Modifier Mania - PowerPoint Presentation

Slide1

Modifier Mania

Presented by: Pat Cox, COC, CPC, CPMA, CPC-I, CEMCLisa Deel, CPC, CEMC, COBGCDenise Taylor, CPC, CEMC, CGSCSlide2

Modifier 22

Increased Procedural ServicesSlide3

Modifier 22

Use this modifier when the work required to provide a service is substantially greater than typically required.It may be identified by adding modifier 22 to the usual procedure codeDocumentation must support theSubstantial additional work and reason for the additional work

ie

, increased intensity, time, technical difficulty of the procedure, severity of patient’s condition, physical and mental effort requiredSlide4

Modifier 22

May be used in these CPT code set sectionsAnesthesiaSurgery

Radiology

Laboratory and pathology

Medicine

Not

on E&M

Slide5

Guidelines

Use only when work factors requiring the physician’s technical skill involve significantly moreWorkTimeComplexityFor surgical and nonsurgical proceduresSlide6

Guidelines

Relative value units for services represent average work effort and practice expenses for a serviceIncreased or decreased payment only under unusual circumstances and after medical records and documentation reviewClaim submission requirementsWritten report - concise statement about how the service differs from the usual (Kiss letter)Operative reportSlide7

KISS Letter

“Kiss Letter”I am requesting special consideration for the operative procedure performed on Patient X on January 12, 2015. I am requesting a payment increase of 25 percent above my usual fee for this procedure, which is proportionate with the extra work effort due to (indicate special condition here)Slide8

KISS Letter

Example Letter (Continued):Then, briefly describe the difficult nature of the serviceInclude typical average circumstances vs. actual circumstanceCompare to normal time to complete procedureEnd letter by referencing the OP noteSlide9

Modifier 22: Example

Laminotomy with decompression of nerve root with a partial facetectomy, foraminotomy, and excision of herniated diskDuring surgery, difficult-to-control hemorrhage requiring 60 additional minutes

CPT Code(s) Billed:

63020 22

—

Laminotomy

(

hemilaminectomy

), with decompression of

nerve root(s), including partial

facetectomy

,

foraminotomy

and/or excision of herniated intervertebral disk; one interspace, cervicalSlide10

Modifier 22: Example

Using an example of a gallbladder surgery, if a patient has a BMI of 48.4 and had previous upper abdominal surgery such that adhesions in the upper abdomen were extremely dense, the gallbladder was densely adherent to the gallbladder bed on the liver and the surgery time was two and one-half hours, that would be a case where the surgeon is justified in using the 22 modifier and asking for extra reimbursement. Slide11

Modifier 22

Don’t assign the modifier if:There is not supportive documentationThere is an existing “add on” code availableAppend to secondary proceduresUse for re-operationsUnlisted proceduresSlide12

Tips

The physician’s documentation should be thorough. If it does not indicate the substantial additional work, carriers will not increase the fee.The additional work must be significant. Most carrier say that unless 25% more work was performed, then modifier 22 should not be appended. When possible, use the diagnosis codes that further describe the circumstances warranting the use of modifier 22.Slide13

Tips

Modifier 22 should not be overused. Abuse of this modifier will attract unwanted scrutiny by an insurance carrier and may trigger an audit. Medicare has suggested that modifier 22 should be used with fewer than 5 percent of all surgical cases. Slide14

Tips

Remember not every difficult case merits a modifier 22. The procedure must be unusually difficult in relation to other procedures of the same type. Per the AMA-”Only rare, outlying cases-those that are far beyond the average difficulty-call for modifier 22”Check with your carrier regarding any special requirements.Slide15

So what’s not a 22?Slide16

Modifier 51

Use modifier 51 Multiple procedures to show that the same provider performed multiple procedures (other than E/M services, Physical Medicine and Rehabilitation services or provision of supplies) during the same session.Slide17

Modifier 51

Modifier 51 indicates: The same procedure performed on different sites; Multiple operations during the same session; or One procedure performed multiple times. Slide18

Modifier 51

Used to identify the secondary procedure, or additional procedures. It is not appended to the primary code. Not appended to “add-on codes” or modifier 51 exempt codes (found in Appendix E of CPT).Refer to the 'Mult Surg' indicator in the Medicare Physician Fee Schedule database (MPFSDB) to determine if CPT modifier 51 is applicable to a particular procedure

code. Slide19

Reimbursement

Rank codes according to the highest relative value unit using the total RVU not wRVU.The primary procedure will be reimbursed at 100% of the allowable50% of the fee schedule amount for the remaining procedures.Surgical procedures beyond the 5th may priced differently depending on the circumstances and/or carrier. Slide20

Multiple Surgery Reduction Rule

Multiple endoscopy payment rules apply for procedure billed with another endoscopy in the same familyEndoscopy includes arthroscopyFor endoscopy performed on the same day as another in the same family, the payment for the procedure with the highest RVUs is 100% of the maximum allowed fee

The maximum allowed fee for every other

procedure in the family is reduced by the value

of the base code for the family

No separate payment for a base procedure

when other endoscopies in the same family

are performed on the same daySlide21

Example of Modifier 51

The patient presents for removal of a 3.5 cm benign skin lesion on the face. A layered closure of the resulting wound is performed in the same operative session. The procedure would be coded as follows: 12052 Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm

11444-51

Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 3.1 to 4.0 cm. Slide22

Modifier 59

Modifier 59 Distinct procedural service indicates a: Different encounter or session; Different procedure; Different site; or Separate incision, excision, injury, lesion, or body part. Slide23

Modifier 59

Modifier 59 should be used only if no more descriptive modifier is available and the use of modifier 59 best explains the circumstances should it be used. “Modifier of last resort.”Appending modifier 59 indicates that the procedure is not considered a component of another procedure but is a distinct, independent procedure. Slide24

Modifier 59

Some payers do not accept modifiers 51 or 59Coders should avoid using modifier 59 to simply override a payer edit. Should be used with caution. As a modifier that affects payment and “unbundling”, it is watched closely by payers.Documentation needs to be specific and easy to identify.Slide25

Example from NCCI Book-Surgery:

A patient underwent placement of a flow-directed pulmonary artery catheter for hemodynamic monitoring via the subclavian vein (93503). Later in the day, the catheter had to be removed and a central venous catheter was inserted through the femoral vein.CPT Code(s) Billed: 93503-Insertion and placement of flow directed catheter (eg, Swan-Ganz) for monitoring purposes

36010 59-Introduction of catheter, superior or inferior vena cava Slide26

Which to use…51 or 59

Were the services performed at separate encounters? – append “59”Did the services involve different sites or organ systems?Separate incisions, excisions?Separate lesions or injuries?Append “59” to the second code, if not append “51Slide27

Modifier -59 Subsets

New HCPCS modifiers;XE - Separate Encounter, a service that is distinct because it occurred during a separate encounter;XS - Separate Structure, a service that is distinct because it was performed on a separate organ/structure;XP - Separate Practitioner, a service that is distinct because it was performed by a different practitioner; and

XU - Unusual Non-Overlapping Service, the use of a service that is distinct because it does not overlap usual components of the main service.Slide28