MDFR21
MDFR21
0
2 OPTUM360 LEARNING
1
Understanding Modifiers
Understanding
s
Modifiers
ge
Comprehensive instruction to effective
Pa
modifier application
e
pl
m
Sa
2 0 21
optum360coding.com
Contents
Introduction ................................................................1 Chapter 7: Professional/Technical Component
What Are HCPCS Modifiers? ...................................................1 Modifiers 26 and TC ................................................ 101
Outpatient Modifier Guidelines/Usage ...............................4 Chapter 8: Laboratory and Pathology-Related
Contents ......................................................................................4 Modifiers 90, 91, and 92 ......................................... 105
Special Notice Regarding Chapter 10 Category II
Modifiers 1P, 2P, 3P, and 8P and Chapter 12 ASC Chapter 9: Miscellaneous Modifiers: 63, 95, 96,
and Hospital Outpatient Modifiers: 25, 27, 73, 97, and 99 ................................................................ 109
and 74 ..........................................................................................5
Chapter 10: Category II Modifiers: 1P, 2P, 3P,
Multiple Modifiers .....................................................................5 and 8P ..................................................................... 117
Modifiers and Unlisted Codes ................................................6 Performance Measurement Modifiers ............................117
s
Determining Correct Use ........................................................6 Using the Modifier Correctly .............................................118
ge
Chapter 1: E/M-Related Incorrect Use of the Modifier .............................................118
Modifiers 24, 25, 57, and AI ......................................13 Chapter 11: HCPCS Level II Modifiers A–Z .............. 119
Chapter 2: Anesthesia-Related Modifiers .................29 Introduction ...........................................................................119
Anesthesia Services Modifiers 23 and 47 ......................... 29 Ambulance Modifiers ..........................................................119
Physical Status Modifiers P1, P2, P3, P4, P5, and P6 ...... 33
HCPCS Anesthesia Modifiers AA, AD, QK, QX, QY, QZ ... 34
HCPCS Level II Monitored Anesthesia Care Modifiers
Pa HCPCS Level II Modifiers .....................................................120
Chapter 12: ASC and Hospital Outpatient
Modifiers: 25, 27, 73, and 74 .................................. 159
G8, G9, and QS ........................................................................ 35 Ambulatory Payment Classifications ...............................159
Chapter 3: Mandated and Preventive Outpatient Code Editor for the Outpatient
e
Services-Related Modifiers 32 and 33 ......................39 Prospective Payment System ............................................160
CPT and HCPCS Modifier Reporting Requirements ....164
Chapter 4: Procedures/Services Modifiers ...............51
pl
53, 59, XE, XP, XS, and XU ..................................................... 54 What is compliance? ............................................................171
Global Component Modifiers 54, 55, and 56 ................... 70 CMS and Modifier 59 Use ...................................................178
Postoperative Modifiers 58, 78, and 79 ............................ 76 Medicare Audits ....................................................................179
Sa
Repeat Procedures and Services Modifiers The OIG’s Compliance Plan Guidance .............................180
76 and 77 .................................................................................. 84 Modifiers and Compliance: A Quick Self-Test ................182
Chapter 5: Multiple Surgeon Modifiers: 62 and 66 ..89 Chapter 14: Modifier Official Descriptors .............. 221
Chapter 6: Surgical Assistant Modifiers 80, 81, Glossary .................................................................. 229
82, and AS ..................................................................95
Index ....................................................................... 245
The use of modifiers is an important part of coding and billing for health care
services. Modifier use has increased as various commercial payers, who in the
past did not incorporate modifiers into their reimbursement protocol, recognize
and accept HCPCS codes appended with these specialized billing flags.
s
Correct modifier use is also an important part of avoiding fraud and abuse or FOR MORE INFO
noncompliance issues, especially in coding and billing processes involving the
See chapter 13, “Modifiers and
ge
federal and state governments. One of the top 10 billing errors determined by
Compliance,” for more details on
federal, state, and private payers involves the incorrect use of modifiers. fraud and abuse.
The CPT code book, CPT 2020, lists the following examples of when a modifier
may be appropriate, including, but not limited to:
Sa
s
The physician or other qualified health care professional may need to
indicate that an evaluation and management service was performed
during a postoperative period for a reason(s) unrelated to the original
ge
procedure. This circumstance may be reported by adding modifier 24 to
the appropriate level of E/M service.
Modifier 24 is added to the selected E/M service code to identify the E/M service
rendered by the same provider as separate and distinct from other services in the
patient’s postoperative period.
Example:
Pa
A patient who is 45 days status post for a cholecystectomy presents to the
same physician for evaluation of pain and bleeding associated with
hemorrhoids. The physician performs a level 2 office visit and appends
e
modifier 24 to indicate that today’s visit is unrelated to the patient’s prior
cholecystectomy.
pl
s
23 Unusual Anesthesia
ge
Occasionally, a procedure, which usually requires either no anesthesia
or local anesthesia, because of unusual circumstances must be done
under general anesthesia. This circumstance may be reported by adding * KEY POINT
modifier 23 to the procedure code of the basic service.
Claims submitted to Medicare,
Pa
Modifier 23 is reported only with anesthesia service codes to identify those
circumstances in which monitored or general anesthesia is required in addition
to the usual service.
Medicaid, and other third-party
payers containing modifier 23 for
unusual anesthesia must have
attached supporting
documentation submitted with the
Example: claim. When documentation is not
A 2-year-old child is brought to the emergency room with a severe leg submitted, the claim is processed as
laceration covered in gravel and dirt that resulted from falling off of his if no modifier had been appended
e
tricycle and onto asphalt and dirt. The patient is extremely agitated, scared, to the service code. In some cases,
crying, and uncontrollable. Due to the patient’s age and the significant the insurance payer may suspend
the claim and request additional
pl
stress being placed on the child, the emergency physician advises the information; however this is the
parents that the use of a general anesthesia is necessary to adequately exception rather than the rule.
debride and suture the complex wound. The anesthesiologist is consulted
and the procedure performed. The anesthesiologist will append modifier
m
47 Anesthesia by Surgeon
Regional or general anesthesia provided by the surgeon may be
reported by adding modifier 47 to the basic service. (This does not
include local anesthesia.) Note: Modifier 47 would not be used as a
modifier for the anesthesia procedures.
Modifier 47 should be reported with a code from the surgery section of the CPT®
book when the surgeon performing the specific procedure is also administering
a regional or general anesthesia.
Example:
An adolescent patient presents to the physician’s operating room with a
fracture to the wrist. The surgeon evaluates the patient and performs a
separate anesthesia H&P to determine any potential contraindications to
anesthesia. After informed consent, the patient is prepped and draped in
the usual sterile manner. The surgeon administers a Bier block and has the
PA monitor the patient. The PA documents that the patient’s vital signs are
© 2020 Optum360, LLC
CPT © 2019 American Medical Association. All Rights Reserved. 29
Chapter 3: Mandated and
Preventive Services-Related
Modifiers 32 and 33
Modifiers 32 and 33 are used in very specific circumstances dictated by law. For
example, modifier 32 indicates that the service being provided has been
mandated—that is, formally ordered by a court or other superior official or payer.
In the case of modifier 33 (Preventive service), it may be necessary to identify for
s
insurance companies those preventive services that require all health insurance
plans to cover preventive services and immunizations without any associated
ge
cost sharing for that particular service as the result of health care reform
regulations. Each modifier is listed below with its official definition and an
example of appropriate use.
32 Mandated Service
Pa
Services related to mandated consultation and/or related service (e.g.,
third party payer, governmental, legislative or regulatory requirement)
may be identified by adding modifier 32 to the basic procedure.
Modifier 32 is appended to the appropriate code to designate those services that
have been formally ordered by an appropriate agency or organization for a
specified purpose.
e
Example:
pl
33 Preventive Service
Sa
Example:
A 67-year-old male patient presents to the office for his annual physical
examination and during the course of the encounter, the provider
recommends a one-time screening for an abdominal aortic aneurysm (AAA)
s
services modifiers 50, 51, 52, 53, 59, XE, XP, XS, and XU
• Global component modifiers 54, 55, and 56
ge
• Postoperative procedures or services modifiers 58, 78, and 79
• Repeat procedures or services modifiers 76 and 77
Note: In the interest of maintaining all modifiers within their specific chapter and
Pa
category, modifiers approved for hospital outpatient use (50, 52, 58, 59, 76, 77,
78, and 79) will also contain coding guidance and tips specific to the ambulatory
surgery center (ASC) and hospital outpatient settings rather than repeating the
modifier in the ASC and outpatient chapter. However, for information on ASC and
QUICK TIP
hospital outpatient only modifiers 27, 73, and 74, see chapter 12 on Hospital ASC and Outpatient
ASC/outpatient modifiers. Coders
e
Modifier 22 is not applicable in ASCs
or hospital outpatient facilities in
accordance with CPT modifiers
INCREASED PROCEDURAL SERVICES MODIFIER 22
pl
62 Two Surgeons
QUICK TIP
When 2 surgeons work together as primary surgeons performing Hospital ASC and Outpatient
Coders
s
distinct part(s) of a procedure, each surgeon should report his/her
distinct operative work by adding modifier 62 to the procedure code Modifiers 62 and 66 are not
and any associated add-on code(s) for that procedure as long as both applicable in hospital ASC or
ge
hospital outpatient facilities in
surgeons continue to work together as primary surgeons. Each surgeon accordance with CPT modifiers
should report the cosurgery once using the same procedure code. If approved for ambulatory surgery
additional procedure(s), (including add-on procedure(s) are performed center (ASC) outpatient hospital
during the same surgical session, separate code(s) may also be reported
Pa
with modifier 62 added. Note: If a co-surgeon acts as an assistant in the
performance of additional procedure(s) other than those reported with
the modifier 62, during the same surgical session, those services may be
reported using separate procedure code(s) with modifier 80 or modifier
82 added, as appropriate.
Modifier 62 is appended to the appropriate service code when two surgeons
e
both function as primary surgeons performing independent components of the
same procedure.
pl
Example:
A patient undergoes an anterior lumbar spinal fusion of L5 through S1
involving cages and bone grafts. A general surgeon and a spine surgeon
m
s
reported with the usual procedure code. Each modifier is listed below with its and represent only the professional
component portion of a procedure
official definition and an example of appropriate use. or service and are stand-alone
ge
procedure or service codes,
26 Professional Component identifying the physician’s or
Certain procedures are a combination of a physician or other qualified provider’s professional efforts. In
most cases, other procedure or
health care professional component and a technical component. When service codes identify the technical
the physician or other qualified health care professional component is component only, and codes that
TC Technical Component
Under certain circumstances, a charge may be made for the technical component
Sa
Example:
A unilateral pulmonary angiogram radiological supervision and
interpretation is performed in an outpatient hospital setting. Report code
75741 with modifier TC to identify the facility’s services.
s
Similar to the CPT coding system, HCPCS Level II codes also contain modifiers
that further define services and items without changing the basic meaning of the
ge
CPT or HCPCS Level II code with which they are reported. However, the HCPCS
Level II modifiers differ somewhat from their CPT counterparts in that they are
composed of either alpha characters or alphanumeric characters. HCPCS Level II
modifiers range from A1 to XU and include such diverse modifiers as E1 Upper
left, eyelid, GJ “Opt out” physician or practitioner emergency or urgent service,
Pa
and Q6 Service furnished under a fee-for-time compensation arrangement by a
substitute physician or by a substitute physical therapist furnishing outpatient
physical therapy services in a health professional shortage area, a medically
underserved area, or a rural area.
splint, bilateral (this scenario can also be reported with modifiers RT and LT,
depending on the third-party payer’s protocol). In some cases, a report may be
required to accompany the claim to support the need for a particular modifier’s
m
use, especially when the presence of a modifier causes suspension of the claim
for manual review and pricing.
Sa
AMBULANCE MODIFIERS
For ambulance services modifiers, single alpha characters with distinct
definitions are paired to form a two-character modifier. The first character
indicates the origination of the patient (e.g., patient’s home, physician office,
etc.), and the second character indicates the destination of the patient (e.g.,
hospital, skilled nursing facility, etc.). When ambulance services are reported, the
name of the hospital or facility should be included on the claim. If reporting the
scene of an accident or acute event (character S) as the origin of the patient, a
written description of the actual location of the scene or event must be included
with the claim(s).
D Diagnostic or therapeutic site other than “P” or “H” when these are used as
origin codes
s
hosptial-based ambulatory surgery, and provider-based clinics have been
reimbursed under ambulatory payment classifications (APCs). The formulation of
*
ge
the APC grouping system took root in the ambulatory patient groups (APGs) KEY POINT
system, devised by the Health Information Systems division of 3M Health Care Not all third-party payers use the
under a grant from the Centers for Medicare and Medicaid Services (CMS). The APC system of reimbursement for
APC reimbursement system for surgical procedures and other services, however, provider-based ASC and hospital
is not the same as the APG system (still in use by some payers). outpatient facility services. There
Pa
The incorporation of APCs into each facility’s internal coding and billing systems
as well as clinical operations represents an enormous challenge. It is generally
are several major third-party payers
currently using—and seemingly
satisfied with—the APG system of
reimbursement for facility services.
agreed that this system of reimbursement requires greater attention to
operational economies and the creation of increased internal efficiencies when
compared with the past implementation of the diagnosis-related group (DRG)
e
system of reimbursement for the hospital inpatient arena.
CPT® and certain HCPCS Level II codes map to a particular APC classification that
pl
services. Now, with reimbursement for some of these health care centers based
on the APC system of reimbursement, accurately coding and reporting services
have never been more critical. A few simple facts about APCs include the
Sa
following:
Modifier 50
Yes No
s
Is the CPT code described
as "bilateral" in the code Modifier 50 is
ge
descriptions? Yes not appropriate if
("0" or "2" on the MPFSDB not performed on
for Medicare patients.) "mirror image."
No
Pa
Do not append modifier 50.
Submit the claim without
modifier 50.
e
Is the CPT code assignment
pl
Yes
If Medicaid or a commercial
Submit to Medicare as a payer, may require two-line
one-line item, CPT code items: xxxxx
xxxxx-50. Monitor reimbursements.
xxxxx-50.
or xxxxx-RT
xxxxx-LT