Tuesday, December 1, 2009

CPT Modifiers – Know Them by Family

HI TO ALL!!! With the Holiday season upon us, it has been a very busy few weeks. However, I came across this article and thought I would share out to all of you. This is from the "Coding Compliance Advisor Newsletter - November 2009"
(put out by WoltersKlewer) I know that modifiers can be so very difficult, but this brief article really helps put it into perspective... ENJOY!

CPT Modifiers – Know Them by Family
By Laureen Jandroep, CPC

To better choose what modifier to use follow these steps:

1. Identify your situation

2. Match it to that family of modifiers

3. Pick the modifier in that family that best describes you situation

Modifiers and Compliance

Modifiers help tell the rest of the story when it comes to coding. As with all coding, any modifiers appended to a code need to be substantiated in the medical record. Due to the nature of many modifiers bypassing computer edits on the payers side that would otherwise block a line item or entire claim from being paid the coder has to be especially careful about the selection of modifiers.

Global Package Modifier Family

If you need to submit a claim for service that occurred in a global period that is not for routine follow up consider one of the “Global Package” modifiers. First you have to determine if the patient is in a global period. Most payers follow Medicare guidelines which are published in the Medicare Physician Fee Schedule Database (http://www.cms.hhs.gov/PhysicianFeeSched/). There is a column for each CPT and HCPCS Level II labeled “Global Days” and will contain one of the following:

000 This means there are no global days assigned to this code. These will generally be assigned to endoscopic or minor procedures.

010 For minor procedure with expected normal follow up in a 10 day period.

090 For major surgery with a 1-day preoperative period and a 90-day postoperative period included in the fee.

MMM For maternity codes where the usual global period does not apply.

XXX For codes where the global concept does not apply

YYY For codes where the carrier is to determine whether the global concept applies.

ZZZ The code is related to another service and is always included in the global period of the other service.

Once you determine that you are indeed in a global period for this patient you need to apply one of these modifiers for your claim to even be considered for reimbursement. Most of these modifiers don’t adjust the fee—it just gets the claim through the door for consideration.

Global Package Modifier Family

Brief Description
How to Use

Unrelated E/M service by the same physician during a post-op period
Use this modifier when you have an E&M visit that has nothing to do with the surgery that has put the patient into a global period. Per CPT Assistant May 1997 “"Modifier -24 is used when a physician provides a surgical service related to one problem and then during the period of follow-up care for the surgery provides an evaluation and management service unrelated to the problem requiring the surgery." Note it does not say unrelated to the surgery itself.

Decision for surgery
For surgeries with a 90-day global period you also have a 1-day preop period that is bundled in. This is for the preop visit after the decision for surgery has been made. If the visit where the decision for surgery was made happens to be the day of or before the surgery it will get bundled in to the surgery code unless you append this modifier.

Staged or related procedure
Use this modifier when you are providing another non EM procedure that is related to the procedure putting the patient in the global period. Without it your claim will be kicked back.

Repeat procedure by same physician
Use this modifier when you need to report the same CPT code within the global period of the first. This will identify the procedure as not being a data entry error and will also get it through the door to even be considered.

Repeat procedure by another physician
Same as for -76 but with a different physician performing the service.

Return to OR for a related procedure during the postop period
Typically this modifier is used when the patient has complications and needs to return to the operating room for treatment.

Unrelated procedure or service by the same physician during the postop period
Use this modifier when you are providing another non EM service that is not related to the surgery that has put the patient in the global period.

Surgical care only
These three modifiers are designed to break up the global package in its relative pieces of one surgical CPT code. There would need to be a documented transfer of care between the physicians sharing the surgery CPT code. Most payers bundle the preop with the surgical care piece so it is rarely used.

Postoperative management only

Preoperative management only

Bundling Modifier Family

In this family of modifiers you’re dealing with codes that could be bundled into other codes or represent a portion of a service represented by a code.

Brief Description
How to Use

Significant separately identifiable E/M service
When ever you bill an E&M service with a procedure you will need to append this modifier to the E&M code or else it will not get paid. The payer considers each procedure code to have an inherent E&M component so unless you append modifier -25 they will think the E&M is this inherent component and will bundle it into the procedure code. Your E&M code should be clearly separate from the procedure note. A different diagnosis helps to show the E&M is truly separate from the procedure but is not required.

Professional component
Many codes when reported represent a global code – most of your radiology codes fall into this category. If reported without a modifier the full fee will be paid. If your physician only provided the professional component (interpretation and report) append -26. If your practice owns the equipment and employs the staff to run it but you did not provide the professional component append –TC.

Distinct procedural service
This modifier is used when you have multiple procedures and one is usually considered a component of another. The National Correct Coding Initiative edits (http://www.cms.hhs.gov/NationalCorrectCodInitEd/) are used by Medicare and many other payers to determine this. If you have two codes that are considered bundled together but they were done at separate times, separate locations on the body, etc. you can override the edit by using -59.

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