Reference Guide to Understanding Modifiers

Transcription

1 Reference Guide to Understanding Modifiers The modifiers outlined in this reference guide are most often used in eye care, and is not a complete listing of available modifiers to date. The definitions and guidelines are those set by the AMA and CMS. Individual payer policies may define and apply modifiers differently per specific insurance plans. It is important when billing specific insurance payers to understand the policy for the CPT services being submitted. The use of modifiers is an important part of coding and billing for health care services. Modifier use can affect reimbursement as well as an important part of avoiding fraud and abuse or noncompliance issues. Billing errors are commonly due to incorrect use of modifiers. Modifiers are appended to a CPT code to report specific circumstances or alterations to a procedure, or services without changing the definition of the code. Both CPT and HCPCS Level II codebooks list modifiers and the description. When reporting codes with more than one modifier, always list the functional or pricing modifiers in the first position. Payers consider pricing modifiers when determining reimbursement. Next, report the informational modifiers, these clarify certain aspects of the services or procedure such as the location or eye. Evaluation and management services (E/M) modifiers: The following modifiers are only ever appended to an E&M or eye code. Never appended to a procedure or diagnostic test. 24 Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period. Example: When an office visit is performed during a global period for reasons unrelated to the original surgery or procedure appended modifier 24 to the appropriate level of E&M or eye code to report to report this circumstance.

2 25 Significant, separate identifiable evaluation and management service by the same physician or other qualified health care 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 was performed, the patient s condition required a significant and separate office visit above and beyond the other service provided. Under CPT it is not required that the office visit have a different diagnosis than the other procedure. Example: Patient presents in the office for their scheduled dilated glaucoma check, upon examination it was determined a foreign body was present and in need of removal. 57 Decisions for surgery When an office visit is performed the day before or the day of a surgery results in the decision to perform the surgery, append modifier 57 to the appropriate office visit level. The office visit could be performed by the surgeon or an outside physician that referred to the surgeon for the surgery. Procedure and services modifiers: 22 Increased procedural services - Should not be appended to an E/M code or Eye code. When a procedural service provided is greater than required for the listed procedure, it may be identified by appending modifier 22 to the procedure code. Documentation must support the substantial extra work and the reason. Appropriate uses: o Excessive blood loss during the procedure o Trauma or anxiety excessive enough to complete the procedure Inappropriate uses: o Another code exists that describes the increased work o Cannot append to an office visit code

3 50 Bilateral Procedure When the exact same unilateral mirrored procedure or service is performed on both eyes, append modifier 50 to the second procedure or service line. Example: Removal of foreign body, external eye; corneal without slit lamp, both eyes 51 Multiple Procedures When multiple and separate procedures are performed together during the same visit on the same or separate eye or location. Example: Removal of foreign body, external eye; corneal without slit lamp, right eye and Removal of foreign body, external eye; corneal with slit lamp left eye 52 Reduced Services Use to Indicate the provider reduced or eliminated some services usually associated with the code that the modifier was appended. It would not be appropriate to appended to an office visit code however. 59 Distinct Procedural Service Under certain circumstances, it may be necessary to indicate a procedure or service was independent from another procedure or service, that are not normally reported together. When the two procedures or services are mutually exclusive under the NCCI edits, but are appropriate under the circumstance, append modifier 59 to the second service line. Documentation must support the necessity of both services and may be required by the payer for claims processing. Claims with modifier 59 appended will be under the payer discretion for reimbursement.

4 Example: Fundus photography with interpretation and report and SCODI, optic nerve When a more specific and appropriate use of an X modifier applies, use in place of modifier 59. XE XS XP XU Separate encounter, a service that is distinct because it occurred during a separate encounter Separate structure, a service that is distinct because it was performed on a separate organ/structure Separate practitioner, a service that is distinct because it was performed by a different practitioner Unusual non-overlapping service, the Use of a Service that is distinct because it does not overlap usual components of the main service. Global component modifiers: Modifiers 54, 55 and 56 are appended to surgical procedures to indicate different providers provided care. These modifiers are only appended to codes that typically have a global period of 90 days. 54 Surgical care only When only the intra-operative or surgical procedure was performed by a provider 55 Postoperative management only When only the post-operative care is being provided by a separate provider, outside of the surgeons practice or group. 56 Preoperative management only When only the pre-operative care is being provider by a physician other than the surgeon, outside of the surgeons practice or group. Postoperative Modifier: 79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period

5 When a second procedure performed during the postoperative period and is unrelated to the original procedure or surgery. Modifier 79 would not apply to office visits (see modifier 24), append only to other unrelated surgical or procedures with a 90-day global period. necessary to indicate the performance of a procedure. Professional / Technical Component Modifiers: Diagnostic tests have a combination of a professional component (interpretation) and a technical component (performing the actual test) built into the reimbursement) 26 Professional Component When the professional component only is reported separately, identify it as such by appending modifier 26. This applies when the test was performed by an outside facility or physician s office and the interpretation only is being performed by the provider billing for services. TC Technical Component When the technical component only is reported separately, identify it as such by appending modifier TC. This applies when the test was performed by the provider billing for services and the interpretation is performed by an outside physician. Note: Appending both 26 and TC to a diagnostic test or service on a claim in not generally not appropriate or necessary. Informational modifiers Information modifiers supply additional information about the services provided, such as anatomical site, or expected coverage. RT Right eye LT Left eye

6 Eyelid modifiers: E1 Upper left E2 Lower left E3 Upper right E4 Lower right Three common ophthalmological procedures requiring the eyelid modifiers: epilation ( ), punctual plug procedures ( ), and Chalazion excisions ( ) Examples: Correction of Trichiasis; epilation, by forceps only Example: Closure of the lacrimal punctum, by plugs, each The following informational modifiers GA, GY, GZ are primarily recognized by Medicare and therefore are only required on Medicare claims. Appending one of these modifiers may be the difference in being paid or being allowed to bill the patient for non-covered services. GA The provider or supplier has provided an Advance Beneficiary Notice of Non-coverage (ABN) to the patient and has a signed copy on file GY Statutorily excluded service - If the service provided is statutorily excluded from the Medicare Program, the claim will deny whether the modifier is present on the claim GZ The provider or supplier expects a medical necessity denial; however, did not provide an ABN to the patient * If an ABN was not obtained when required, GZ modifier would be appended. However, Medicare will not allow this item or service to be billed to the patient.

7 Example: Refraction to Medicare: Lab Tests / CLIA Certificate of Waiver CLIA (Clinical Laboratory Improvement Amendments) of 1988 are United States federal regulatory standards that apply to all clinical laboratory testing performed on humans in the United States, except clinical trials and basic research. These are considered "CLIA waived" and therefore require a "CLIA Certificate of Waiver" this waiver number is required in box 23 when billing Medicare for any of the following lab tests TearLab Osmolarity Test - Microfluidic analysis utilizing an integrated collection and analysis device, or tear osmolarity AdenoPlus - Infectious agent antigen detection InflammaDry test - immunoassay for analyte other than infectious agent antibody or infectious agent antigen; qualitative or semi-quantitative, multiple step method QW - States the test being performed is a "simple laboratory examinations and procedures having insignificant risk of an erroneous result". Modifier QW must be append when billing for any CLIA waived lab test. Example: TearLab submitted to Medicare Example: United Healthcare policy preference is to list lab tests on one line item.