Lesson 3 Modifiers Flashcards
Definition of Modifier
Two digit characters that may be appended to most CPT codes
Used to communicate special circumstances
Adverbs=Modifer, Noun=CPT code
When are modifiers used?
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
What are the three types of modifiers?
CPT modifiers
Facility modifiers
HCPCS modifiers
How many CPT modifiers?
31
Physician services
Facility Modifiers
13
Hospital outpatient services
Level II/HCPCS Modifiers
Alphanumeric
Most in HCPCS Level II code book
Required for government payers (Medicare)
Physical Status Modifiers
Physical risk to patient or complexity of anesthesia
Selected by anesthesiologist
Indicates multiple modifiers, listed first after code
-99
NCCI
National Correct Coding Initiative
Controls improper coding that would lead to inappropriate payment for Medicare claims
Edits
Code combinations that are screened against each other to determine whether code in the combination can be reported at the same time
OCE
Medicare Outpatient Code Editor
Hospitals/facilities
OPPS
Outpatient Prospective Payment System
Column1/Column2 Code Pair Edits
Based on one code’s being a component of the other comprehensive code
Mutually Exclusive Code Edits (MEC)
Could not have reasonably been performed during a single patient encounter
Modifier Indicators
Allow a code to pass through an edit with a modifier
0=not allowed
1=allowed
9=not applicable
Medically Unlikely Edits (MUE)
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.
Modifiers to bypass NCCI edits
Anatomic (RT,LT, etc.)
Global surgery (25, 58, 78, 79)
Other (27,59,91)
Anatomic modifiers
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)
Finger modifiers
FA-F9 (L then R, Large to small)
Does not include metacarpal bones
Toe modifiers
TA-T9 (L then R, Large to small)
Does not include metatarsal bones
Eyelid modifiers
E1-E4
Coronary Arteries modifiers
Only 3
LC - Left circumflex CA
LD - Left anterior descending CA
RC - Right CA
Modifier 25
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
Modifier 58
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
Modifier 79
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
Modifier 27
Multiple outpatient hospital E/M encounters on the same date
Hospital use
Added to subsequent E/M codes
Needs documentation
Modifier 59
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
Modifier 91
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
