Denials Ch 10 - Modifiers

Question 1

Modifiers

Answer 1

Modifiers are appended to CPT® and HCPCS Level II codes to report specific circumstances or alterations to a procedure, service, or medical equipment without changing the definition of the code. Both CPT® and HCPCS Level II code books list modifiers and their descriptions.

CPT® modifiers are two-digit codes. Appendix A lists CPT® modifiers, and includes a wide range of modifiers, including those used for anesthesia and modifiers reported by ASCs and hospital outpatient facilities. HCPCS Level II modifiers are in Appendix B of the HCPCS Level II code book.

When reporting codes with more than one modifier, always list functional, or pricing modifiers in the first position. Payers consider functional modifiers when determining reimbursement. Next, report the informational modifiers; these modifiers clarify certain aspects of the procedure or service provided for the payer (procedures performed on the left or right side of the patient’s body).

Modifiers affecting payment include those that identify the following:

Procedures with both professional and technical components, but only one component is included on the claim
When more than one provider performed all or part of the procedures
Procedures that were increased or decreased from the usual procedure definition, but no other procedure code correctly identifies the modified procedure
When multiple different procedures were performed during the same session
When a single procedure was performed more than once during the same session
When a single procedure was performed bilaterally

Question 2

Modifier 22

Answer 2

Increased Procedural Services: When the service provided is greater than that usually required for the listed procedure, it may be identified by adding modifier 22 to the usual procedure code number. Documentation must support the substantial additional work and the reason for the additional work. Modifier 22 is not appended to E/M codes.

(Append modifier 22 to a procedure code when the provider describes “above and beyond” circumstances within his operative report, and there is no other procedure code to describe the extensive services.)

Appropriate Uses:

Excessive blood loss during the procedure
Excessively large surgical specimen
Trauma extensive enough to complicate the procedure and not billed as additional procedure codes
Other pathologies, tumors, malformations (genetic, traumatic, surgical) that interfere directly with the procedure but are not billed separately
Inappropriate Uses:

Increased time to perform a procedure due to provider variation in practice or minor anatomical variation
Another code exists that describes the increased work
Keywords: extended time, took longer than normal, extenuating circumstances, etc.

Question 3

Modifier 24

Answer 3

Unrelated E/M by the Same Physician or Other Qualified Healthcare Professional During a Postoperative Period: The physician or other qualified healthcare professional may need to indicate an E/M service was performed during a postoperative period for reasons unrelated to the original procedure. This circumstance may be reported by adding modifier 24 to the appropriate level of E/M service.

Appropriate Uses:

Added to CPT® codes 99202-99499 and 92012-92014 to indicate the evaluation is unrelated to the surgical procedure.
Some insurance carriers allow the use of modifier 24 when the E/M is due to a complication of the surgical procedure. This is carrier specific.
Inappropriate Uses:

Adding modifier 24 for hospital visits during the initial postoperative period, unless the physician is providing one of the following services:
Immunosuppressive therapy
Chemotherapy
Critical care services unrelated to the original surgery
Office visit during the global period when the major purpose of the visit is to follow up on the original surgery.
Keywords: unrelated, outside of, not related to, etc.

Question 4

Modifier 25

Answer 4

Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Healthcare Professional on the Same Day of the Procedure or Other Service: 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 beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure performed. It is not required that the E/M service have a different diagnosis than the other procedure.

Appropriate Uses:

With E/M codes describing initial hospital inpatient or observation care visits (99221-99223), inpatient or observation consults (99252-99255), or hospital inpatient or observation discharges (99238 or 99239) on the same day as a separate inpatient hospital service, such as dialysis, that would not typically require such E/M services.
When a significant, separately identifiable E/M service is performed on the same day as a preventive care visit. The E/M service must be performed for a non-preventive reason and must be clearly documented.
Inappropriate Uses

Used to indicate the E/M service resulted in the decision to perform a major surgery (see Modifier 57).
On a surgical procedure code (10004-69990). It is added to the E/M code when both are performed together.
On an office visit E/M code when the primary purpose of the visit is to perform a minor surgical procedure. In this instance, only the minor surgical procedure should be billed.
Keywords: unrelated, outside of, not related to, etc.

Question 5

Modifier 26

Answer 5

Professional Component: Certain procedures are a combination of a professional component and a technical component. When the professional component is reported separately, identify it as such by adding modifier 26 to the usual procedure code.

Appropriate Uses:

An imaging study is performed in a hospital and interpreted by a physician. The physician appends modifier 26 to the code and the hospital submits a claim for the technical component of the test using modifier TC.
The physician should only submit a claim for professional services in those instances where he or she interprets the test and prepares a written report of that interpretation for use by others.
Inappropriate Uses:

Using both modifier 26 and modifier TC to report the professional and technical components by a single provider. If the same provider performs both the professional and technical components, it is considered global and no modifier is appended.
Using the modifier when re-reading a study originally interpreted by another provider. Many insurance carriers, including Medicare, will only pay for a single interpretation of a study, regardless of how many professionals review the study for their own decision-making purposes.
Keywords: independent radiologist, performed in a hospital, etc.

Question 6

Modifier 50

Answer 6

Bilateral Procedure: Bilateral procedures performed at the same operative session code. For most insurance carriers, bilateral services are reported with a single use of the appropriate code with modifier 50 appended. Some insurance carriers require the code be reported twice with modifier 50 added to one of the codes.

Not all procedures can be reported with modifier 50. Some code definitions include the statement “unilateral or bilateral” or similar language, indicating that the code is used only once even if the procedure is performed on both sides.

Instructions for use of modifier 50 are often found in the CPT® guidelines and parenthetic instructions.

Appropriate Uses:

When the exact same service is performed bilaterally.
Medicare indicates which CPT® codes can be reported with modifier 50 on the Medicare Physician Fee Schedule (MPFS). Other insurance carriers also determine when they will accept the modifier 50.
Medicare recognizes the modifier 50 appended to radiology codes when the same study is performed on each side. Not all insurance carriers allow this modifier combination.
Inappropriate Uses:

Bilateral procedures performed on different areas of the right and left sides of the body.
Appending the modifier 50 to a code identified as a bilateral procedure in the description of the code (for example, 40843 Vestibuloplasty; posterior, bilateral).
Appending the modifier 50 to a code identified as a unilateral or bilateral procedure in the description of the code (for example, 31231 Nasal endoscopy, diagnostic, unilateral or bilateral).
Keywords: bilateral, both sides, left and right, etc

Question 7

Modifier 51

Answer 7

Multiple Procedures: When multiple procedures, other than E/M services, Physical Medicine and Rehabilitation services, or provision of supplies are performed at the same session by the same provider.

Appropriate Uses:

Append modifier 51 to additional procedures (that are not modifier 51 exempt) performed during the same operative session.
Multiple instances of the same service if each service is listed on a separate line and does not require modifier 59.
Inappropriate Uses:

Separating or unbundling a procedure into its components and appending modifier 51 to one or more components.
Appending modifier 51 to add-on codes or to codes listed as modifier 51 exempt.
Appending to an E/M code.
Keywords: a different procedure, separate from, etc.

Question 8

Modifier 52

Answer 8

Reduced Services: Under certain circumstances a service or procedure is partially reduced or eliminated at the physician’s or other qualified healthcare professional’s discretion. Under these circumstances, the service provided can be identified by its usual procedure code and the addition of modifier 52.

Appropriate Uses:

Indicate the provider reduced or eliminated some services usually associated with the code to which the modifier is appended.
Inappropriate Uses:

Indicate terminated procedures (refer to modifier 53).
Appended to E/M services.
Appended to time-based services, such as psychotherapy, anesthesia, or critical care services.
Keywords: partially, to be reduced, part of procedure not completed, etc.

Question 9

Modifier 53

Answer 9

Discontinued Procedure: Under certain circumstances, the physician or other qualified healthcare professional may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances, or those that threaten the well-being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued.

Appropriate Uses:

When a provider begins a procedure, but decides to discontinue due to:
Uncontrollable bleeding, hypotension, or physiologic changes
Unexpected findings during surgery making continuing surgery unnecessary or ill-advised
Anesthesia complication
Modifier 53 may be used to report terminated procedures in the office.
Inappropriate Uses:

Elective cancellation of a procedure prior to anesthesia induction and/or surgical preparation in the surgical suite.
Keywords: procedure stopped before completion, aborted the procedure, etc.

Question 10

Modifiers 54, 55, and 56

Answer 10

Modifiers 54, 55, and 56 are appended to procedures to indicate different providers provided the preoperative (modifier 56), intraoperative (modifier 54) and postoperative services (modifier 55). These modifiers are only appended to codes that have a global period. For procedures without a global period (global period of zero days), pre- and postoperative services are reported separately without using modifiers.

Insurance carriers usually establish the percentage of the global fee attributable to each partial service. For Medicare, the surgeon performing the procedure must see the patient at least once before transferring care to the provider assuming postoperative management.

Appropriate Uses:

Modifier 54 is appended to indicate the provider performed only the surgical procedure.
If a single provider provides surgical and postoperative care, but not the preoperative care, modifiers 54 and 55 are appended.

Inappropriate Uses:

Appending modifier 54 to surgical codes without a global period.
Appending modifier 55 to inpatient postoperative visits by a provider of a different specialty; those visits should be identified by hospital visit E/M codes (99231-99233).
Appending modifier 54, 55, or 56 to an E/M code.
Modifier 54 Keywords: only performed the surgical procedure, no pre or post-op management, etc.

Modifier 55 Keywords: post-op follow-up only, postoperative care turned over to, transfer of care, etc.

Modifier 56 Keywords: pre-op evaluation only, covering for surgeon, etc.

Question 11

Modifier 57

Answer 11

Decision for Surgery: When an E/M service provided the day before or the day of a surgery results in the decision to perform surgery, append modifier 57 to the appropriate level of E/M service. Most insurance carriers, including Medicare, only recognize this modifier when appended to an E/M service performed on the day of or day before a major surgical procedure, which is identified as having a 90-day global period. Some insurance carriers recognize the use of this modifier for minor procedures.

Appropriate Uses:

For a Medicare claim, append modifier 57 to the E/M service during which the decision was made, if that E/M visit occurred the day before or the day of a surgical procedure with a 90-day global period.
When the decision for a subsequent surgery occurs during the global period of a previous surgery, append both modifier 24 and modifier 57 to the E/M code.
Inappropriate Uses:

Do not use on a Medicare claim for the decision to perform a minor procedure.
Do not use on an E/M code on the day of surgery when the actual decision for surgery was made in advance.
Do not append to a surgical procedure.
Keywords: decision to perform surgery, will need to go to OR, etc.

Question 12

Modifier 58

Answer 12

Staged or Related Procedure or Service by the Same Physician or Other Qualified Healthcare Professional During the Postoperative Period: It may be necessary to indicate the performance of a procedure or service during the postoperative period was:

a) planned prospectively at the time of the original procedure (staged);

b) more extensive than the original procedure; or

c) for therapy following a diagnostic surgical procedure

Report the circumstance by adding modifier 58 to the staged or related procedure.

Appropriate Uses:

When a patient is planned to have the second procedure (eg, daily debridement of a burn).
When the procedure is more extensive than the original procedure (eg, a lumpectomy followed by a complete mastectomy on the same breast).
Inappropriate Uses:

When a patient is returned to the operating room for a complication.
Keywords: return to OR, will proceed with additional services in next procedure, etc.

Question 13

Modifier 59

Answer 13

Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify services not normally reported together but are appropriate under the reported circumstances. CMS NCCI documentation has specific examples for the correct use of modifier 59.

Appropriate Uses:

Used with code pairs listed in the National Correct Coding Initiative (NCCI) edits when supported in the documentation as a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or a separate lesion and allowed by the NCCI edit.
Modifier 59 is appended to the column 2 code if circumstances permit both services to be reported separately.
Modifier is considered the modifier of last resort and is only used when there is no other appropriate modifier.
Inappropriate Uses:

Depending on carrier policy, do not use with codes that are not listed in the NCCI edits.
Do not use with E/M codes.
For Medicare claims, do not use with a code pair that has a correct coding modifier (CCM) indicator restricting the use of a modifier or if one of the X-[ESPU] modifiers is more appropriate. The abbreviation represents the separate Encounter, Structure, Practitioner, and Unusual service.
Documentation does not support the services were separate and distinct.
If another modifier exists to describe the service.
Do not append with modifier 51 on the same procedure code.
Keywords: separate procedure, needed additional services, etc.

Question 14

Modifier 79

Answer 14

Unrelated Procedure or Service by the Same Physician or Other Qualified Healthcare Professional During the Postoperative Period: The physician or other qualified healthcare professional may need to indicate the performance of a procedure or service during the postoperative period was unrelated to the original procedure. This circumstance may be reported by using modifier 79.

Appropriate Uses:

The second procedure must be unrelated to the original procedure, must be performed by the same provider, and must be performed during the global period of the first procedure.
Inappropriate Uses:

Do not use modifier 79 when the second procedure is related to the first.
Keywords: not related to previous care, etc

Question 15

Modifier 80

Answer 15

Assistant Surgeon: Surgical surgeon assistant services may be identified by adding modifier 80 to the usual procedure code(s).

Appropriate Uses:

The provider assisted the surgeon during the procedure.
An assistant surgeon is appropriate for the procedure. The MPFS Relative Value Files containing this information can be found on the CMS website.
Inappropriate Uses:

Use by a provider not qualified to assist in surgery.
Use with a procedure that is not eligible for an assistant surgeon.
Keywords: assisted, surgeon called in to help, etc.

Question 16

Question: Our surgeon is planning to perform a levator resection on a patient’s right eye for ptosis. The ophthalmologist wants to do this as a bilateral procedure, but the patient’s left eye is a non-seeing eye. Since the operation on the right side may be medically necessary, but the left side would likely be considered cosmetic, how should I code this surgery?

Answer 16

Answer: Report each side of the bilateral procedure on a separate line, appending modifiers LT and RT, linking each side to the appropriate diagnosis code explaining the necessity for the surgery. If you have more specific details (e.g., upper right eyelid, upper left eyelid), you can instead use the eyelid modifiers (E1-E4).

In this case, one side will be medically necessary, while the other will be cosmetic — the procedure will not benefit the vision on the non-seeing eye.

Do this: Have the patient sign an advance beneficiary notice of non-coverage (ABN) prior to the surgery, stating that they are aware that Medicare will not cover the procedure performed on the left eye. Be sure your ABN is in layman’s terms and specifies the specific reasons for non-coverage.

You must also specify the estimated cost of the service on the ABN. The original signed ABN indicating the patient’s decision (be sure the patient has selected one of the options) to accept financial responsibility, is maintained by the practice and a fully executed copy must be provided to the patient. Append modifier GA to the procedure done on the non-seeing eye to indicate that the patient was informed in advance and has selected the option to be responsible for the non-covered service and unpaid amount.

Example: The patient has congenital ptosis (Q10.0), and his left eye is non-seeing. The ophthalmologist performs levator resection (67904, Repair of blepharoptosis; (tarso) levator resection or advancement, external approach) bilaterally. Code as follows:

Line 1: 67904-RT linked to Q10.0
Line 2: 67904-LT-GA linked to Z41.1 Encounter for cosmetic surgery
If your documentation shows that the procedure was medically necessary on the right side, Medicare will reimburse the full amount for 67904-RT. The cosmetic diagnosis linked to 67904-LT-GA will prompt the carrier to deny the specific service due to the diagnosis and noncoverage of cosmetic services, and the EOB received by the patient will confirm that the patient is responsible for payment.

Question 17

Question: We are receiving denials on E/M visits billed with modifier 24. Can you help me understand this modifier?

Answer 17

Answer: Bundling unrelated E/M services during a postop period isn’t as easy as simply applying modifier 24 to the E/M. But if you know the global days for a given surgery, and what those packages do — and do not — include, you’re a long way towards knowing how to apply the modifier correctly.

So, the next time a patient returns to your practice during the global period of a surgery for an unrelated problem, here are three facts to remember and a myth to forget as you code the encounter.

Question 18

Fact 1: Global Days Are Essential

Answer 18

The first step to understanding modifier 24 is to get a firm grasp on how global surgical packages work.

Medicare defines what it’s going to pay you for a procedure using information that goes beyond the intraoperative services you’re performing. Also included in that global package are any preoperative visits that occur following the decision for surgery, any complications that are addressed postoperatively, any postop visits within the global surgical period, any postsurgical pain management, supplies, and miscellaneous services.

There are, however, certain services that you should not include in the surgical package, and you can report these during the postsurgical period. Some of these require a modifier; some do not. The services not included in the global package include:

Initial consultation or evaluation when the patient’s condition is discussed
Services by other physician groups.
Visits unrelated to the diagnosis for the surgical procedure.
Treatment for underlying conditions
Diagnostic tests or procedures
Distinct procedures that are not reoperations or treatments for complications
Postoperative complications that require a return trip to the operating room or ambulatory surgery center (ASC)

Question 19

Fact 2: 24 Only Applies to E/M Codes

Answer 19

If you report an E/M service that’s unrelated to the surgery, you’ll append modifier 24 to the E/M code — but you should never append modifier 24 to a procedure code. It only applies to E/M codes. Therefore, if the physician performs a surgical procedure that has a 10- or 90-day global period and then sees the patient for an unrelated E/M service during that global period, you can report the service when you append modifier 24 to the E/M code.

Fact 3: Auditors Examine Whether Visit Was Related to Surgery

If your documentation shows that somehow the visit is related to the surgery, do not use the 24 modifier.

Remember, documentation drives your modifier use. You want to be sure you’re documenting exactly what’s going on with the patient in case an auditor reviews your record. If the auditor finds that your provider only documents a postoperative visit and nothing else, you will have the claim denied.

In addition, if the documented diagnosis for the E/M visit is the same as the surgical diagnosis, auditors would take a closer look. You aren’t required to have separate diagnoses, but thanks to the specificity of ICD-10-CM, using the same diagnosis will make auditors double-check the diagnosis.

Of course, if the patient suffers from a condition that has a nonspecific diagnosis code, using the same diagnosis might be appropriate.

Myth: Returning Patients to the OR Warrants Modifier 24

Complications of surgery can be billable during the global period if the patient must return to the operating room — but 24 is not the right modifier in this situation.

If the physician must return to the OR to treat a postop complication, both Medicare and private payers will pay at a reduced rate when you attach modifier 78 to the code.

Question 20

Question: How do I use modifier 25?

Answer 20

Modifier 25 is probably one of the most used, and one of the most misused, modifiers that you can employ in your coding.

If you read the modifier’s descriptor closely, you can begin to see some of the problems you can encounter when using it. Simply put, if the procedure or other service is not on the same day, if the E/M service is not significant or separate from the procedure, and if the same physician or qualified healthcare professional (QHP) did not perform both the E/M service and the procedure (or if either service was performed by someone other than a physician or QHP), then you have incorrectly applied the modifier.

Example: Your office schedules a patient for a leg lesion removal, and your provider performs 11401 Excision, benign lesion including margins, except skin tag (unless listed elsewhere), trunk, arms or legs; excised diameter 0.6 to 1.0 cm. Billing a separate E/M service with modifier 25 in this scenario would not be appropriate because the lesion removal was the sole reason the patient came to the office. The provider did not perform a significant or separately identifiable E/M service, so you cannot charge for it.

Coding caution: In general, modifier 25 should also only be used on E/M services performed in conjunction with minor procedures that have a 0- or 10-day global period. Procedures with a 90-day global period will typically take modifier 57.

If, on close examination of a provider’s notes, you can separate out a history, exam, and/or MDM that add up to a specific E/M level, then you likely have a case for appending the modifier to the E/M service in question. You should note, too, that you don’t necessarily have to have a separate diagnosis to justify the E/M.

Example: An established patient presents with a 2 cm laceration to the forehead after she fell from her bike just before arriving at your office. Your provider reviews her vaccination record to make sure her tetanus shot is up to date, checks the patient for headaches and nausea, palpitates and inspects the area around the laceration for any other deformity and, in the absence of any other problems, performs 12011 Simple repair of superficial wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.5 cm or less, giving the patient instructions to keep the bandage clean and dry and return in 10 days.

The clear extra and separate work the provider performs to identify the patient’s immunization status, possibility of a fracture, and concerns for a possible concussion, even though the other conditions are ruled out, documents that your physician provided separate work in addition to the laceration repair. This means you can bill an E/M service separately using modifier 25.

Bottom line: Before you submit any claims featuring modifier 25, ask yourself these 4 questions.

1.Was the procedure or service unscheduled?

2.Did the E/M service uncover signs and symptoms in the patient that the provider must address with a procedure or service?

3.Did the provider address more than one diagnosis?

4.Did the provider perform work that went above and beyond normal preoperative and postoperative work?

If you answer ‘yes’ to any of them, then there’s a good chance that an E/M service with modifier 25 appended will be seen as medically necessary providing you have the documentation to support it.

Question 21

Question: When is it appropriate to report modifier 57?

Answer 21

Answer: Modifier 57 is one of those CPT® options that at first glance appears easy to code. If a patient sees a Medicare provider for an E/M visit that results in a decision for a same day (or the day prior to) surgery, then you should use modifier 57, right? The answer is not always that straightforward.

You must take many variables into account before you appropriately append modifier 57 to an E/M visit. And, that’s why this modifier sits on the RACs’ to-do lists.

Example: If you schedule a 0- or 10-day global period, such as certain lesion excisions, you can’t report an E/M with modifier 57 to get paid for both the E/M and the procedure. You’d use modifier 25 instead — assuming the documentation warrants both.

But, if you do a major surgery like a fracture reduction with a 90-day global, you can also bill an E/M service with modifier 57 to get paid for both as long as your documentation supports it.

You should consider only using modifier 57 with an E/M on the day before or the day of a major surgical procedure, never a minor surgical procedure.

Warning: You should never report modifier 57 for an E/M service the day of or day before a preplanned or scheduled major (90-day) surgical procedure.

Best bet: Remember to append modifier 57 to the E/M service code to indicate that the E/M service led to the decision to perform a surgery with a 90-day global period on the same day. Always append modifier 57 to the E/M service code, not the surgical procedure code.

Tip: An audit letter for a claim with a modifier 57 may be an unwelcome sight, but it should never be a cause for extreme stress. The letter should spell out exactly 1) which records the payer needs, and 2) the deadline by which you should have those records ready for audit.

It’s your responsibility to read all audit letters thoroughly and to respond as soon as possible. This is especially vital because the auditor is looking for reimbursement of over-coded or over-billed money. If you don’t respond by the deadline, the auditor will consider that you agree with their charge, and the contractor will be notified to recover the money.

Question: We billed a private payer 99213-25; 20610; J7328-RT; J7328-LT for Gelsyn-3 injections into the left and right knees of a patient with osteoarthritis in both knees. The payer rejected the claim, stating that “the procedure code is inconsistent with the modifier used or a required modifier is missing.” What are we doing wrong?

Answer: The issue here is the choice and placement of the modifiers. Billing 99213 with modifier 25 (is correct assuming that the E/M service was significant and separately identifiable from the work associated with the injections the provider administered at the encounter.

However, appending the RT and LT modifiers to J7328 Hyaluronan or derivative, Gel-Syn, for intra-articular injection, 0.1 mg is incorrect, as it is the procedure, and not the medication, that receives any laterality modifiers. For medications, the only information required other than the correct HCPCS or CPT® code is the number of units that your provider administered.

The laterality modifier needs to be applied to the procedure itself, which you correctly give as 20610 Arthrocentesis, aspiration and/or injection, major joint or bursa (e.g., shoulder, hip, knee, subacromial bursa); without ultrasound guidance. But even here you cannot use the RT or LT modifiers. As the procedure was performed in both knees, you would instead append modifier 50 Bilateral procedure, which is the missing modifier mentioned in the payer’s denial.

So, you should resubmit the claim using 99213-25; 20610-50; and J7328, specifying the exact amount of Gelsyn-3 your provider injected.