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0% found this document useful (0 votes)
212 views12 pages

MDFR21

Hi

Uploaded by

chaitanya varma
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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2

0
2 OPTUM360 LEARNING
1

Understanding Modifiers
Understanding

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Modifiers

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Comprehensive instruction to effective

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modifier application

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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

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Determining Correct Use ........................................................6 Using the Modifier Correctly .............................................118

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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
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Services-Related Modifiers 32 and 33 ......................39 Prospective Payment System ............................................160
CPT and HCPCS Modifier Reporting Requirements ....164
Chapter 4: Procedures/Services Modifiers ...............51
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ASC and Outpatient Modifiers: 73 and 74 ......................168


Increased Procedural Services Modifier 22 ...................... 51
Bilateral, Multiple, Reduced, Discontinued, and Chapter 13: Modifiers and Compliance .................. 171
Distinct Procedures or Services Modifiers 50, 51, 52, Introduction ...........................................................................171
m

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
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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

© 2020 Optum360, LLC


CPT © 2019 American Medical Association. All Rights Reserved. 1
Introduction
For many years, physicians and hospitals have learned that coding and billing are
inextricably entwined processes. Coding provides the common language
through which the physician and hospital can communicate—or bill—their
services to third-party payers, including managed care organizations, the federal
Medicare program, and state Medicaid programs.

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

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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.

WHAT ARE HCPCS MODIFIERS?


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A modifier comprises two alpha, numeric, or alphanumeric characters reported
with a HCPCS code, when appropriate.

Modifiers are designed to give Medicare and commercial payers additional


information needed to process a claim. This includes HCPCS Level I (Physicians’
Current Procedural Terminology [CPT®]) and HCPCS Level II codes.
e
The reporting physician appends a modifier to indicate special circumstances
that affect the service provided without affecting the service or procedure
pl

description itself. When applicable, the appropriate two-character modifier code


should be used to identify the modifying circumstance. The modifier should be
placed after the usual procedure code number.
m

The CPT code book, CPT 2020, lists the following examples of when a modifier
may be appropriate, including, but not limited to:
Sa

• Service/procedure is a global service comprising both a professional and


technical component and only a single component is being reported
• Service/procedure involves more than a single provider and/or multiple
locations
• Service /procedure was either more involved or did not require the degree
of work specified in the code descriptor
• Service/procedure entailed completion of only a segment of the total
service/procedure
• An extra or additional service was provided
• Service/procedure was performed on a mirror image body part (eyes,
extremities, kidneys, lungs) and not unilaterally
• Service/procedure was repeated

© 2020 Optum360, LLC


CPT © 2019 American Medical Association. All Rights Reserved. 1
Chapter 1: E/M-Related
Modifiers 24, 25, 57, and AI
Modifiers 24, 25, 57, and AI may be appended to evaluation and management
services only. Each modifier is listed below with its official definition and an
example of appropriate use.

24 Unrelated Evaluation and Management Service by the Same


Physician Or Other Qualified Health Care Professional During a
Postoperative Period

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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

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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

25 Significant, Separately Identifiable Evaluation and Management


Service by the Same Physician Or Other Qualified Health Care
Professional on the Same Day of the Procedure or Other Service
m

It may be necessary to indicate that on the day a procedure or service


identified by a CPT® code was performed, the patient's condition
required a significant, separately identifiable E/M service above and
Sa

beyond the other service provided or beyond the usual preoperative


and postoperative care associated with the procedure that was
performed. A significant, separately identifiable E/M service is defined
or substantiated by documentation that satisfies the relevant criteria for
the respective E/M service to be reported (see Evaluation and
Management Services Guidelines for instructions on determining level
of E/M service). The E/M service may be prompted by the symptom or
condition for which the procedure and/or service was provided. As such,
different diagnoses are not required for reporting of the E/M services on
the same date. This circumstance may be reported by adding modifier
25 to the appropriate level of E/M service.
Note: This modifier is not used to report an E/M service that resulted in
a decision to perform major surgery, see modifier 57. For significant,
separately identifiable non-E/M services, see modifier 59.
Modifier 25 is used to identify an E/M service rendered on the same day as a
procedure or service by the same physician or other qualified health care

© 2020 Optum360, LLC


CPT © 2019 American Medical Association. All Rights Reserved. 13
Chapter 2:
Anesthesia-Related Modifiers
Modifiers 23 and 47, modifiers describing physical status (P1, P2, P3, P4, P5, and
P6), and HCPCS Level II modifiers AA, AD, G8, G9, QK, QS, QX, QY, and QZ may be
appended only to identify anesthesia services. Each modifier is listed below with
its official definition and an example of appropriate use.

ANESTHESIA SERVICES MODIFIERS 23 AND 47

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23 Unusual Anesthesia

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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
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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

23 to the appropriate anesthesia code to indicate the unusual


circumstances necessitating the use of general anesthesia. The surgeon will
report the correct debridement and/or repair codes.
Sa

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

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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

The unmarried parents of a 3-month-old female infant are ordered by the


court to undergo DNA testing to determine paternity and establish
court-ordered visitation and child support as appropriate. The laboratory
performing the testing would report the service and append modifier 32 to
m

indicate that the testing is being conducted at the court’s request.

33 Preventive Service
Sa

When the primary purpose of the service is the delivery of an


evidence-based service in accordance with a US Preventive Services
Task Force (USPSTF) A or B rating in effect and other preventive services
identified in preventive services mandates (legislative or regulatory), the
service may be identified by appending modifier 33, Preventive Service,
to the service. For separately reportable services specifically identified
as preventive, the modifier should not be used.
This modifier should be reported with codes that represent preventive services
with the exception of those codes that are inherently preventive such as a
screening mammography or an immunization recognized by the Advisory
Committee on Immunization Practices (ACIP).

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)

© 2020 Optum360, LLC


CPT © 2019 American Medical Association. All Rights Reserved. 39
Chapter 4:
Procedures/Services Modifiers
The modifiers discussed within this chapter may be appended to codes from the
surgery, radiology, pathology/laboratory, and medicine sections of the CPT®
manual. For ease of use and understanding, the chapter is subdivided into five
categories according to specific groupings of modifiers as shown below:

• Increased procedural services modifier 22


• Bilateral, multiple, reduced, discontinued, and distinct procedures or

s
services modifiers 50, 51, 52, 53, 59, XE, XP, XS, and XU
• Global component modifiers 54, 55, and 56

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• 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

approved for ASC outpatient


Modifier 22 indicates that the procedure or service performed required hospital use.
significantly greater effort and work than what would usually be involved. As
stated earlier, it may be reported with any code from the surgery, radiology,
m

pathology/laboratory, and medicine sections of the CPT book. However, it is not


appropriate to report modifier 22 with an evaluation and management service
code.
Sa

22 Increased Procedural Services


When the work required to provide a service is substantially greater
* KEY POINT
than typically required, it may be identified by adding modifier 22 to the Claims submitted to Medicare,
usual procedure code. Documentation must support the substantial Medicaid, and other third-party
additional work and the reason for the additional work (i.e., increased payers containing modifier 22
Increased procedural services, that
intensity, time, technical difficulty of procedure, severity of patient's do not have supporting
condition, physical and mental effort required). Note: This modifier documentation attached to the
should not be appended to an E/M service. claim demonstrating the increased
effort involved will generally be
Modifier 22 is appended to the procedure or service code that warranted the processed as if the procedure
increased effort and should typically be submitted with a narrative detailing the code(s) did not contain the
specific increased work and complexity that necessitated the use of this modifier. modifier. Some third-party payers
may suspend the claims pending a
Example: request for additional information;
however, this is typically the
A patient is scheduled for repair of a small bowel obstruction. The patient is exception and not the rule.
prepped and draped and taken to the operating room. The physician begins

© 2020 Optum360, LLC


CPT © 2019 American Medical Association. All Rights Reserved. 51
Chapter 5: Multiple Surgeon
Modifiers: 62 and 66
Modifiers 62 and 66 represent multiple surgeons and may be appended to
procedure codes to indicate that the service required the need for more than one
surgeon functioning in different capacities. Each modifier is listed below with its
official definition and an example of appropriate use.

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

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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

work together as cosurgeons; the general surgeon performs the surgical


approach, and the orthopaedic surgeon performs the fusion. Each surgeon
would report the same CPT® codes and append modifier 62 to each of the
service codes assigned to indicate that each physician performed a distinct
Sa

component of the same operative procedure.

© 2020 Optum360, LLC


CPT © 2019 American Medical Association. All Rights Reserved. 89
Chapter 7:
Professional/Technical
Component Modifiers 26 and TC
Modifiers 26 and TC represent distinct components of a global procedure or
service. When the physician component is reported separately, the service may
be identified by appending modifier 26 to the usual procedure code. Similarly,
* KEY POINT
when the technical component is reported separately, modifier TC should be Certain procedure codes describe

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

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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

to the usual procedure number.


Pa
reported separately, the service may be identified by adding modifier 26

Modifier 26 should be used when the physician or nonphysician provider is


represent both the professional and
technical components as complete
procedures or services are called
global service codes. It is not
rendering only the professional component of a global procedure or service necessary to report modifier 26 with
code. This modifier is never reported on evaluation and management service codes that aptly describe and
codes. represent only the professional
e
component of a procedure or
service.
Example:
pl

A computed tomography (CT) including pre films, administration of


contrast, and post films of both the abdomen and pelvis was performed in
the outpatient hospital department. Report code 74178 with modifier 26 to
denote physician services only.
m

TC Technical Component
Under certain circumstances, a charge may be made for the technical component
Sa

alone. In those cases, the technical component charge is identified by adding


modifier TC to the usual procedure number. Technical component charges are
institutional charges and are not billed separately by physicians. However,
portable x-ray suppliers bill only for the technical component and should use
modifier TC. The charge data from portable x-ray suppliers is then used to build
customary and prevailing profiles.

Modifier TC should be used to report only the technical component of a global


procedure or service code. Remember, typically the technical component is
provided by the facility or mobile x-ray unit. This modifier is never reported on
evaluation and management service codes.

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.

© 2020 Optum360, LLC


CPT © 2019 American Medical Association. All Rights Reserved. 101
Chapter 11: HCPCS Level II
Modifiers A–Z
INTRODUCTION
The HCPCS Level II codes are alphanumeric codes developed by the Centers for
Medicare and Medicaid Services as a complementary coding system to the AMA’s
CPT® codes. HCPCS Level II codes describe procedures, services, and supplies not
found in the CPT book.

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

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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.

It is important to note that HCPCS Level II modifiers may be used in conjunction


e
with CPT codes, such as 69436-LT Tympanostomy (requiring insertion of
ventilating tube), general anesthesia, left ear. Likewise, CPT modifiers can be
used when reporting HCPCS Level II codes, such as L4396-50. Ankle contracture
pl

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

E Residential, domiciliary, custodial facility (other than 1819 facility)

© 2020 Optum360, LLC


CPT © 2019 American Medical Association. All Rights Reserved. 119
Chapter 12: ASC and Hospital
Outpatient Modifiers: 25, 27, 73,
and 74
AMBULATORY PAYMENT CLASSIFICATIONS
Since the implementation of Medicare’s outpatient prospective payment system
(OPPS), effective August 1, 2000, hospital outpatient services including

s
hosptial-based ambulatory surgery, and provider-based clinics have been
reimbursed under ambulatory payment classifications (APCs). The formulation of
*

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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

holds a predefined reimbursement amount. The financial welfare of any facility


outpatient (OP) department, OP clinic, hospital ASC, freestanding ASC, or private
physician practice has always depended on the accurate coding and reporting of
m

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:

• APCs are groups of services with homogeneous or nearly identical clinical


characteristics as well as costs.
• At this time, APCs affect only hospital OP department/clinic and
hospital-based ambulatory surgery payment for Medicare patients.
(Freestanding ASCS are paid under a different payment system.)
• Physician payments are not affected.
• The APC payment system is correlated to CPT and certain HCPCS Level II
codes.
• Many CPT and HCPCS Level II codes map to an APC payment group.
• The encounter date for each patient may include one or more APC services.

The use of modifiers has proven a crucial component to Medicare’s appropriate


and optimal reimbursement of services under APCs. Modifiers are addressed in

© 2020 Optum360, LLC


CPT © 2019 American Medical Association. All Rights Reserved. 159
Chapter 13: Modifiers and Compliance

Modifier 50

Does medical record documentation support the same


procedure code performed on the right and left sides\same site?

Yes No

s
Is the CPT code described
as "bilateral" in the code Modifier 50 is

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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

approved for a bilateral billing? Reference modifier 51


("1" indicator on MPFSDB for multiple procedures.
for Medicare patients.)
m
Sa

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

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CPT © 2019 American Medical Association. All Rights Reserved. 193

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