Lesson 3 Modifiers

Question 1

Definition of Modifier

Answer 1

Two digit characters that may be appended to most CPT codes
Used to communicate special circumstances
Adverbs=Modifer, Noun=CPT code

Question 2

When are modifiers used?

Answer 2

Procedure performed bilaterally
More than one procedure performed at same time
More than one physician/location
Procedure increased or decreased
Only part of procedure performed
Unusual events occurred
Two components: technical and professional
Physical status for anesthesia

Question 3

What are the three types of modifiers?

Answer 3

CPT modifiers
Facility modifiers
HCPCS modifiers

Question 4

How many CPT modifiers?

Answer 4

31

Physician services

Question 5

Facility Modifiers

Answer 5

13

Hospital outpatient services

Question 6

Level II/HCPCS Modifiers

Answer 6

Alphanumeric
Most in HCPCS Level II code book
Required for government payers (Medicare)

Question 7

Physical Status Modifiers

Answer 7

Physical risk to patient or complexity of anesthesia

Selected by anesthesiologist

Question 8

Indicates multiple modifiers, listed first after code

Answer 8

-99

Question 9

NCCI

Answer 9

National Correct Coding Initiative

Controls improper coding that would lead to inappropriate payment for Medicare claims

Question 10

Edits

Answer 10

Code combinations that are screened against each other to determine whether code in the combination can be reported at the same time

Question 11

OCE

Answer 11

Medicare Outpatient Code Editor

Hospitals/facilities

Question 12

OPPS

Answer 12

Outpatient Prospective Payment System

Question 13

Column1/Column2 Code Pair Edits

Answer 13

Based on one code’s being a component of the other comprehensive code

Question 14

Mutually Exclusive Code Edits (MEC)

Answer 14

Could not have reasonably been performed during a single patient encounter

Question 15

Modifier Indicators

Answer 15

Allow a code to pass through an edit with a modifier
0=not allowed
1=allowed
9=not applicable

Question 16

Medically Unlikely Edits (MUE)

Answer 16

Reduce number of health care claims sent back because of clerical or practice management errors
Test claim for same beneficiary, CPT code, date of service, billing provider against Medicare’s rules
Keying errors, etc.

Question 17

Modifiers to bypass NCCI edits

Answer 17

Anatomic (RT,LT, etc.)
Global surgery (25, 58, 78, 79)
Other (27,59,91)

Question 18

Anatomic modifiers

Answer 18

Used only when a procedure is performed on one side of the body and the site of the procedure has a paired organ (lungs, overies, etc)

Question 19

Finger modifiers

Answer 19

FA-F9 (L then R, Large to small)

Does not include metacarpal bones

Question 20

Toe modifiers

Answer 20

TA-T9 (L then R, Large to small)

Does not include metatarsal bones

Question 21

Eyelid modifiers

Answer 21

E1-E4

Question 22

Coronary Arteries modifiers

Answer 22

Only 3
LC - Left circumflex CA
LD - Left anterior descending CA
RC - Right CA

Question 23

Modifier 25

Answer 23

Global Surgery Modifier
Significant, Separately Identifiable E/M Service by the same physician on the same day of the procedure
Above and beyond the other service provided
Beyond the usual pre op and post op care

Question 24

Modifier 58

Answer 24

Global Surgery Modifier
Staged or related procedure by same physician during post op period
Planned/Staged
More extensive than original procedure
Therapy following surgery
Reapplication of cast within 90 day global period

Question 25

Modifier 79

Answer 25

Global Surgery Modifier
Unrelated procedure by same physician during post op period
Both diagnosis and procedure must be unrelated to the reason for the previous surgery

Question 26

Modifier 27

Answer 26

Multiple outpatient hospital E/M encounters on the same date
Hospital use
Added to subsequent E/M codes
Needs documentation

Question 27

Modifier 59

Answer 27

Distinct procedure service
Used to identify procedures that are not normally reported together
Last resort modifier: when another modifier is more appropriate, it should be used rather than modifier 59

Question 28

Modifier 91

Answer 28

Repeat clinical diagnostic lab test
Repeat the same lab test on the same day to obtain multiple test results
Not for reruns b/c of mistakes