Chpt 2 Flashcards
Modifiers
Give additional information
Append to a CPT code to indicate that a service or procedure has been altered for some reason but it does not change the main definition of the code
CPT modifiers
Two-digit numeric codes
Appendix A
HCPCS Modifiers
Two-digit alphanumeric modifiers
Physician services
Place modifiers in 24d of CMS-1500 form following the CPT code
Reporting modifiers
Review modifier instructions for the payer you are billing
Ranking of Modifiers
Pricing modifiers before statistical and informational modifiers
Pricing modifiers
AA, AD, AH, AJ, AS, GM, QB, QK, QU, QX, QY, QZ, SG, TC, UN, UP, UQ, UR, US
22, 26, 50, 51, 52, 53, 54, 55, 56, 62, 66, 73, 74, 78, 80, 82, 99
Statistical and informational modifiers
Use in any order except QT, QW, and SF. These can only be used in the first modifier field
Modifier 99
Indicates that multiple modifiers are needed for an individual CPT code
Not recognized by all insurance plans
Modifiers used for Ambulatory Surgery Center Hospital Outpatient Use
Reported on UB-04/CMS-1450 form
Level I modifiers
22, 27, 33, 50, 52, 58, 59, 73, 74, 76, 77, 78, 79, 91
Level II modifiers
LT, RT, E1, E2, E3, E4, FA, F1-F9, TA, T1-T9, LV, LD, LM, RC, RI, GG, GH, QM, QN, XE, XS, XP, XU
Modifier 22
Increased procedural services
Service is greater than usually required for the procedure
Should not be appended to an E/M code
Only truly unusual cases which must have documentation
Modifier 23
Unusual anesthesia
A procédure routinely done with no or local anesthesia requires use of general anesthesia
Modifier 24
Unrelated E/M service by the same physician during postoperative period
Appended to the E/M code
Modifier 25
Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service
Modifier 26
Professional component
Should not be appended to codes that do not have a technical component as part of the code definition
Modifier 27
Multiple outpatient hospital E/M encounters on the same date
Not to be used for physician reporting of multiple E/M services performed by the same physician on the same day
Modifier 32
Mandated services
Required by an insurance company or governmental, legislative or regulatory agency
Modifier 33
Preventive service
For separately reported services specifically identified as preventive, the modifier should not be used
Modifier 47
Anesthesia by surgeon
Not used when local anesthesia is used
Never appended to the anesthesia code, but to a procedure or service code.
Modifier 50
Bilateral procedure
Same operative session
Used only with codes that describe a unilateral procedure
Some people prefer rt and lt modifiers instead of 50
Modifier 51
Multiple procedures
Same provider/same operative/procedural session
Used only by providers and is not used by facilities
Modifier 52
Reduced services
Partially reduced or eliminated at the physician’s discretion
May require documentation
For outpatient hospital reporting use 73 and 74 not 52
Modifier 53
Discontinued procedure
Procedure started but discontinued
Not to report elective cancellation
Indicates that additional services might be provided in the future
For outpatient hospital center use 73 and 74, not 53
Modifier 54
Surgical care only
Don’t provide pre-or postoperative care
Modifier 55
Postoperative management only
Modifier 56
Preoperative management only
Modifier 57
Decision for surgery
Appended to E/M code when , during the service, the initial decision was made to perform surgery
Modifier 58
Staged or related procedure or service by the same physician during the postoperative period
During original, second is scheduled (staged procedure)
During postoperative period, more extensive care is needed
During the postoperative period, therapy is required following the surgical procedure
Do not use when 78 is appropriate
Modifier 59
Distinct procedural service
Procedure independent from other non-E/M services performed on the same day.
Procedures that are not typically treated together
Use only if another appropriate modifier is not available
Subsets of Modifier 59
-X[EPSU] modifiers
XE separate encounter
XS separate structure
XP separate practitioner
XU unusual non-overlapping service
Do not include modifier 59 if you use one of these
Modifier 62
Two surgeons
Primary surgeons work together to perform a distinct part of a single reportable procedure
Each surgeon reports his own work with modifier 62
Use 80 or 82 if one surgeon assists
Modifier 63
Procedure performed on infants less than 4 kgs
Only used on codes 20100-69990 unless otherwise designated in the manual
Modifier 66
Surgical team
Requires several physicians and complex equipment
Each provider appends 66
Need documentation
Modifier 73
Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure prior to the administration of anesthesia
Well-being of patient is threatened
Not used for elective cancellation
Modifier 74
Discontinued outpatient hospital/Ambulatory surgery center procedure after administration of anesthesia
Modifier 76
Repeat procedure or service by same physician
The original procedure or service code is the same for both sessions
Not appended to an E/M code
Modifier 77
Repeat procedure or service by another physician
Basic service had to be repeated
Same code as original
Not appended to an E/M code
Modifier 78
Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period
Append 78 to the code of the subsequent procedure
Documentation may be requested
Modifier 79
Unrelated procedure or service by the same physician during the postoperative period
Unrelated to the original procedure
Modifier 80
Assistant surgeon
Assistant physician uses the same code but appends 80
Medicare part b does not cover the services of an assistant surgeon for certain procedures
Exemptions on CMS website
Payment cannot be collected from the patient if the provider is a participating Medicare provider
Modifier 81
Minimum assistant surgeon
Assistant required only for a short time or if a 2nd or 3rd assistant surgeon was needed during the procedure
Modifier 82
Assistant surgeon when qualified resident surgeon is not available in a teaching facility
Must have certification on file
Modifier 90
Reference (outside) laboratory
Modifier 91
Repeat clinical diagnostic laboratory test
Same lab test repeated on the same day to get multiple test results
Not for problems with initial collection, confirmation of initial test results, or the availability of an all inclusive code
1st test with normal code, 2nd test with normal code-91
Also not used when a series of tests are run on the same day
Modifier 92
Alternative laboratory platform testing
Ie. Kit or transportable instrument
Modifier 93
Synchronous telemedicine service rendered via telephone other real-time interactive audio-only telecommunications system
Must meet the key components as if the service was performed face-to-face
Modifier 95
Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system
Must be a service listed in appendix P to be used
Modifier GT listed for HCPCS services for Medicare but not all payers take this
Star icon must appear next to code
All components are completed via telemedicine and documented by provider
Modifier 96
Habilitative services
PT / OT
Services not yet learned
Modifier 97
Rehabilitative services
Occur after a patient was sick, hurt, or disabled
Modifier 99
Multiple modifiers
Use when more than 2 modifiers are necessary
99 first followed by the next three modifiers with the rest in the narrative box number 19 on CMS-1500
HCPCS Level II modifiers
Also provides codes for ambulances and DME
Codes may or may not be reimbursed
Contact the insurance carrier to see if the code is covered
The service being provided needs to be explained further
See websites of various carriers and CMS for clarification on usage of these modifiers
Comprehensive list in Appendix 2 of HCPCS book
HCPCS Modifiers
Multiples of supplies
Various body parts when multiple procedures are reported
G1-G5: dialysis for unlisted code
Additional G modifiers for Medicare
J-V: outlines types of modifiers
Ambulance origin and destination modifiers
Left comes before right, A often before numbers
