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Coding with Modifiers: CPT, Medicare, and the Real World
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Will you be discussing Cahaba's redefinition of the use of
No, not during this presentation. Believe me, there are
enough issues that affect everyone to take up an hour's time!
Will you be discussing the use of modifier 77?
No. This presentation will focus on Modifiers:• used with E/M codes: 24, 25, and 57• used to indicate more/less than the normal service was performed: 22, 52, and 53• used for later surgical services during global of earlier service: 58, 78, and 79• used for multiple procedures: 50, 51, and 59
Is there a modifier that we can use with consultations for
If you are the same group and specialty, per CPT Modifier
24 could be used, as the service is unrelated to "typicval" post-op care. However, Medicare and most payers consider addressing post-op complications to be included in the global surgical payment when handled by the operative group and specialty.
If more than one mod on 1 cpt for example 22, 59, 58 what Per the January 2010 AMA CPT Asst. Newsletter: "CPT is the correct order should be appended?
coding guidelines do not address this issue. Please note that payment policies, including the appropriate order of modifiers on claim forms, are set by third-party payers, not by the CPT coding system. Therefore, any specific payment-related questions or issues should be directed to the respective third-party payers."
That said, some have tried to track what the majority of their payers prefer, or just applied common sense, and have published some kind of order. I usually put modifiers that are SUPPOSED to trigger an automatic denial first (like GY or 32) when we know it won’t be paid, or modifiers required to prevent a global-package bundled denial (like 24/25/57 for E/Ms, 58/78/79 for procedures) or an NCCI-related denial (59 or other) first when we DO want it paid, followed by modifiers that trigger a fee adjustment (like 26, 51, 80, 62, etc.), followed by informational modifiers like GC and AI.
On code 35476. if 3 venous angioplasy are done, can we
Medicare allows units for some codes, while for others it
just at the units. which modifiers are needed for medicare? prefers that the additional codes be reported on separate
lines with either 59 or 76 (depending on the MAC). A good reference for finding out if Medicare allows units for a certain code is to access Medicare's MUE edit table and look up the code. If the maximum number of acceptable units is greater than "1" you know unit reporting is allowed.
We are a pcp office- when a pt comes in for a possible uti
If a service is being denied because of a claims processing
we dip their urine 81002 we are being told by horizon that alteration, but not a policy change, then trying to adapt your pcp's can no longer perform a uadip that the pt must be sent reporting to still be paid, perhaps by using a modifier, may to a lab or specialist. I feel this is crazy, is there a modifier be appropriate. However, it the payer has indicated a we can use to perform this test in house. we are also clia
change in policy that prohibits payment for a service,
bypassing this payer mandate by altering our billing wouldn't be prudent. Instead, I would contact the payer and address the policy change directly.
Is there ever a time when it is ok to use mod 51 with ped
Not per CPT instructions, but state Medicaids and some
private payers require coding methodology that is not always in line with CPT instructions.
Is it appropriate to add modifiers RT/LT to diagnostic
These modifiers are considered NCCI modifiers, meaning
procedures; such as extremity US or Xrays?
their INTENDED purpose is to assist in situations where one code on the claim would otherwise be denied as an inlusive component of another code on the claim. If this situation doesn't exist, Modifiers RT and LT could still be used, but it is not required.
Do you need to add a 25 modifier along with a decision for Not per CPT if the procedure is a major one.
surgery service we recieved a denial for not using a 25 modifier in addition to the 57.
When coding for an axial dexa scan 77080 and an
Before you choose to bypass an edit, you need to see if
appendicular dexa scan 77081 on the same date of service, Medicare has explained why they consider the secondary Medicare always denies. We've been told by Medicare that procedure to be bundled in some/most cases. Then you both will pay if we add a 59 modifier to 77080, but we've
would know if your case is unique. If they haven't
also always been told that the modifier can't be used unless explained this clearly, then you have to either have a the documentation warrants its use. The codes themselves separate session or site. Deciding if you have a separate site tell of a different site, so is this coding for reimbursement if is tricky, since it could mean a different site on the same the report does not outline why both areas are studied?
organ, through a different incision, etc.
Are we wrong to use the 59 in this case? We have the same dx for both codes.
Which modifiers are needed on code 35476 if 3 angioplasty Please consult with your MAC to see if they prefer units, are done for medicare? or can we just bill as 3 unitis?
vs. reporting the add'l 35476s on add'l claim lines using either 59 or 76.
Which modifiers are needed on code 35476 if 3 angioplasty Duplicate. Please see above.
are done for medicare? or can we just bill as 3 unitis?
If a patient has surgery by 1 of our physicians & our
Medicare (and most payers) will only pay for one
physician does an intraopertive x-ray (and dictates a
interpretation of an image for a common purpose.
separate note), what modifiers can we use in order to get
Overreads for QA purposes cannot also be billed.
paid? The radiology group contracted w/the hospital has also billed for interpretation of the xray.
Are you able to use mod 25 with every office consultation You can use the modifier as often as a medically necessary when billing for extended opthamoscopy and OCT?
E/M is provided on the same date as a procedure/other service, in cases where the E/M is significant and separately identifiable. I am unable to say if that will always be the case in the situation you describe.
What are the appropriate modifier(s) for E/M 99203, repair For most payers, just adding Modifier 25 to the E/M should 12001, and tetanus 90471 & 90714?
If a pft is performed, but results could not be interpreted
CPT has indicated that Modifier 52 may be used for the
due to poor inspiration effort of patient, would you amend a unsuccessful performance of a service, but Medicare has 52 mod to the pft?
made statements in the past that this is not allowed. I would consult with your specific MAC or third party payer.
When is modifer LT & RT appropriate rather than modifier Modifier 50 is used if the EXACT same service provided 50?
on both sides. RT and LT can be used for this, but they are most useful for identifying services as distinct from one another in cases where the service performed on one side would be considered as bundled with the other code if performed on the same side.
Can you explain the 51 modifier rule when multiple
The primary (highest RVU) procedure rendered during the
procedures are done thoughout the day both in and out of
overall DOS is listed first with no modifier. The other
OR by the same Physician? Example Trauma with multiple surgical codes will have Modifier 51 appended unless an procedures in ED, OR, and bedside thoughout the same
exception applies (add-on, 51 exempt).
What is the best way to determine if your situation qualifies First, determine if an edit exists that will result in the denial for the use of modifier 59? We have a wound clinic and
of one/more codes on your claim because of an assumption
through my research I have found conflicting information. that its work was already paid to you inside another code The situation I am referencing is treatment of a different
being billed. Second, try to understand the edit. In what
system: cardiovascular (edema) and integumentary (skin).
cases is it valid? Knowing this, examine your situation to see if it falls outside this situation due to the second code representing a different site or session. Apply 59 if these criteria are met.
We see a high volume of 25 and 59 modifier (E/M with
These modifiers are used quite frequently. Requiring
claims with surgery) claims as a payer . Should
documentation for all or most claims involving Modifier 25
documentation be required on all or most of these types of and 59 would probably overload your review capacity. That billings?
said, targeted reviews of providers whose frequency of use significantly exceeds the norm would be advisable to weed out incorrect coding.
When billing a Preventive Med Well code along with an
This could be payer-specific, but technically yes, the 25
Admin for Immz code along with an E&M is is appropriate should be added to all E/M codes billed.
to use a 25 on both the preventive med and E&M?
Is a CPT descriptor say "extensive" and used can the
Yes, because there would still be a standard/normal level of
surgeon add modifer -22? If so, waht would I need to see
time/ffort/complexity that would apply to the code which
to support the "extensive" descriptor and modifier -22? Is may be significantly exceeded due to extenuating it enought to note time and adhersions or do they need to
circumstances. The provider should document the items
mentioned in the presentation slide:• What made the service “increased” (“The procedure was technically demanding and significantly more time consuming than usual…”)• % of increased difficulty• “We are requesting a ___% fee increase…”
If I'm using a Q6 modifier for a locum but have to use
I would add 25/52 first, followed by Q6.
modifier 25 or 52 (for example) which should go first?Can I use a modifier 53 if a nurse is trying to do a lab thru a As mentioned above, CPT has indicated that Modifier 52 port and for some reason the blood refused to come through may be used for the unsuccessful performance of a service, port? It flushed okay but we couldn't get the blood same.
but Medicare has made statements in the past that this is not allowed. I would consult with your specific MAC or third party payer.
Would performing a simple mastectomy (19303) with a
sentinel lymph node biopsy (38525) be considered multiple procedures
If a CPT descriptor say "extensive"/"complicated" and is
performed can the surgeon add modifer -22 for any additioanl complications? If so, do I need to see specific info to support the "extensive"/"complication" descriptor and modifier -22? Is it enough to note time and adhesions or do they need to document more details? If -22 cannot be used, what/how would you recommend I explain to the surgeon?
Where do you find information on whether there is an edit Each payer has control over its edits. Medicare publishes in place for a particular code?
its edits, called the National Correct Coding Initiative (NCCI) edits, here: http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html
We have a disagreement going.why should we affix mod
Nothing in the description for Modifier 25 says that the
25 to an E/M where the pt has a URI and they get a shot of E/M service has to be unrelated or not pertain to the depomedrol and decadron? It's really not separate since it's procedure—just that it consist of separate work pertaining to the reason for the visit? If we do not append above/beyond the standard pre-post procedure work the 25 modifier than our third party insurances will pay
bundled into the performance of the procedure. If an
only on the meds and the administration code sometime's
evaluation was necessary to determine the necessity of
not even the admin code just the meds.
performing the injection, the E/M can be billed unless the payer is Medicare. Medicare will not pay for an evaluation that identifies the need for a minor procedure, considering this to always be bundled into the minor procedure.
Would it be appropriate to use modifier 25 when a
Per CPT, Modifier 25 is used when a minor surgical
Medicare patient comes in with the Chief Complaint of
procedure is performed with an E/M, not an imaging
back pain, a 99213 service is completed, and the Physician service. That said, some payers may require Modifier 25 to has decided that the patient needs to have an MRI done in
be attached to an E/M billed with imaging services. Please
On procedures with the zzz indicator, when is it appropriate This global days designation is associated with add-on to use a -58 mod.?
codes. Modifer 58 is used with add-on codes the same as with regular surgical codes.
We know modifier 53 is used for discontinued procedures Modifier 53 would still be used if the reason for the AFTER anesthesia, but what do you do when a procedure
termination was an extenuating circumstance and the
that does not require anesthesia, is discontinued?
termination occurred after preparation for the procedure. Note that the modifier description in Appendix A mentions "anesthesia induction and/or surgical preparation," emphasis on the OR.
When billing CPT 99392 with 90460 in addition to
When multiple significant, separately identifiable E/M
99215.Is modifier 25 applicable to both 99392 (to explain codes are billed that consist of work above/beyond any 90460 addition) as well as 25 on the 99215?
E/M type work included in another procedure, then yes it would be appropriate to add Modifier 25 to both.
Medicare states a global poat op period may allow for the
There is no modifier for this situation. Modifier 25 can only
treatment of the underlying condition. example Pacermaker be used to extract the E/M code from the global of a insertionfor a fib. Day 1 the pt is seen and the decision to
MINOR procedure, and it's not the decision-for-surgery
perform this is made. The visit is billed with mod 57. Day visit. The E/M is alos not taking post-operatively, in which 2, the phy has to see the pt prior to the procedure and adjust case Modifier 24 would have been appropriate. This would the meds for the a fib, later that day the procedure is done. be billed unmodified and the denial appealed with notes, Can day 2 be billed with mod 25 or 24?
unless the payer gives specific permission to use Modifier 57, though not accurate.
Can you use a 53 if the patient has an anxiety attack during That sounds reasonable.
an EMG/NCV study?
Journal of Medicine and Medical Sciences Vol. 1(10) pp. 447-452 November 2010 Available online http://www.interesjournals.org/JMMS Copyright ©2010 International Research Journals Prevalence and treatment outcome of vulvovaginal candidiasis in pregnancy in a rural community in Enugu State, Nigeria P. A. Akah1, C. E. Nnamani1,2 and P.O. Nnamani3* 1Department of Pharmacology and Tox
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