When coding outpatient encounters and visits during the certified coding specialist (CCS) examination, you are instructed to assign applicable CPT/HCPCS modifiers for hospital-based facilities. Modifiers should be used consistently with all payers, whether they recognize them or not, unless a payer rejects claims with some modifiers. This way everyone in the facility who is responsible for assigning modifiers is following the same guidelines in all instances. Modifiers are two digit numeric or alphanumeric characters that are appended to CPT and HCPCS Level II codes.
A modifier provides a means to indicate that a service or procedure was altered by specific circumstances, without changing the definition of the code. For example, use modifiers 52, 73 and 74 to report discontinued procedures. Proper usage is essential to getting paid appropriately for the services provided. For example, outpatient prospective payment system (OPPS) modifier -CA is appended to inpatient procedure codes performed on an outpatient basis on patients who expire before being admitted.
Modifier assignment is often confusing to coders. When trying to determine if a modifier is appropriate, coders should ask if any of the following apply. Was the same service performed more than once on the same date? Will a modifier eliminate the appearance of duplicate billing or unbundling? Will the modifier add more information regarding the anatomic site of the procedure? Will a modifier provide any additional information on the services provided? If any of these circumstances apply, then it may be appropriate to append a modifier to the procedure code. It is also important that the documentation in the medical record support the use of the modifier.
Two modifiers may be appended to each CPT or HCPCS code. The UB-04 will allow four modifiers. However, it is not clear if the Centers for Medicare and Medicaid Services (CMS) or other payers will recognize modifiers three and four. It is important to list first the modifiers that will affect reimbursement. For example, modifier -25 is used to indicate separate evaluation and management services. Modifier -50 is used to indicate a bilateral procedure. Both will affect reimbursement.
The CPT modifiers that are currently approved for hospital reporting are: -25, -27, -50, -52, -58, -59, -73, -74, -76, -77, -78, -79 and -91. The HCPCS modifiers that are currently approved for hospital reporting are: -CA, -E1 through -E4, -FA through -F9, -GA, -GG, -GH, -GY, -GZ, -LC, -LD, -RC, -LT, -RT, -QM, -QN, and -TA through -T9. It is very important to understand how to use modifiers because they will often mitigate Outpatient Code Editor (OCE) and Correct Coding Initiative (CCI) edits. Some of the more problematic modifiers are addressed here.
Modifier -25 identifies significant separate evaluation and management (E/M) services provided on the same date as a procedure or other service. Modifier -25 is appended to the E/M code. It is important to determine the intent of the visit before making the decision to assign an E/M code with modifier -25.
If a patient presents specifically for a procedure or service and no separate E/M services are provided beyond those necessary for the procedure being performed, it is not appropriate to assign an E/M code or modifier -25. If a patient is presenting for the evaluation of an injury or illness and just happens to have a procedure or service during the visit, then it is appropriate to assign an E/M code with modifier -25. For example, a patient presents to the emergency department (ED) for evaluation after an automobile accident. It is determined that the patient requires a skin laceration repair. In this instance, code both the laceration repair code and the E/M code with modifier -25 appended. Under OPPS when there is an E/M code and a procedure with a payment status indicator S or T on the claim and modifier -25 is not appended to the E/M code, OCE edit #21 will be triggered and the E/M code will not be reimbursed.
Modifier -50 is used to report bilateral procedures performed during the same operative session. Modifier -50 is used only if the same procedure is performed on both paired body parts.
For example, use modifier -50 with CPT code 64721 when a patient undergoes bilateral open carpal tunnel releases. Report the CPT code once with modifier -50. If the CPT code description includes the word "bilateral," do not use modifier -50. The code itself includes the description, and appending modifier -50 is redundant reporting. Modifier -50 should also not be assigned for discontinued procedures.
HCPCS Level II modifiers -LT and -RT are used to identify the left and right sides of the body and are often confused with modifier -50. Use modifiers -LT or -RT only when a procedure is performed on one side of the body and is a paired organ (e.g. lungs, kidneys, ears or ovaries). Modifiers -LT and -RT should also be used when the procedures performed are similar but not identical and are both performed on paired body parts. For example, a patient has a lesion removed from the left breast and a biopsy of a lesion of the right breast. In this instance, assign 19120 with modifier -LT and 19100 with modifier -RT.
Modifier -52 is used to indicate the partial reduction or discontinuation of a procedure or other service that does not require anesthesia. This modifier provides a means for reporting reduced services without disturbing the identification of the basic service.
Modifiers -73 and -74 are used to report discontinued procedures when extenuating circumstances or those that threaten the well- being of the patient cause the physician to cancel a surgical or diagnostic procedure subsequent to the surgery. Modifier -73 identifies procedures discontinued prior to the administration of anesthesia. Modifier -74 identifies procedures discontinued after the administration of anesthesia or after the procedure was started (e.g., incision made, intubation started, scope inserted). For purposes of billing Medicare, anesthesia is defined to include local, regional block(s); moderate sedation/analgesia ("conscious sedation"); deep sedation/analgesia; or general anesthesia.
Append modifier -52, -73 or -74 to the code for the intended procedure. If multiple procedures were planned and the surgery is terminated prior to completion, report the completed procedures only without the modifier. Other planned procedures that were not performed are not reported. When none of the planned procedures are completed, report only the first planned procedure with modifier -52, -73 or -74. Do not use modifiers -52, -73 or -74 to report elective cancellations of surgery. The elective cancellation of a procedure should not be reported.
If a procedure is terminated prior to the induction of anesthesia and before the patient is wheeled into the procedure room, the procedure should not be reported. The patient has to be taken to the room where the procedure is to be performed to report modifiers -52 and -73.
Modifier -59 is used to report distinct procedural services. This modifier identifies procedures that are not normally reported together but were performed on a different body site or during a different procedure or surgical session, required a separate incision, were related to separate injuries or were performed during different sessions or encounters.
If there is HCPCS Level II modifier that better describes the circumstances (such as FA, LT or RT), use that modifier instead. For example, a procedure may have been performed on different digits (FA, F1, F2, etc.). Modifier -59 should not be used just to mitigate OCE/CCI edits. One of the circumstances identified above should be present. For example, if simple repairs of the trunk and the nose are performed during the same visit, report codes 12001 and 12011. Modifier -59 should be appended to code 12011 to indicate that the procedure was performed on a different body site.
Modifier -76 is used to report repeat procedures by the same physician. Modifier -77 is used to report repeat procedures by a different physician. These modifiers may be appended to repeat procedures performed by technicians, but ordered by a physician. For example, use modifier -76 or -77 to report repeat EKGs. The code is assigned twice with the modifier appended to the second code. Modifiers -76 and -77 should not be used with repeated laboratory or pathology procedures. Use modifier -91 instead.
Modifier -91 is appended to repeat clinical diagnostic laboratory tests performed on the same date. Modifier -91 is not to be used for procedures repeated to verify results or due to equipment failure or specimen inadequacy. If the same test was performed on different sites, use modifier -59 instead. For example, if two wound cultures were taken from two different wound sites, modifier -59 would be appended to the second wound culture code. However, if a second culture was taken of the same wound site, then it would be appropriate to append modifier -91 to the second wound culture code. If a lab panel is performed and one of the tests within the panel is repeated, modifier -91 is appended to the repeat lab test.
Generally, HCPCS Level II modifiers are required to add specificity to the reporting of procedures performed on eyelids, fingers, toes and coronary arteries. If more than one Level II modifier applies, the HCPCS code is repeated on another line with the appropriate Level II modifier: For example, code 26010, drainage of finger abscess; simple, done on the left thumb and second finger would be coded using 26010FA and 26010F1.
In instances where it may appear that more than one modifier fits the circumstances, always use the most specific modifier. If there is a CPT modifier and a HCPCS modifier that fits the circumstance, then generally the HCPCS modifier is the most specific.
Take some time now to review the descriptions for the modifiers not discussed in detail. The CPT code book includes a listing of all modifiers approved for hospital use. After you have completed your review, check yourself with the quiz below.
1. A patient is seen in the clinic for chemotherapy infusion. The physician discusses the procedure with the patient. The nurse takes vital signs and prepares the patient for the chemotherapy. Should an E/M code be assigned with modifier -25 along with the chemotherapy infusion code?
2. How is a bilateral tubal ligation reported? Which of the following would be the appropriate code selection?
3. An electrolyte panel is performed, and on the same date, the potassium level is repeated. Which of the following would be the appropriate code selection?
a. 80051 and 84132
b. 80051 and 8413259
c. 80051 and 8413291
4. The excisions of two different lesions of the left breast are performed, utilizing two separate incisions. Which of the following would be the appropriate code selection?
a. 19120 units of 2
b. 19120LT and 19120LT
c. 19120LT and 1912059LT
5. An excision of a chalzion of the left upper eyelid and a biopsy of the left lower eyelid are performed during the same operative episode. Which of the following would be the appropriate code selection?
a. 67800 and 67810
b. 67800 and 6781059
c. 67800E1 and 67810E2
d. 67800E1 and 6781059E2
This month's column has been prepared by Cheryl D'Amato, RHIT, CCS, director of HIM, and Melinda Stegman, MBA, CCS, clinical technical editor, Ingenix (www.ingenix.com), which specializes in the development and use of software and e-commerce solutions for managing coding, reimbursement, compliance and denial management in the health care marketplace.
Coding Clinic is published quarterly by the American Hospital Association.
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Answers TO CCS PREP!: 1. b: In this instance, it is not appropriate to assign the E/M code with modifier -25. The patient presented specifically for the chemotherapy, and no additional E/M services were provided; 2. a: Code 58600 has bilateral in its definition; 3. c: Appending modifier -91 to the repeat potassium level indicates a repeat laboratory test; 4. c: Modifier -LT is appended to both procedure codes to identify on which breasts the procedures were performed. Modifier -59 is listed first for the second instance of 19120 because it may affect reimbursement and indicates that the procedure was performed on a different lesion; 5. c: Modifiers E1 and E2 indicate that the procedures are performed on different eyelids. It is not necessary to assign modifier -59 in this instance to indicate a different site.