesthesia Care (MAC) for deep complex, complicated or markedly invasive surgical procedure.
PART - B Anesthesia G9 Monitored Anesthesia Care (MAC) for patient who has history of severe cardiopulmonary condition.
PART - B ABN GA Waiver of liability statement issued, as required by payer policy.
PART - B Resident GC Service performed in part by a resident under the direction of a teaching physician.
PART - B Resident GE Service performed by a resident without the presence of a teaching physician under the primary care exception.
PART - B Radiology GG Performance and payment of a screening mammography and diagnostic mammography on the same patient, same day.
PART - B Opt-Out GJ “Opt-Out” physician or practitioner service provided in an emergency or urgent service.
PART - B Ambulance GM Multiple patients on one ambulance trip.
PART - B PT/OT GN Physical/Occupational Therapy (PT/OT) – Services delivered under an outpatient speech language pathology plan of care.
PART - B PT/OT GO Physical/Occupational Therapy (PT/OT) – Services delivered under an outpatient occupational therapy plan of care.
PART - B PT/OT GP Physical/Occupational Therapy (PT/OT) – Services delivered under an outpatient physical therapy plan of care.
PART - B Telehealth GT Via interactive audio and video telecommunications system.
PART - B Hospice GV Attending physician not employed or paid under arrangement by the patient’s hospice provider. 
PART - B Hospice GW Service not related to the hospice patient’s terminal condition.
PART - B Excluded GY Item or service statutorily excluded or does not meet the definition of any Medicare benefit.
PART - B ABN GZ Advance Beneficiary Notice (ABN) was not signed by the beneficiary.
PART - B CAP J1 “No pay” Competitive Acquisition Program (CAP)modifier for drug line.
PART - B CAP J2 Competitive Acquisition Program (CAP) emergency re-supply.
PART - B CAP J3 Competitive Acquisition Program (CAP) “Furnish as Written.”
PART - B Drugs JW Drug amount discarded/not administered to any patient.
PART - B Drugs  KD Drug or biological infused through Durable Medical Equipment (DME). 
PART - B Medical Policy KX Requirements specified in the medical policy have been met.
PART - B Anatomical LC Left circumflex coronary artery.
PART - B Anatomical LD Left anterior descending coronary artery.
PART - B Laboratory LR Laboratory round trip.
PART - B Eye LS FDA-monitored Intraocular Lens (IOL) implant.
PART - B Anatomical LT Left side.
PART - B CAP MS Competitive Acquisition Program (CAP) Medicare secondary payer.
PART - B Anesthesia P1 Physical Status – A normal healthy patient.
PART - B Anesthesia  P2 Physical Status – A patient with mild systemic disease.
PART - B Anesthesia  P3 Physical Status – A patient with severe systemic disease.
PART - B Anesthesia  P4 Physical Status – A patient with severe systemic disease that is a constant threat to life.
PART - B Anesthesia  P5 Physical Status – A moribund patient who is not expected to survive without the operation.
PART - B Anesthesia  P6 Physical Status – A declared brain-dead patient whose organs are being removed for donor purposes.
PART - B Wrong Procedure PA Surgery wrong body part. Wrong surgical or other invasive procedures performed on a patient.
PART - B Wrong Procedure PB Surgery wrong patient. Wrong surgical or other invasive procedures performed on a patient
PART - B Wrong Procedure PC Wrong surgery on patient. Wrong surgical or other invasive procedures performed on a patient.
PART - B Radiology PI Positron Emission Tomography (PET) or PET/Computed Tomography (CT).
PART - B Radiology PS Positron Emission Tomography (PET) or PET/Computed Tomography (CT).
PART - B Surgical PT Colorectal cancer screening test; converted to diagnostic test or other procedure.
PART - B Clinical Research Studies Q0 Investigational clinical service provided in a clinical research study that is in an approved clinical research study.
PART - B Clinical Research Studies Q1 Routine clinical service provided in a clinical research study that is in an approved clinical research study.
PART - B Kidney Q3 Live kidney donor surgery and related services.
PART - B Physician Q5 Service furnished by a substitute physician under a reciprocal billing arrangement.
PART - B Physician Q6 Services furnished by a locum tenens physician.
PART - B Footcare Q7 One class A finding.
PART - B Footcare Q8 Two class B findings.
PART - B Footcare Q9 One class B and two class C findings.
PART - B Prison/Custody QJ Services/items provided to a prisoner or patient in state or local custody; however, the state or local government, as applicable, meets the requirements in 42 CFR 411.4(b).        For outpatient claims, providers should append modifier QJ on all lines with a line item date of service during the incarceration period. All associated charges should be billed as non-covered.
PART - B Anesthesia QK Medical direction of two, three or four concurrent procedures.
PART - B Ambulance QL Patient pronounced dead after ambulance called (do not use origin and destination modifiers, only QL).
PART - B Anesthesia QS Monitored Anesthesia Care (MAC) services.
PART - B Laboratory QW Clinical Laboratory Improvement Amendments (CLIA) waived test.
PART - B Anesthesia QX Certified Registered Nurse Anesthetist (CRNA) service with medical direction by a physician.
PART - B Anesthesia QY Medical direction of one Certified Registered Nurse Anesthetist (CRNA) by an anesthesiologist.
PART - B Anesthesia QZ Certified Registered Nurse Anesthetist (CRNA) service without medical direction by a physician.
PART - B DME RA Replacement of a Durable Medical Equipment (DME), orthotic or prosthetic item.
PART - B Anatomical RC Right coronary artery.
PART - B Anatomical RT Right side.
PART - B ASC SG Ambulatory Surgical Center (ASC) – Facility service.
PART - B Anatomical T1 Left foot, second digit.
PART - B Anatomical T2 Left foot, third digit.
PART - B Anatomical T3 Left foot, fourth digit.
PART - B Anatomical T4 Left foot, fifth digit.
PART - B Anatomical T5 Right foot, great toe.
PART - B Anatomical T6 Right foot, second digit.
PART - B Anatomical T7 Right foot, third digit.
PART - B Anatomical T8 Right foot, fourth digit.
PART - B Anatomical T9 Right foot, fifth digit.
PART - B Anatomical TA Left foot, great toe.
PART - B Radiology/Pathology TC Technical component.
PART - B Radiology UN Portable X-Ray Supplier – Two patients served.
PART - B Radiology UP Portable X-Ray Supplier – Three patients served.
PART - B Radiology UQ Portable X-Ray Supplier – Four patients served.
PART - B Radiology UR Portable X-Ray Supplier – Five patients served.
PART - B Radiology US Portable X-Ray Supplier – Six patients served.

Thursday, July 21, 2016

Procedures Billed With Two or More Surgical Modifiers


Carriers may receive claims for surgical procedures with more than one surgical modifier. For example, since the global fee concept applies to all major surgeries, carriers may receive a claim for surgical care only (modifier “-54”) for a bilateral surgery (modifier “-50”). They may also receive a claim for multiple surgeries requiring the use of an assistant surgeon.

Bilateral Surgery

Bilateral procedures performed; Reference OAC 5160-4-22 Surgical Services for physician claims and appendix A, Outpatient Hospital Modifiers, to OAC rule 5160-2-21 for institutional claims.

Bilateral surgeries are procedures performed on both sides of the body at the same operative session or on the same day (two ears, two feet, two eyes, etc.)

Guidelines for bilateral procedures are as follows:

** The surgical procedure should be billed on a single line with modifier 50 and one unit.

** Modifier 50 should not be used to report:

o Procedures that are bilateral by definition or their descriptions include the terminology as “bilateral” or “unilateral”.

o Diagnostic and radiology facility services. Institutional claims received for an outpatient radiology service appended with modifier 50 will be denied.


Following is a list of possible combinations of surgical modifiers.

(NOTE: Carriers must price all claims for surgical teams “by report.”)

Bilateral surgery (“-50”) and multiple surgery (“-51”).

• Bilateral surgery (“-50”) and surgical care only (“-54”).

• Bilateral surgery (“-50”) and postoperative care only ("55”).

• Bilateral surgery (“-50”) and two surgeons (“-62”).

• Bilateral surgery (“-50”) and assistant surgeon (“-80”).

• Bilateral surgery (“-50”), two surgeons (“-62”), and surgical care only (“-54”).

• Bilateral surgery (“-50”), team surgery (“-66”), and surgical care only (“-54”).

• Multiple surgery (“-51”) and surgical care only (“-54”).

• Multiple surgery (“-51”) and postoperative care only ("55”).

• Multiple surgery (“-51”) and two surgeons (“-62”).

• Multiple surgery (“-51”) and surgical team (“-66”).

• Multiple surgery (“-51”) and assistant surgeon (“-80”).

• Multiple surgery (“-51”), two surgeons (“-62”), and surgical care only (“-54”).

• Multiple surgery (“-51”), team surgery (“-66”), and surgical care only (“-54”).

• Two surgeons (“-62”) and surgical care only (“-54”).

• Two surgeons (“-62”) and postoperative care only (“55”).

• Surgical team (“-66”) and surgical care only (“-54”).

• Surgical team (“-66”) and postoperative care only (“55”).


Payment is not generally allowed for an assistant surgeon when payment for either two surgeons (modifier “-62”) or team surgeons (modifier “-66”) is appropriate. If carriers receive a bill for an assistant surgeon following payment for co-surgeons or team surgeons, they pay for the assistant only if a review of the claim verifies medical necessity.

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.

Friday, July 15, 2016

Modifier KX for use with Therapy Services




Modifier KX is used to confirm requirements outlined in the appropriate Local Coverage Determination (LCD), are met for the procedure billed.

By adding modifier KX to a claim, you are stating that your claim has met specific documentation requirements in the policy, and would be available upon request from the Medicare Administrative Contractor (MAC).

Add this modifier to each procedure code once the specific therapy cap has been met.

Modifier KX should follow the appropriate therapy modifiers.

Documentation must support and justify that the beneficiary qualifies for the therapy cap exception and that services are reasonable and necessary and require the skills of a therapist
The KX may be submitted on physical therapy, occupational therapy or speech language pathology claims.
Appropriate Use:
When additional documentation supports the medical requirements of the service under a valid medical policy.
Inappropriate Use:
When the claim provides all information on the service billed and medical documentation does not provide further explanation.
Claim does not meet policy guidelines/ Indications and Limitations of Coverage and/or Medical Necessity.
The most frequent use of the KX modifier is in relation to therapy services.
Physical/Speech/Occupational Therapy
When the service qualifies for an automatic claims processing exception * based on the published list of excepted conditions and complexities, submit the service with Healthcare Common Procedure Coding System (HCPCS) modifier KX.
The KX must be added to each claim line identified as a therapy service when therapy cap exceptions meet all guidelines for an automatic exception and must follow the required therapy HCPCS modifiers GN (speech-language pathology), GO (occupational therapy) and GP (physical therapy). This allows payment for the approved therapy services, even though they are above the therapy cap financial limits.
The presence of the KX modifier demonstrates that services billed:
Qualify for the therapy cap exception
Are reasonable and necessary services that require the skills of a therapist,
Are justified by appropriate documentation in the medical record
Therapy services submitted without the KX modifier, for claims above the therapy threshold, will deny.
Exceptions to therapy caps based on the medical necessity of the service are in effect only when included in Congressional legislation.

Tuesday, July 12, 2016

Modifier and corrrect coding initative applied hospital and facility

Coding a Facility Claim Procedure, Modifier and Diagnosis Codes   -    A critical element in claims filing is the submission of current and accurate codes to reflect the services provided. Correct coding is essential for correct reimbursement. We have applied procedure code edits to outpatient claims for our Medicare Advantage members since 2008. Effective September 15, 2012, wewill apply these edits to our Commercial outpatient claims.

Complete and accurate procedure code, modifier and diagnosis code usage at the time of billing ensures accurate processing of correct coding initiative edits. Wecan only use the primary modifier submitted with the alternate procedure code for outpatient billing. We encourage you to purchase current copies of CPT, HCPCS and ICD code books.


The correct coding initiative edits and medically unlikely edits will apply to outpatient claims from the following hospitals and facilities:

• Acute care hospitals

• Long term acute care hospitals

• Ambulatory surgical centers

• Psychiatric facilities

• Substance abuse facilities

• Inpatient rehabilitation facilities

• Skilled nursing facilities


Note: Ambulatory surgical centers will follow institutional correct coding initiative edits forour commercial business, while our Medicare Advantage business will process against the professional edits.



Modifiers

A modifier allows a provider to indicate that a service or procedure is altered by some specific circumstance, but the definition or code is not changed. Modifiers may be used in some instances when additional information is needed for proper payment of claims. Valid modifiers and their descriptions are found in the most current CPT and HCPCS coding books.

Weprocess claims using only the first modifier for outpatient institutional claims. While up to three modifiers are accepted, claims are processed using only the first modifier. Therefore, submit the most important modifier affecting reimbursement in the first position on paper and electronic claims.

Note: If your claim is denied due to a lack of documentation to support the use of a specific modifier, you may submit an appeal. Your appeal must be submitted in writing and accompanied by the necessary documentation. 4


Modifiers may be used to indicate that:

• A service or procedure has been increased or reduced

• Only part of a service was performed

• A bilateral procedure was performed

• A service or procedure was provided more than once

• Unusual Events Occurred

Saturday, July 9, 2016

Where to use Modifier 77

Modifier 77

Key Points/Instruction/What you need to know

Modifier 77 is used to report a repeat procedure by another physician and is appended to the repeat procedure to:
Report the same service provided by another physician.
Indicate that a basic procedure or service had to be repeated.
Appropriate Uses:
Adding modifier 77 to the professional component of an X-Ray or Electrocardiogram (EKG) procedure when the patient has two or more tests and more than one physician provides the interpretation and report.
o CMS  will reimburse a second interpretation of the same EKG or X-ray only under unusual circumstances, such as:
A questionable finding for which the physician performing the initial interpretation believes another physician's expertise is needed, or
A change in diagnosis resulting from a second interpretation
Note: Absent these circumstances, Novitas Solutions may reimburse only the interpretation and report that directly contributed to the diagnosis and treatment of the individual patient.
Inappropriate Uses:
Billing for multiple services which are considered bundled.
Appending Modifier 77 to an Evaluation and Management Code.

Claim Submission Instructions

Report each procedure on separate lines.
List the procedure code once by itself and then again with modifier 77.
Do not use the units' field to indicate the procedure was performed more than once on the same day.
Add modifier 77 when billing for multiple services on a single day and the service cannot be quantity billed.

Wednesday, July 6, 2016

CRNA services modifiers

CRNA Services


AA
Anesthesia services personally performed by an anesthesiologist. The -AA modifier is used for all basic procedures.

P1
Normal healthy patient.

P2
Patient with mild systemic disease.

P3
Patient with severe systemic disease.

P4
Patient with severe systemic disease that is a constant threat to life.

P5
Moribund patient who is not expected to survive without the operation.

QS
Monitored anesthesia care service (can be billed by CRNA or a physician). This modifier for monitored anesthesia care (QS) is for informational purposes. Please report actual monitoring time on the claim form. This modifier must be billed with another modifier to show that the service was personally performed or medically directed.

QX
CRNA service; with medical direction by a physician.

QZ
CRNA service; without medical direction by a physician.

Saturday, June 25, 2016

What is Modifiers - For Beginners

Modifiers

A modifier provides a physician with the means to indicate that a service/procedure is altered by some specific circumstance, but not changed in its definition or code. By modifying the meaning of a service, modifiers may be used in some instances when additional information is needed for proper payment of claims. Valid modifiers and their descriptions can be found in the most current CPT and HCPCS coding books.

When multiple modifiers are necessary for a single claim line, modifiers should be submitted in the order that they affect payment.

Note: If your claim is denied due to a lack of documentation to support the use of a specific modifier, you may submit a claim payment appeal. Your appeal must be submitted in writing and accompanied by the necessary documentation.

Modifiers may be used to indicate that:

• A service or procedure has both a professional and technical component

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

• A service or procedure has been increased or reduced

• Only part of a service was performed

• A bilateral procedure was performed

• A service or procedure was provided more than once

• Unusual events occurred


Procedure Modifier and Diagnosis Codes

A critical element in claims filing is the submission of current and accurate codes to reflect the services provided. Correct coding is essential for correct reimbursement. Inclusion of a complete and accurate list of diagnosis codes associated with the patient at the time of the encounter, including chronic conditions not necessarily treated at the time of the encounter, is part of correctly coding an encounter. It ensures that we can best match patients with appropriate care and disease management programs and members are properly classified by risk programs. We encourage you to purchase current copies of CPT, HCPCS, and ICD 10 CM code books.

Wednesday, June 1, 2016

Global Surgery modifiers - 24, 25 and 57 - payment Guide

Payment for Evaluation and Management Services Provided During Global Period of Surgery

A. CPT Modifier “-24” - Unrelated Evaluation and Management Service by Same Physician During Postoperative Period

Carriers pay for an evaluation and management service other than inpatient hospital care before discharge from the hospital following surgery (CPT codes 99221-99238) if it was provided during the postoperative period of a surgical procedure, furnished by the same physician who performed the procedure, billed with CPT modifier “-24,” and accompanied by documentation that supports that the service is not related to the postoperative care of the procedure. They do not pay for inpatient hospital care that is furnished during the hospital stay in which the surgery occurred unless the doctor is also treating another medical condition that is unrelated to the surgery. All care provided during the inpatient stay in which the surgery occurred is compensated through the global surgical payment.



B. CPT Modifier “-25” - Significant Evaluation and Management Service by Same Physician on Date of Global Procedure


Medicare requires that Current Procedural Terminology (CPT) modifier -25 should only be used on claims for evaluation and management (E/M) services, and only when these services are provided by the same physician (or same qualified nonphysician practitioner) to the same patient on the same day as another procedure or other service. Carriers pay for an E/M service provided on the day of a procedure with a global fee period if the physician indicates that the service is for a significant, separately identifiable E/M service that is above and beyond the usual pre- and post-operative work of the procedure. Different diagnoses are not required for reporting the E/M service on the same date as the procedure or other service. Modifier -25 is added to the E/M code on the claim.


Both the medically necessary E/M service and the procedure must be appropriately and sufficiently documented by the physician or qualified nonphysician practitioner in the patient’s medical record to support the claim for these services, even though the documentation is not required to be submitted with the claim.


If the physician bills the service with the CPT modifier “-25,” carriers pay for the service in addition to the global fee without any other requirement for documentation unless one of the following conditions is met:


• When inpatient dialysis services are billed (CPT codes 90935, 90945, 90947, and 93937), the physician must document that the service was unrelated to the dialysis and could not be performed during the dialysis procedure;


• When preoperative critical care codes are being billed on the date of the procedure, the diagnosis must support that the service is unrelated to the performance of the procedure; or


• When a carrier has conducted a specific medical review process and determined, after reviewing the data, that an individual or a group has high use of modifier “-25” compared to other physicians, has done a case-by-case review of the records to verify that the use of modifier was inappropriate, and has educated the individual or group, the carrier may impose prepayment screens or documentation requirements for that provider or group. When a carrier has completed a review and determined that a high usage rate of modifier “-57,” the carrier must complete a case-by-case review of the records. Based upon this review, the carrier will educate providers regarding the appropriate use of modifier “-57.” If high usage rates continue, the carrier may impose prepayment screens or documentation requirements for that provider or group.

Carriers may not permit the use of CPT modifier “-25” to generate payment for multiple evaluation and management services on the same day by the same physician, notwithstanding the CPT definition of the modifier.



C. CPT Modifier “-57” - Decision for Surgery Made Within Global Surgical Period

Carriers pay for an evaluation and management service on the day of or on the day before a procedure with a 90-day global surgical period if the physician uses CPT modifier “-57” to indicate that the service resulted in the decision to perform the procedure. Carriers may no pay for an evaluation and management service billed with the CPT modifier “-57” if it was provided on the day of or the day before a procedure with a 0 or 10-day global surgical period.

Saturday, May 28, 2016

DME Modifiers- AU, AV, AW, KM & KN


Payment of DMEPOS Items Based on Modifiers


The following modifiers were added to the HCPCS to identify supplies and equipment that may be covered under more than one DMEPOS benefit category:

• AU Item furnished in conjunction with a urological, ostomy, or tracheostomy supply;

• AV Item furnished in conjunction with a prosthetic device, prosthetic or orthotic; and

• AW Item furnished in conjunction with a surgical dressing.

Codes A4450 and A4452 are the only codes that have been identified at this time that would require use of all three of the above listed modifiers. Providers must report these modifiers on claims for items identified by codes A4450 and A4452 that are furnished on or after January 1, 2005. Modifier AU may also be applicable to code A4217. Providers must report modifier AU on claims for items identified by code A4217 that are furnished in conjunction with a urological, ostomy, or tracheostomy supply on or after January 1, 2005. Items identified by code A4217 that are furnished in conjunction with durable medical equipment are reported without a modifier. In the future, other codes may be identified as codes that must be submitted with these modifiers. Medicare contractors base payment for the codes A4217, A4450, and A4452 on the presence or absence of these modifiers.

Codes L8040 thru L8047 describe facial prostheses. Providers must report the following modifiers on claims for replacement of these items:

• KM Replacement of facial prosthesis including new impression/moulage; and

• KN Replacement of facial prosthesis using previous master model.

Providers must report these modifiers on claims for replacement of items identified by codes L8040 thru L8047 that are furnished on or after January 1, 2005. Medicare contractors base payment for the codes L8040 thru L8047 on the presence of these modifiers. These modifiers are only used when the prostheses is being replaced.

In accordance with section 302(c) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), the fee schedule update factors for 2004 thru 2008 for durable medical equipment (DME), other than items designated as class III devices by the Food and Drug Administration (FDA), are equal to 0 percent. The HCPCS codes for DME designated as class III devices by the FDA are identified on the DMEPOS fee schedule available on the above mentioned web site by presence of the KF modifier.

Elevating/stair climbing power wheelchairs are class III devices. Suppliers billing the DMERCs must submit claims for the base power wheelchair portion of this device using HCPCS code K0011 (programmable power wheelchair base) with modifier KF for claims submitted on or after April 1, 2004, with dates of service on or after January 1, 2004. For claims with dates of service on or after January 1, 2004, the elevation feature for this device should be billed using HCPCS code E2300 and the stair climbing feature for this device should be billed using HCPCS code A9270.

Regional home health intermediaries (RHHIs) will not be able to implement the KF modifier until January 1, 2005. Therefore, for claims with dates of service prior to January 1, 2005, HHAs must submit claims for the base power wheelchair portion of stair climbing wheelchairs with HCPCS code E1399. For claims with dates of service on or after January 1, 2005, HHAs must submit claims for the base power wheelchair portion of stair climbing wheelchairs with HCPCS code K0011 with modifier KF.

The fee schedule amounts for K0011 with and without the KF modifier appear on the fee schedule file referenced at www.cms.hhs.gov/providers/pufdownload/default.asp#dme. For claims with dates of service prior to January 1, 2005, RHHIs should pay claims for stair climbing wheelchair bases billed with code E1399 using the fee schedule amounts for K0011 with the KF modifier. All other claims for programmable power wheelchair bases should be paid using the fee schedule amounts for K0011 without the KF modifier.

Effective for claims with dates of service on or after January 1, 2005, HHAs must submit modifier KF along with the applicable HCPCS code for all DME items classified by the FDA as class III devices.

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