Seminar 6

Modifiers and Usage

Provide additional information regarding the product or service

Two digit codes CPT codes are numeric HCPCS codes are alpha

What do modifiers do?

Clarify procedure performed Extenuating circumstances Give reasons why something was done

Modifiers:The modifier on a claim is very important because:

It will tell the payer what kind of reimbursement you are seeking (i.e. professional or technical)

If there was a problem with the procedure itself (cancelled)

You may get payment on something which otherwise you would have not

Remember: It may be necessary to use the phrase

“additional documentation available upon request” in the narrative field of your claim in order to support the modifier used.

When documentation is requested because of modifier usage, the number one reason for denial is because the documentation is not returned in a timely manner.

Most commonly used: 25- Separate procedure during same

encounter: Significant, separately identifiable E/M

service by the same physician on the same day of the procedure of other service, may be the most important for family physicians

For example: classic use of this modifier; an annual preventative medicine encounter during which the patient says “oh, by the way…” as a result, you address the “by the way” ailment and the preventative service.

In this case you can submit codes for both a preventative service (99396) and a regular OV (99213) by attaching -25 to the OV code.

This tells the third party payer that you did perform two significant, separately identifiable E/M services for the same patient on the same date, and it should keep the payer from bundling the services.

Modifier 50: Applies to any bilateral procedure

performed on both sides at the same session

Do not use modifiers RT/LT when modifier 50 applies. A bilateral procedure is reported on one line using modifier 50. the quantity entry to use when modifier -50 is reported is one.

Modifiers LT/RT: identical body parts (eyes, arms, legs)

Used when a procedure is performed on both sides of the body

Could be same site, or different site Also when procedure is done on only

one side of the body

Difference between -50 & LT/RT Use modifier 50 when a unilateral

procedure is performed on both sides Use modifier 50 for eligible only services

(use only for surgical codes (Surgery section codes 10040-69990)

Use LT/RT when using anatomic guidelines

Depends on the insurance company which modifier they prefer

Usually second modifier is “dropped”

Modifier 59: “distinct procedural service” is similar

to modifier 25, but it is applicable to procedural rather than E/M services

You will attach modifier 59 to a code to indicate that a procedural service is distinct or independent from other services performed the same day, particularly when the services or procedures aren’t normally reported together but are appropriate under the circumstances

Modifier 51 Used to show that more than one

procedure was performed Multiple procedures require

documentation (timely)

Difference between modifiers 51 and 59:

51: numerous procedures 59: distinct service Can bill a procedure with both modifiers Example: 36556-59-51 (many times last

modifier will be dropped)

Modifier 99 Multiple services: use this modifier to

report a procedure or service that has more than one modifier but the third-party payer does not allow the addition of multiple modifiers to the code

There is a comprehensive list of modifiers that can be found in your CPT book

Review modifiers to become acquainted with the different ones

This affects reimbursement greatly, so you should be knowledgeable

Which modifier indicates diagnostic mammogram converted from screening mammogram on the same day?

a. -59b. -58c. -ATd. -GH

Which modifier indicates diagnostic mammogram converted from screening mammogram on the same day?

a. -59b. -58c. -ATd. -GH

When two surgeons work together as primary surgeons performing distinct part(s) of a single reportable procedure, each surgeon should report his/her distinct operative work by adding which of the following modifiers?

a. -54b. -66c. -59d. -62

When two surgeons work together as primary surgeons performing distinct part(s) of a single reportable procedure, each surgeon should report his/her distinct operative work by adding which of the following modifiers?

a. -54b. -66c. -59d. -62

When a patient is in a postoperative period and returns to the operating room for an unrelated procedure by the same physician, which of the following modifiers would you attach to the procedure being performed?

a. -59b. -24c. -78d. -79

When a patient is in a postoperative period and returns to the operating room for an unrelated procedure by the same physician, which of the following modifiers would you attach to the procedure being performed?

a. -59b. -24c. -78d. -79

Anesthesia complicated by emergency conditions would require the use of what modifier or CPT code?

a. -23b. 99140c. 99100d. P5

Anesthesia complicated by emergency conditions would require the use of what modifier or CPT code?

a. -23b. 99140c. 99100d. P5

Evaluation and management services were performed on an established patient in which the decision to perform a major surgery scheduled for the following morning was made. The patient was counseled for 15 minutes regarding treatment options, risks, and projected outcome. Which of the following modifiers would be appended to the service performed?

a. -56b. -52c. -50d. -57

Evaluation and management services were performed on an established patient in which the decision to perform a major surgery scheduled for the following morning was made. The patient was counseled for 15 minutes regarding treatment options, risks, and projected outcome. Which of the following modifiers would be appended to the service performed?

a. -56b. -52c. -50d. -57

An x-ray of the radius and ulna was performed by the radiology technician. The radiologist reads or interprets the two x-rays and forwards the reports to the patient’s physician for follow up. What modifier is used to reimburse the radiologist?

a. -56b. -26c. -50d. -TC

An x-ray of the radius and ulna was performed by the radiology technician. The radiologist reads or interprets the two x-rays and forwards the reports to the patient’s physician for follow up. What modifier is used to reimburse the radiologist?

a. -56b. -26c. -50d. -TC

Which modifier would be used to describe services by a Registered Dietician?

a. AFb.AHc. AJd.AE

Which modifier would be used to describe services by a Registered Dietician?

a. AFb.AHc. AJ

d.AE

Which modifier is used to describe the following services?:

A procedure which required minimum surgical assistant to complete?

Which modifier is used to describe the following services?:

A procedure which required minimum surgical assistant to complete?

Modifier 81

Which modifier is used to describe the following services?:

A procedure which required an anesthesia physical status modifier describing:

a patient with mild systemic disease?

Which modifier is used to describe the following services?:

A procedure which required an anesthesia physical status modifier describing:

a patient with mild systemic disease?

Anesthesia modifier P2

Which modifier is used to describe the following services?:

A procedure which was explained to the patient and the decision to perform surgery was made after the E/M service was provided?

Which modifier is used to describe the following services?:

A procedure which was explained to the patient and the decision to perform surgery was made after the E/M service was provided?

Modifier 57

Which modifier is used to describe the following services?:

Patient developed complications after surgery and the procedure needed to be repeated. The same physician returned to the operating room to perform the procedure.

Which modifier is used to describe the following services?:

Patient developed complications after surgery and the procedure needed to be repeated. The same physician returned to the operating room to perform the procedure.

Modifier 76

Which modifier is used to describe the following services?:

A situation which required a second lab test to be done because another test result was required for drug levels on the same day

Which modifier is used to describe the following services?:

A situation which required a second lab test to be done because another test result was required for drug levels on the same day

Modifier 91

Which HCPCS modifier describes:

Right hand, second digit

Which HCPCS modifier describes:

Right hand, second digit

Modifier F6

Which HCPCS modifier describes:

Left foot, great toe

Which HCPCS modifier describes:

Left foot, great toe

Modifier TA

Which HCPCS modifier describes:

Right coronary artery

Which HCPCS modifier describes:

Right coronary artery

Modifier RC

Which HCPCS modifier describes:

An item that was replaced due to a defect in the product

Which HCPCS modifier describes:

An item that was replaced due to a defect in the product

Modifier FB

Which HCPCS modifier(s) would be used:

Procedure performed: simple drainage of a finger abscess, left-hand thumb and second finger.

The CPT code is 26010 What are the modifiers?

Which HCPCS modifier(s) would be used:

Procedure performed: simple drainage of a finger abscess, left-hand thumb and second finger.

The CPT code is 26010 What are the modifiers?

Which HCPCS modifier(s) would be used:

Procedure performed: simple drainage of a finger abscess, left-hand thumb and second finger.

The CPT code is 26010 What are the modifiers?

26010-FA Left hand thumb 26010-F1 Second finger

Which CPT modifier describes a repeat procedure by another physician?

a. 77b.76c. 78d.79

Which CPT modifier describes a repeat procedure by another physician?

a.77b.76c. 78d.79

True or False

Adding modifier -76 or -77 is based on whether the physician performing the procedure is the same or different

True

Adding modifier -76 or -77 is based on whether the physician performing the procedure is the same or different

Which modifier is used to describe the following services?:

An outpatient hospital procedure which required discontinuation of surgery/procedure after the patient has been prepped but before anesthesia is administered

Which modifier is used to describe the following services?:

An outpatient hospital procedure which required discontinuation of surgery/procedure after the patient has been prepped but before anesthesia is administered

Modifier 73

Which modifier is used to describe the following services?:

A procedure which a physician provided the care after surgery/procedure was performed, but did not perform the surgery/procedure itself

Which modifier is used to describe the following services?:

A procedure which a physician provided the care after surgery/procedure was performed, but did not perform the surgery/procedure itself

Modifier 55

Which HCPCS modifier is used to describe the following services?:

A patient sees a clinical psychologist for individual psychotherapy.

The CPT code reported is 90804 What is the modifier?

Which HCPCS modifier is used to describe the following services?:

A patient sees a clinical psychologist for individual psychotherapy.

The CPT code reported is 90804 What is the modifier?

Modifier AH

Which HCPCS modifier describes services provided by:

Occupational therapy

Which HCPCS modifier describes services provided by:

Occupational therapy

Modifier GO

What does modifier E4 describe?

What does modifier E4 describe?

Lower right, eyelid

Questions???