Modifiers Flashcards
-22
increased procedural services, Indicates services significantly greater than usual
Accompanied by written report with supportive documentation
Describes increased physician work
-23
Unusual Anesthesia, Use of anesthesia where no anesthesia or local would be the norm
Example: Highly agitated senile patient
Only used with anesthesia codes
Written report with submission of modifier may be required
-24
Unrelated E/M Services by Same Physician or Other Qualified Health Care Professional During a Postoperative Global Period, E/M Service not related to surgery is separately billable
Use -24 on E/M code only
If E/M provided during postop global period, no separate payment for E/M related to surgical procedure
Example: Patient is in global period for hip surgery and is now seen for a fractured collarbone
-25
Significant, Separately Identifiable E/M Service, by the Same Physician or Other Qualified Health Care Professional and Same Day of Procedure or Other Service,
Documentation must support service
Example: Patient seen for sinus congestion, provider performs H&P, prescribes decongestant, notes lesion on back, and removes
Code: Procedure + E/M-25
Example: A patient seen on consultation by pain management and subsequent to rendering an opinion was given a nerve injection. Modifier -25 is placed on E/M code
-26
Professional Component, Professional component (physician, -26)
Technical component (technician + equipment, -TC)
Example: Radiologist reviews x-rays (-26) taken by supervised technician (-TC)
-32
Mandated Service, Mandated by payer, workers’ comp, or official body
Not request of patient, patient’s family, or another physician
Example: Workers’ Comp requests examination of person currently receiving disability benefits
-33
Preventive Services,Patient Protection and Affordable Care Act of 2010 requires coverage without cost
United States Preventive Services Task Force grades preventive services
Grade A: substantial
Grade B: moderate
-47
Anesthesia by Surgeon, Physician administers regional or general anesthesia
Acts as surgeon and anesthesiologist
Only used with Surgery codes
No separate payment when used on Medicare patients
-50
Bilateral Procedure, Bilateral
Example: Procedure on hands
Caution: Some codes describe bilateral procedures; in these cases do not apply modifier -50
-51
Multiple Procedure—Three Types
Same Procedure, Different Sites
Example: Multiple lacerations repaired
Multiple Operation(s), Same Operative Session
Procedure Performed Multiple Times
Example: Trigger point injections (20552)
-51 cont.
Multiple Procedure
List most resource intense first (highest RVU value)
Next other procedure(s) + -51 (unless code is -51 exempt or an add-on code)
Usual payment: 1st procedure 100%, 2nd 50%, 3rd 25%
Medicare: 1st procedure paid 100%, 2nd–5th paid 50%, more than 5, priced manually
-52
Reduced Services Service reduced from code description Physician directed reduction Documentation substantiates reduction Not for patients unable to pay fee Submit full charge, payer will adjust Example: Lip shave (40500) but advancement flap not performed = 40500-52
-53
Discontinued Procedure
Surgical/diagnostic procedures
Started then stopped due to patient’s condition
Does not apply to presurgical discontinuance
-53 cont.
Discontinued Procedure DO NOT USE -53 WHEN: Patient cancels scheduled procedure With E/M codes With time-based code
-54
Surgical Care Only
Physician provides only procedure (intraoperative)
Documented patient transfer must be in record
Some payers require copy of transfer
-55
Postoperative Management Only
Physician provides care only after hospital discharge
If transferred while patient hospitalized, report postop management with subsequent hospital codes 99231-99233
Documentation of transfer in medical record
Surgery code billed with -55 modifier and surgery date of service
Bill after first postoperative visit
-56
Preoperative Management Only
Physician provided only preoperative care
Not acceptable for Medicare
Requires surgical code with modifier -56
Usual Reimbursement for Portions, Surgical Package
10% preoperative
70% intraoperative
20% postoperative
Each payer determines portions
-57
Decision for Surgery Used with
E/M, 99201-99499
Medicine, 92012-92014 ophthalmologic services
Medicare: Only for preop period of major surgery (day before or day of)
90 day global
-58
Staged/Related Procedure/Service by Same Physician or Other Qualified Health Care Professional During Postoperative Period (1 of 2)
Subsequent procedure planned or related to the first surgery
During postop of previous surgery in series
Example: Multiple skin grafts completed in several sessions
Global period starts over
-58 cont.
Do not use when code describes a session
Example: 67208: lesion destruction of retina, one or more sessions
-59
Distinct Procedural Service
Different session or encounter
Different procedure
Different site
Separate incision, excision, lesion, injury
Do not use when another HCPCS modifier is appropriate
-59 cont.
Example: Physician removes several lesions from patient’s leg, also notes and biopsies a mole of torso
Biopsy code for mole + -59
Indicates biopsy distinct procedure, not part of lesion removal
CMS established four HCPCS subset modifiers that are:
Referred to as–X{EPSU} modifiers
More descriptively define modifier -59
Payer specific
For more information see page 271 of the text.
-62
Two Surgeons
Both function as co-surgeons (equals)
Usually different specialties
Each surgeon reports same surgery code appending -62
Each surgeon dictates his/her portion of procedure
-63
Procedure Performed on Infants Less Than 4 kg
Kilogram: 2.2 lb (4 kg = 8.8 lb)
Small size increases complexity
Use with all Surgery section codes except Integumentary and those exempt by parenthetical notes
-66
Surgical Team
Team: Several physicians (3 or more) with various specialties plus technicians and other support personnel
Very complex procedures
Payers may increase payment
-76
Repeat Procedure/Service by Same Physician or Other Qualified Health Care Professional
Note: “Same Physician or Other Qualified Health Care Professional”
Used to indicate necessary repeated service, not typographical error
Example: X-rays before and after fracture repair
Aerosol treatment for an asthma attack repeated in 90 minutes (94640-76)
-77
Repeat Procedure/Service by Another Physician or Other Qualified Health Care Professional
Note: “Another Physician or Other Qualified Health Care Professional”
Performed by one individual, repeated by another individual
Submitted with a written report to establish medical necessity may be requested
-78
Unplanned Return to Operating/Procedure Room Same Physician Following Initial Procedure for a Related Procedure During Postoperative Period
For complication of first procedure
Example: Patient has outpatient procedure in morning, was returned to operating room in afternoon with severe hemorrhage
Indicates not typographical error
Does not change global period time
-79
Unrelated Procedure or Service by Same Physician or Other Qualified Health Care Professional During Postoperative Period
Example: Several days after discharge for procedure, patient returns for an unrelated procedure/service
Diagnosis would be different
Remember the E/M code would have -24
If surgery is unrelated to original procedure, a new global period starts
-80, -81
-80 Assistant and -81 Minimum Assistant Surgeons
-80 Assistant
Reimbursed at 15–30%
Payers identify procedures for which they reimburse assistant
-81 Minimum Assistant Surgeon
Services at a level less than that described in -80 (Assistant Surgeon)
Reimbursed at 10%, if at all
-82
Assistant Surgeon
Teaching hospitals:
Have residents who assist as part of education—no fee, no modifier -82
Must demonstrate no qualified resident available
Unavailability documented in written report
-90
Reference (Outside) Laboratory Physician has business relationship with outside lab Physician pays lab Physician bills payer for lab services Cannot use for Medicare
-91
Repeat Clinical Diagnostic Laboratory Test
Repeat same laboratory tests on same day for multiple test results
Not tests rerun to confirm original test results
Not malfunction of equipment or technician error
-92
Alternative Laboratory Platform Testing
Indicates kit or transportable instrument
Usually single use, disposable
Example: 86701, HIV test kit
-95
Synchronous Telemedicine Services
Used when provider and patient interact from separate locations
Identified by (★) star symbol
Complete code list found in Appendix P
-96, -97
-96 Habilitative Services and -97 Rehabilitative Services
-96 Habilitative Services
Help with learning daily living skills/functions not yet developed
-97 Rehabilitative Services
Help with regaining daily living skills/functions that have been lost or impaired due to injury or illness
Intent with both services is individuals will retain and improve their skills/functions
-99
Multiple Modifiers
Used when service needs more than one modifier but payer only allows for one modifier with each code
CPT modifiers
Used to describe alterations to CPT code
Full list, CPT, Appendix A
modifier functions
Altered (i.e., more or less) Bilateral Multiple Only portions of service (i.e., professional service only) More than one surgeon Unusual service