Coding with Modifiers by huanghengdong

VIEWS: 45 PAGES: 119

									  Coding with Modifiers




  Oregon Medical Association
      October 29, 2009

Frann M. Britton, RN, CCS,CCS-P
CPT Categories
• Category I
  – Describe a procedure or service identified
    with a 5-digit numeric CPT code
  – Generally based on the procedure being
    consistent with contemporary medical practice
  – Being performed by many physicians in a
    clinical practice in multiple locations



                                                2
CPT Categories
• Category II Performance Measurement
  – Are intended to facilitate data collection by
    coding certain services and/or tests results
    that are agreed on as contributing to positive
    health outcomes and quality patient care.
  – Tracking codes for performance
    measurement
  – May be services that are typically part of an
    Evaluation and management service

                                                     3
CPT Categories
• Category II Performance Measurement
  – May be a component part of a service and are
    not appropriate for Category I CPT codes.
  – Do not have relative value
  – No payment associated with these codes
  – Will decrease need for record abstraction and
    chart review
  – Minimize administrative burden on physicians
    and health plans
                                                4
CPT Categories
• Category II Performance Measurement
  – Performance Measures Advisory Group
     • Evidenced-based measurements with
       established ties to health outcomes
     • Measurements that addresses clinical
       conditions of high prevalence, high risk, or
       high cost
     • Well-established measurements that are
       currently being used by a large segment of
       the health care industry nation wide.
                                                      5
CPT Categories
• Category II Performance Measurement

  – The use of these codes is optional and is not
    required for correct coding.




                                                    6
CPT Categories
• Category III Emerging Technology
  – Temporary set of tracking codes for emerging
    technologies, services, and procedures.
  – Intended to facilitate data collection and
    assessment of these services and
    procedures.
  – Used for data collection purposes to
    substantiate widespread usage or in the FDA
    approval process.

                                                   7
CPT Categories
• Category III Emerging Technology
  – Must have relevance for research, either
    ongoing or planned.
  – Once approved by Editorial Panel are added
    to Level I CPT codes
  – No relative values
  – Payment subject to payer policies
  – Archived after 5 years if not added to CPT

                                                 8
HCPCS Coding System
• HCPCS
 – CMS„s Health Care Common Procedure
   Coding System
 – Developed in 1983 to standardize the coding
   systems to process Medicare claims on a
   national basis.
 – 2 levels CPT and HCPCS



                                                 9
HCPCS Coding System
• Level I CPT
  – Makes up the majority of the HCPCS system
• Level II National Codes
  – Durable medical equipment
  – Ambulance services
  – Medical and surgical supplies, drugs
  – Orthotics, prosthetics, dental and eye services


                                                 10
HCPCS Coding System
• Level II National Codes
  – 5 character alphanumeric codes
  – First character is a letter A-V (except I)
    followed by 4 numeric digits (A4550)
  – Alphabetic (eg, RT) and alphanumeric (eg,
    E2) modifiers
  – Updated annually by CMS
  – Required for reporting most medical services
    and supplies provided to Medicare and
    Medicaid patients.
                                                   11
National Correct Coding Initiative
• Edit of code pairs of CPT or HCPCS that are not
  separately payable except under certain
  conditions.
• Same beneficiary, same physician, same date
• Promote national correct coding
• Eliminate improper coding




                                                12
National Correct Coding Initiative
• Developed by CMS to prevent
  inappropriate payment of services that
  should not be reported together.
• 2 NCCI tables:
  – “Column One/ Column Two Correct Coding
    Edit Table” and “Mutually Exclusive Edit
    Table”.



                                               13
National Correct Coding Initiative
• Each edit table contains edits of pairs of
  HCPCS/CPT codes in general should not
  be reported together.
• If a provider reports the two codes of an
  edit pair, the column two code is denied.
• When clinically appropriate to utilize an
  NCCI-associated modifier, both the
  column one and column two codes are
  eligible for payment.
                                               14
National Correct Coding Initiative
• Column two codes are often a component
  of a more comprehensive column one
  code it is not true for many edits.
• The code pairs simply represents two
  codes that should not be reported
  together.
• Vaginal hysterectomy and total abdominal
  hysterectomy code together.
                                         15
National Correct Coding Initiative
• NCCI is used by all practioners, hospitals,
  providers or suppliers eligible to bill
  Medicare.




                                            16
National Correct Coding Initiative
• Coding conventions defined in CPT
• Current standards of medical and surgical
  care
• Input from specialty societies
• Analysis of current coding practice
• Updated on quarterly basis
• Denial based on NCCI edits may not bill
  patient
                                          17
National Correct Coding Initiative
• 2 columns, 1st lists CPT code
• 2nd (component) code, integral to Column
  1
• Denied without modifier
• Mutually exclusive edit
  – 2 codes cannot reasonably be performed
    together based on code definitions or
    anatomic considerations.

                                             18
Procedures and Global Period
All procedure on the Medicare Physician Fee Schedule are
assigned a Global period of 000,010,090,XXX,YYY or ZZZ.
The global concept does not apply to XXX
procedures.
The global period for YYY procedures is defined
by the Carrier.
All procedures with a global period of ZZZ are
related to another procedure, and the global
period for the ZZZ code is determined by the
related procedure.
                                                     19
Procedures and Global Period
NCCI edits are applied to same day services by the same
provider to the same beneficiary.

An E/M service is separately reportable on the same DOS
as a procedure with global days, 000,010,090 under limited
conditions.

Minor procedures global days are 000 or 10.
Major procedures have 90 global days.



                                                       20
Procedures and Global Period
If an E/M is performed on the same date of service as a
major surgical procedure for the purpose of deciding
whether to perform this surgical procedure, append modifer
-57 to the E/M.

The decision to perform a minor surgical procedure is
included in the payment for the minor surgical procedure
and should not be reported separately as an E/M service.

A significant and separately identifiable E/M service
unrelated to the decision to perform the minor surgical
procedure is separately reportable with modifier-25.
                                                          21
Procedures and Global Period
Medicare example:
  “If a physician determines that a NEW patient with head
  trauma requires sutures, confirms the allergy and
  immunization status, obtains informed consent, and
  performs the repair, an E/M service is not separately
  reportable.

  HOWEVER, if the physician also performs a medically
  reasonable and necessary full neurological examination,
  an E/M service may be separately reported”.


                                                            22
Procedures and Global Period
XXX procedures have inherent pre-procedure,
intra-procedure and post-procedure work usually
performed each time the procedure is completed.
   (EKG‟s. x-rays, ultrasounds)


This work should never be reported as a separate
E/M.

An separate E/M can be reported with -25 if it is
significant, separately identifiable.
                                                    23
NCCI Modifiers
• Anatomic modifiers
     • E1-E4, FA, F1-F9, TA, T1-T9, LC, LD, RC,LT,RT
• Global surgery modifier
     •   -25 Significant E/M same day as Procedure
     •   -58 Staged or related Procedure during Postop
     •   -78 Unplanned Return to OR during postop
     •   -79 Unrelated procedure during postop
     •   -59 Distinct Procedure
     •   -91 Repeat Clinical Diagnostic Lab
     •   -27 Multiple Outpatient E/M on same Date

                                                         24
NCCI Modifiers
 Important to use NCCI-associated
 modifiers only when appropriate

 – Separate patient encounter
 – Separate anatomic sites
 – Separate specimens
 – Paired organs



                                    25
Modifiers
Evaluation and Management Only

-24 Unrelated E/M Unrelated E/M during the
    postoperative period
.
-25 Separate E/M

-57 Decision for Surgery
                                         26
Modifiers
Evaluation and Management Only

-24 Unrelated E/M Unrelated E/M during the
  postoperative period

• The same physician and unrelated to the original
  surgery
• Separate note if he/she evaluates the previous
  surgical site and determines the site requires care,
  this would not be part of the new encounter.
                                                   27
Modifiers
Evaluation and Management Only

-25 Significant, separately identifiable E/M service
  performed by the same physician on the day of a
  procedure.
  Modifier -25 is critical to appropriate
  communication about what happened in a patient
  encounter on a given date
• Procedures with 0,10, global days, endoscopies,
  XXX services.
                                                  28
Modifiers
•    Modifier was added by CMS in 1992 to help reduce the
     documentation burden on physicians.

•    Says the provider went “above and beyond” the other service
     provided.

•    Modifier-25 is not restricted to any level or SOS.

•    The same diagnosis may accurately describe the nature or reason
     for the encounter and the procedure.

    The record, however—should document an important,
    notable, distinct correlation with signs and symptoms to
    make a diagnostic classification or demonstrate a distinct
    problem.

                                                                   29
Modifiers
• Evaluation and Management Only

• -57 Decision for Surgery is appended to an E/M
  only when that service represents the initial
  decision to perform a major surgical procedure.
• E/M the day prior to or day of a major procedure
  with a 90 day global period.
• Be prepared to submit consultation, visit or
  hospital note to support decision for surgery.

                                                     30
Modifiers
-22 Unusual Procedure

• When the service provided is greater than that
  usually required for the listed procedure.
• Used in the following sections:
  –   Anesthesia
  –   Surgery
  –   Radiology
  –   Laboratory and Pathology
  –   Medicine
                                                   31
Modifiers
-22 Unusual Procedure operative cases
• Trauma extensive enough to complicate the
  particular procedure and that cannot be billed
  with additional procedures
• Significant scarring requiring extra time and work
• Extra work resulting from morbid obesity
• Increased time resulting from extra work by the
  physician
• Needs a concise statement about how the service
  differs from the usual
• An operative report submitted with the claim      32
Modifier -22
• Occasionally a provider may perform two procedures
  that should not be reported together based on an NCCI
  edit.
• If the edit allows use of NCCI-associated modifiers to
  bypass it and the clinical circumstances justify use of
  one of these modifiers, both services may be reported
  with the NCCI-associated modifier.
• If the NCCI edit does not allow use of NCCI-associated
  modifiers to bypass it and the procedure qualifies as an
  unusual procedural service, the physician may report the
  column one column one HCPCS/CPT code of the NCCI
  edit with modifier 22.

                                                        33
Modifier -22
• The Medicare carrier cannot override an
  NCCI edit that does not allow use of
  NCCI-associated modifiers,

• The carrier has discretion to adjust
  payment based on modifier 22.



                                            34
Modifiers
-26 Professional Component
  – Certain procedures are a combination of a physician
    component and a technical component. When the
    physician component is reported separately add -26.
  – If the radiologist owns the equipment, interprets the
    test, and pays the technologist, modifier TC and 26 do
    not apply.
  – Physician does not own the equipment -26
  – Facility provided the equipment and technician –TC
  – CPT 76140 only has a professional component
     modifier -26 would not be used.
                                                       35
Modifiers
-26 Professional Component

  – CPT 51725 simple cystometrogram (CMG)
    This code includes all supplies, equipment,
    and the technician‟s work, including
    interpretation of the results.
    If the physician only interprets the results and
    dictates a report, modifer -26 would be
    appended to the code.
    The hospital would submit the same code with
    -TC                                            36
Modifiers
-50 Bilateral Procedure
• Unless otherwise identified in the listings, bilateral
  procedures that are performed at the same
  operative session should be identified with -50.
• Bilateral procedures are typically performed on
  both sides of the body (mirror image) during the
  same operative session.
• Append to unilateral code as a one-line entry, unit
  of one
• Modifier does affect payment 2nd pr at 50%
                                                     37
Modifiers
-50 Bilateral Procedure

•   If the procedure is performed unilaterally and
    the descriptor indicates bilateral, append
    modifier-52.
•   69210 removal cerumen one or both ears
•   Do not use -50 code
•   Procedure performed unilaterally and descriptor
    indicates bilateral add -52

                                                38
Modifiers
-50 Bilateral Procedure

•   Many payers will not accept -50 for radiology
    use LT and RT

•   Medicare allows LT and RT instead of -50 when
    the code does not indicate a bilateral
    procedure.


                                                    39
Modifiers
-50 Bilateral Procedure bilateral code sets:
69210 Ear wax removal 1 or both ears
55300 Vasotomy, unilateral or bilateral
27158 Osteotomy, pelvis, bilateral
30801 Cautery and/or ablation, mucosa turbinates
      unilateral or bilateral
40843 Vestibuloplasty; posterior, bilateral
35548 Bypass graft, with vein, unilateral
35549 Bypass graft, with vein, bilateral
                                               40
Modifiers
-51 Multiple Procedures
• Used when multiple procedures, other than E/M,
  are performed at the same session by the same
  provider, the primary procedure or service is listed
  first.
• -51 is add to the additional procedures.
• List procedures in ranking order highest RVU
  listed first.
• -51 not needed for Medicare
                                                   41
Modifiers
-51 Multiple Procedures   has 3 applications


• Multiple, related surgical procedures performed at
  the same session
• Surgical procedures performed in combination
  whether through the same or another incision or
  involving the same or different anatomy
• A combination of medical and surgical procedures
  performed at the same session
                                                  42
Modifiers
-51 Multiple Procedures
• Do not append -51 to E/M service
• Do not append to “add- on “ codes
• Do not append to “each additional”
   (finger fracture's, tendon repair)
• “List separately in addition to primary
  procedure.” (lesions, vertebral segments)
• Modifier 51 exempt symbol Ø
                                              43
Modifiers
-51 Multiple Procedures

• Two or more physicians at same operations

• Each surgeon reports his/her own CPT codes
  without modifer -51

• Modifier -51 same surgeon, same session,
  multiple procedures as long as they are not
  considered incidental or bundled


                                                44
Modifiers
-51 Multiple Procedures

• 100% first procedure
• 50% 2nd – 5th each additional
•      after 5th “by report basis”

• 100, 50, 25 Other payer specific payment
  policy
                                             45
Modifiers

-52 Reduced Service – part of service
 or procedure reduced or eliminated at
 the physician‟s discretion.

• Provides a means of reporting reduced
  services without disturbing the
  identification of the basic service.

                                          46
Modifiers
-52 Reduced Service –

• May or may not affect reimbursement
• Chart note or op note should be sent
  with claim
• Not all carriers recognize
• Not recognized with E/M – CMS

                                         47
    Modifiers
•   -53 Discontinued Procedure


• When patients experience unexpected responses
  (hypotension, arrhythmia) causing a procedure to be
  terminated

• Procedure stopped due to patients life-threatening
  condition

• After anesthesia is administered to patient

• Payers cover only the primary procedure

• Not for laparoscopic or endoscopic procedure converted
  to an open procedure
                                                           48
Modifiers

 -54 Surgical Care Only

 -55 Postoperative Management Only

 -56 Preoperative Management Only


                                     49
Global Surgical Package
• Refers to payment policy of bundling
  payment for the various services
  associated with an operation into a single
  payment covering;
  – Operation
  – Postoperative hospital visits
  – Normal typical follow-up care


                                               50
Global Surgical Package
• CMS
 – Preoperative period begins one day prior to
   surgery in or out of the hospital and continues
   for 90 days.

 – Carefully monitored by Medicare – may
   lengthen preoperative period.



                                                 51
Modifiers

-54 Surgical Care Only

 When one physician performed a
 surgical procedure and another
 provided preoperative and/or
 postoperative management.



                                  52
Modifiers

-54 Surgical Care Only

  – Intraoperative care only
  – Fracture reduction in the ED
    • 69% of the global fee

    • 25605-54 closed reduction distal radius



                                                53
Modifiers

-55 Postoperative Management Only

 When one physician performed the
 postoperative management and another
 performed the surgical procedure.



                                        54
43770-54 Laparoscopy, gastric band
         Bariatric surgery

43770-55 Laparoscopy, gastric band
         Bariatric surgery



                                     55
43770 Laparoscopy, gastric band
Bariatric surgery

Work     Expense     Mal Practice
17.85    7.72         2.19



Pre 9%   Intra 81%   Post 10%


                                    56
Modifiers
-55 Postoperative Management Only

• Date of surgery plus number of days
  – 35321-55 x5 units
• Bill after patient is seen initially in f/u
• Payment 10-20% of post-op allowable
• Transfer of care documented

                                                57
Modifiers

-56 Preoperative Management Only

 When one physician performed the
 preoperative care and evaluation and
 another performed the surgical
 procedure.



                                        58
Modifiers

- Needs to be communication between
  the surgeon and the physician providing
  either pre-op or post-op services.

- Discharge summary of the hospital or
  ASC



                                            59
Modifiers

- Payment
- Modifier -56 based on the preoperative
  value of the global surgery fee
- Report date of surgery on 1500
- CPT 33400-56 Aortic valve repair



                                           60
Modifiers
-58 Staged or Related Procedure or Service by the
  same physician during the postoperative period

• Planned prospectively, more extensive than the
  original procedure or represents a therapeutic or
  diagnostic procedure or service

• Used during the global surgical period for the original
  procedure
• New postoperative period begins
• Not used for return to the operating room for
  treatment of a problem


                                                            61
Modifiers
• If a diagnostic endoscopic procedure
  results in the decision to perform an open
  procedure, both procedures may be
  reported with modifier-58 appended to the
  CPT code for the open procedure.
• If the scope is a “scout” procedure to
  asses anatomic landmarks and or/extent
  of disease it is not report separately.

                                           62
A surgeon performed a radical mastectomy
(19200) on a 56-yr-old woman. The patient
indicated that she preferred a permanent
prosthesis after the surgical wound healed.
The surgeon took the patient back to the
operating room during the post-op period and
inserted a permanent prosthesis.

CPT code:

                                         63
A diabetic patient with advanced circulatory
problems had three gangrenous toes
removed from her left foot (28820, 28820-51,
28820-51). During the post-op it became
necessary to amputate the patient‟s left foot.

CPT code:



                                           64
  Rational:

• Because there is a possibility, in the light of
  the patient‟s condition, that amputation
  might be necessary, this is considered a
  staged procedure.




                                                65
• 35840 Exploration for postoperative
  hemorrhage thrombosis or infection;
  abdomen

• Code:




                                        66
Modifiers
• -59 Distinct Procedural Service
    Documentation must support:
     • Different Session or Pt Contact
     • Different procedure or surgery
     • Different site or organ system
     •   Separate incision or excision
     •   Separate lesion
     •   Separate injury
     •   Separate area of surgery in extensive injuries, not
         ordinarily encountered or performed on the same day,
         by the physician
                                                        67
Modifiers
• Modifier -59
  – For “exceptions” to the normal rules
  – By passes the NCCI edits
  – Using incorrectly – tells payer every service is
    an exception
  – Leads to further review of a provider‟s billing
    practices
  – Inappropriate or indiscriminate use of the NCCI
    modifiers could be considered fraudulent or
    abusive
                                                 68
Modifiers
• Modifier -59
  – Use of modifier -59 to indicate different
    procedures/surgeries does not require a
    different diagnosis for each CPT/HCPCS code.

  – Different diagnoses are not adequate criteria
    for use of modifier -59. The codes remain
    bundled unless the procedure are performed at
    different anatomic sites or separate encounters.
                                                 69
Modifiers
• Modifier -59
  – Different anatomic sites includes different
    organs or different lesions in the same organ.
  – Does not include treatment of contiguous
    structures of the same organ.
     • E.g. nail, nail bed, and adjacent soft tissue
       constitutes treatment of a single anatomic site.




                                                          70
Modifiers
• Modifier -59
  – Treatment of posterior segment structures in
    the ipsilateral eye constitutes treatment of a
    single anatomic site.

  – Arthroscopic treatment of a shoulder injury in
    adjoining areas of the ipsilateral shoulder
    constitutes treatment of a single anatomic site.


                                                     71
Modifiers
• Modifier -59
  – CPT 38221 bone marrow, biopsy
  – CPT 38220 bone marrow, aspiration only
  – Code both if different anatomic sites same
    incision do not code and do not use -59

  – Medicare CPT 38221 and G0364 (bone marrow
    aspiration performed with bone marrow biopsy
    through same incision on the same DOS).

                                                 72
Modifiers
• Modifier -59
• Should not be used when another, more
  descriptive modifier is available
• Documentation needs to be specific to the
  distinct procedure or service and be
  clearly identified in the medical record
• By passed NCCI edits

                                          73
Modifiers
• Modifier -59

  – CPT 87070 Culture bacterial, blood
     • Different site (both arms)


  – CPT 87071 Culture bacterial; quantitative,
               aerobic of two sites
     • Wound infection, lower leg with cultures from
       proximal wound and distal wound site
                                                       74
Modifiers
• Modifier -59

  – CPT 97597 Removal devitalized tissue
                 Patient‟s right hip and ankle


     • 97597-59 later in the day debrided another 20sq cm
                from the sacral area




                                                      75
Surgeon removed a soft tissue 3cm
tumor from a patient‟s left wrist in the
outpatient surgery department. During
the same operative session, a 0.8-cm
lesion was excised from the patient‟s
right leg.

CPT code:


                                           76
Patient had a total colonoscopy with
random biopsies from the ascending colon,
transverse colon and sigmoid colon. A hot
biopsy destroyed a 3-mm polyp in the
sigmoid colon.

CPT code:



                                      77
70 yr old woman, with SOB under went
chest x-ray single view. Later in the day
the radiologist asked the patient to return
for a more extensive study.

CPT code:




                                              78
Modifiers
-62 Co-surgeon two surgeons performing
  distinct part(s) of a procedure

• Complexity of the procedure
• The patient‟s condition or both

• Additional surgeon is not acting as assistant but
  is performing a distinct portion of the procedure


                                                  79
Modifiers
-62 Co-surgeon two surgeons performing
  distinct part(s) of a procedure

• Each surgeon bills the same CPT/ICD
• Separate operative reports to document
  their level of involvement in the surgery
• Spine surgery – physicians discuss in
  advance what portion of the procedure
  each is expected to perform
                                              80
Modifiers
-62 Co-surgeon two surgeons performing
  distinct part(s) of a procedure

• Spine surgery opens and closes only, -62
  is appended to the primary procedure only

• -80 when needed to continue as assistant

                                             81
Modifiers
-62 Co-surgeon two surgeons performing
  distinct part(s) of a procedure

• For surgical procedures
• Endovascular repair (34800, 34802,
  34804, 34812, 34813,34820, 34825)
• Radiological procedures
  – CPT 77778-26-62 urologist
  – CPT 77778-26-62 radiologist
                                         82
Modifiers
-62 Co-surgeon two surgeons performing
  distinct part(s) of a procedure

• Review payer guidelines
• Documentation must support need for 2
  surgeons,
• Each bills with same CPT/ICD codes
• Each surgeon must dictate his/her own operative
  report
• Not used for surgeon acting as “the assistant
  surgeon”
                                               83
Modifiers
-63 Procedure Performed on Infants
  Less than 4 kg
• Increased complexity and physician work
• Used only with codes from Surgery section of CPT
• Only invasive surgical procedures

• Not for surgery that assumes the patient is a neonate or
  infant (eg. Surgery to correct a congenital abnormality)
  the relative value already reflects the additional work.

• Use -22 or -63 not both at same session
                                                         84
Modifiers
Modifier 66 Surgical Team

  Highly complex procedures requiring the
  concomitant services of different specialties,
  performing different portions of a procedure.

  Heart transplant
  Lung transplant
  Liver, pancreas
                                                   85
Modifiers
Modifier 66 Surgical Team


• Each surgeon bills with -66 appended to the
  procedures
• Requires usually requires prior authorization
• Send op report


                                            86
Modifiers
-76 Repeat Procedure by Same Physician

• Intended to describe the same procedure or
  service repeated rather than the same procedure
  being performed at multiple sites.

• Modifier indicates not a duplicate
• Must be same procedure, same physician



                                                87
Modifiers
-76 Repeat Procedure by Same Physician

  – Surgical procedure –same date or during global
  – Medical – same date
    •   93010 EKG
    •   93010-76 2 EKG‟s same day
    •   71010-26 Chest x-ray
    •   71010-76-26 same day for chest tube placement



                                                        88
Modifiers
-77 Repeat Procedure by Another Physician

• Medical necessity must support reason for
  the repeat procedure

• Second physician is not affected by first
  physician‟s service


                                              89
Modifiers
-78 Return to the Operating Room for a Related
  Procedure during the Post-operative Period

  – Subsequent procedure is related to the first and
    requires the use of the operating room
  – May be used on the same day or during global period
  – Do not use the code for the original procedure
  – Repeat surgery is due to a complication of the original
    procedure
  – Append modifier to each procedure performed that
    requires treatment for the complication
                                                         90
Modifiers
-78 Return to the Operating Room for a Related
  Procedure during the Post-operative Period

  – Do not use for procedures that indicate in the
    descriptor “subsequent, related, or redo”
  – If the complication does not require return to the OR do
    not append -78
  – Reimbursement intra-operative portion only
  – New global days do not begin
  – Use a complication diagnosis code not the same dx as
    the original surgery

                                                        91
Modifiers
-78 Return to the Operating Room for a Related
  Procedure during the Post-operative Period

Complications of Surgical and Medical Care, Not Classified
  Elsewhere
• 998.11 Hemorrhage complicating a procedure
• 998.32 Disruption of external surgical wound
• 998.59 Post-operative wound infection
         – 682.6 knee, 682.2 back, 041.12 MRSA




                                                        92
Modifiers
-78 Return to the Operating Room for a
  Related Procedure during the Post-
  operative Period

Mechanical Comp Internal Ortho Device
• 996.42 Dislocation of joint
• V43.64 Total hip

  – Use with CPT 27265 only

                                         93
Modifiers
-78 Return to the Operating Room for a
  Related Procedure during the Post-
  operative Period

Complications of Surgical and Medical Care, Not
  Classified Elsewhere
• 998.59 Post-operative wound infection


                                                  94
Medicare Operating Room
• Operating room or place equipped
  specifically for procedures.
  –   Hospital operating room
  –   Ambulatory surgery center
  –   Cardiac cath suite
  –   Laser suite
  –   Endoscopy suite
  –   ICU when patient to sick to move


                                         95
Modifiers
-79 Unrelated Procedure or Service by Same
  Physician During the Postoperative Period

  –   Different diagnosis
  –   Does not require a return to the OR
  –   Is not limited to surgical procedures
  –   Restricted to the same physician
  –   Append -79 to all procedures that apply not just first
  –   Begins new 90 day global period

                                                               96
Modifiers
80-82 Assistant Surgeons

  – 80 Assistant Surgeon
  – 81 Minimum Assistant Surgeon
  – 82 Assistant Surgeon (when qualified
       resident not available)
  -AS Physician assistant, nurse practitioner,
      clinical nurse specialist

                                                 97
 Modifiers
   Co surgeon (-62) share responsibility for a surgical procedure,
   each serving as a primary surgeon during some portion of the
   surgery. Both must be surgeons, and usually of different
   specialties.

• CMS, to qualify as assistant the surgeon must actively assist.
  Must be involved in the actual performance of the procedure.

• To qualify for CMS definition of an assistant surgeon
  (-80), the assistant surgeon needs to be able to take over the
  surgery should the primary surgeon become incapacitated.

• The surgical note should clearly document what the assistant
  surgeon did during the operating session.



                                                                     98
Modifiers
-81 Minimum Assistant Surgeon

• Assistance for a short period of time
• Medicare 13% of allowable

• Work Comp


                                          99
Modifiers

-82 Assistant Surgeon (When Qualified
  Resident Surgeon Not Available)

• Prerequisite unavailability of qualified
  resident (teaching hospitals)




                                             100
Modifiers
-90 Reference (Outside) Laboratory

• Laboratory bills the physician and the
  physician office bills the insurance
  company.
• 36415 lab draw
• 80061-90 Lipid panel

                                           101
Modifiers
-91 Repeat Clinical Diagnostic Test

• Necessary to repeat the same lab test
  – Not to:
  – Confirm initial test results
  – Due to testing problems encountered with
    specimens or equipment
  – For any other reason, one-time reportable
    result is all that is required

                                                102
Modifiers
-91 Repeat Clinical Diagnostic Test

• Follow-up potassium level after treatment
  of hyperkalemia
• Repeat ABG‟s
• Drug testing for each drug
  – 80100 Cocaine
  – 80100-91 methamphetamine
  – 80100-91 THC
                                          103
Modifiers
-91 Repeat Clinical Diagnostic Test

• 82948 Glucose, blood, reagent strip
• 82948-91
• 82951 glucose, three specimens




                                        104
Modifiers
-91 Repeat Clinical Diagnostic Test vs
  modifier -59

• -59 Same procedure for a different
  specimen

• Laboratory test that is performed more
  than once on the same day for the same
  patient. To obtain subsequent test results.
                                            105
Modifiers
HCPCS Level II

• 33 Anatomic modifiers
• 10 Anesthesia modifiers
• 300 CMS



                            106
Modifiers
Anatomical - HCPCS


  -LT Left side of the body
  -RT Right side of the body

  -FA Left hand – thumb
  -T5 Right foot - Great toe


                               107
Modifiers
HCPCS Level II
• -GA ABN signed
• -QW CLIA waved test
• -TC Technical component
• -GY Item or service does not meet the
        definition of a Medicare benefit
• -GZ Item or service expected to be denied
        as not reasonable and necessary
                                         108
 Modifiers
HCPCS Level II
• -GY modifier : physicians, practitioners, or suppliers want to
  indicate that the item or service is statutorily non-covered or
  is not a Medicare benefit.

• -GZ modifier: to indicate that they expect that Medicare will
  deny an item or service as not reasonable and necessary
  and they have not had an Advance Beneficiary Notification
  (ABN) signed by the beneficiary.

• -GA modifier: when physicians, practitioners, or suppliers
  want to indicate that they expect that Medicare will deny a
  service as not reasonable and necessary and they do have
  on file an ABN signed by the beneficiary.

                                                             109
Modifiers
HCPCS Level II

Foot Care
• Q7 One class A finding
• Q8 Two class B findings
• Q9 One class B and two class C findings


                                            110
“Never Events”
Invasive procedures include a range of procedures
from minimally invasive dermatological procedures
• Biopsy, excision, and deep cryotherapy for
   malignant lesions.
• Extensive multi-organ transplantation
• Percutaneous transluminal angioplasty and
   cardiac catheterization.
• Placement of probes or catheters requiring the
   entry into a body cavity through a needle or
   trocar.
• Do not include
   – use of instruments such as otoscopes for examinations.   111
   – very minor procedures such as drawing blood.
“Never Events”

• A surgical or other invasive procedure is
  considered to be the wrong procedure if it
  is not consistent with the correctly
  documented informed consent for that
  patient.



                                           112
“Never Events”
• Surgical or other invasive procedure is
  considered to have been performed on the
  wrong body part if it is not consistent with the
  correctly documented informed consent for that
  patient including surgery on the right body part,
  but on the wrong location on the body;

• Left versus right (appendages and/or organs), or
  at the wrong level (spine).

                                                  113
“Never Events”
• The event is not intended to capture
  changes in the plan upon surgical entry
  into the patient due to the discovery of
  pathology in close proximity to the
  intended site when the risk of a second
  surgery outweighs the benefit of patient
  consultation; or the discovery of an
  unusual physical configuration (e.g.,
  adhesions, spine level/extra vertebrae).
                                             114
Modifiers
HCPCS PC


• PA: Surgery Wrong Body Part
• PB: Surgery Wrong Patient
• PC: Wrong Surgery on Correct Patient



                                         115
Modifiers
HCPCS

• PA:   Surgery Wrong Body Part
  E876.7 Correct operation on wrong body part

• PB:   Surgery Wrong Patient
  E876.6 Performance of operation on pt not scheduled for surgery

• PC:    Wrong Surgery on Patient
  E876.5 Wrong operation correct patient (wrong device
         implanted into correct surgical site

                                                             116
Modifiers
HCPCS PC


82 yr old male had surgery performed on his
  right knee for a torn meniscus. The left knee
  had the torn meniscus.

Code:

                                             117
Questions



            118
Resources

• http://www.cms.hhs.gov/Transmittals/downloads/R1
  02NCD.pdf
• CPT 2009, Edition, American Medical Association
• International Classification of Diseases, 2009 Edition
• Coding with Modifiers, AMA
• Center for Medicare and Medicaid Services, Program
  Manual
• Medicare Claims Processing Manual


                                                       119

								
To top