Sunday, January 23, 2011

Modifiers - significant issues & changs

To my readers: I found this post on the Advance site and thought this info was too good not to share! *********************************************

Don't Let Modifiers Change Your Coding

Take a look at some of the more significant issues and changes to CPT modifiers.

By Melissa Brown, RHIA, CPC, CPC-I, CFPC

An annual phenomenon for coders is the eager anticipation of the arrival of the new CPT manuals. We know to look for added, deleted, and revised codes -- all critical pieces -- but we may not pay enough attention to the little details, the ones so little they are only two characters in length. That's right: I'm talking about modifiers.

While modifiers have been fairly stable over their history, they have gone under some key modifications in recent years. We saw the most drastic changes in 2008, and 2011 offers a few more tweaks. Let's take a look at some of the more significant issues and changes. Realize that some payers will have their own interpretations, which could affect reimbursement or how you apply the modifiers, so be sure to check with your payer to know what to expect.

Modifier 22
Prior to 2008, this modifier was described in CPT as "Unusual Procedural Services." Due to ambiguity of what would be considered "unusual," the modifier was changed in 2008 to read "Increased Procedural Services" and the descriptor expanded to define criteria for increased work. Some specialist have fallen into the trap of believing every service they provide warrants a modifier 22 because every patient they have is "unusual" by nature of their specialty or expertise. While the patient population they serve may indeed be unusual in nature, this alone does not justify the use of modifier 22. Specifically, CPT has indicated the documentation has to support a significant increase time, complexity or effort. It's important that the documentation include the reasons for additional time or work, and not just a generic statement. The more detailed the documentation, the better justification if/when the payer needs more details.

For example, "50 percent more time than usual was required to excise the tumor due to the presence of an unusually dense mass of adhesions at the operative site; causing the total procedure to last 90 minutes instead of the average 60 minutes" is more effective than, "procedure took an extra 30 minutes due to adhesions." The more detailed description gives the payer a comparison for considering how much to increase pay for the service and specific reasons for the increased work.

Appropriate circumstances to report modifier 22 (when properly documented):

  • Intra-operative hemorrhage resulting in a significant amount of increased operative time.
  • Emergency situations that require significant effort beyond the normal service. This does not include minor intra-operative complications that sometimes occur.
  • Abnormal pathology, anatomy, tumors and/or malformations that directly and significantly interfere with the normal progression of a procedure.

Inappropriate circumstances:

  • Additional time alone does not justify the use of modifier 22.
  • Do not use this modifier when the existing CPT code describes the service.
  • Do not use to indicate a specialist (no matter how specialized) performed the service.
  • If the complication is due to the surgeon's choice of approach; for example, the surgeon has elected a vaginal approach for a hysterectomy that would not have resulted in increased time or effort if performed abdominally.

Modifiers 25 and 59
Because there was confusion between these two modifiers, the language in the descriptors were changed in 2008 to emphasize that modifier 25 Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service is to be used with E/M services only and modifier 59 Distinct Procedural Service is for use with non-E/M services. Both descriptions were modified to remove restrictions as to which types of providers could use them. This allows providers that are recognized by various payers to use the modifiers (e.g., chiropractors, physician assistants, physical or occupational therapists).

There is much confusion on the appropriate use of modifier 25. For instance, there is a popular belief that modifier 25 can be applied only if the diagnosis for the E/M is different than the diagnosis for the procedure. According to the CPT descriptor, different diagnoses are not required for reporting modifier 25.

Appropriate circumstance for reporting Modifier 25

  • A significant E/M service unrelated to the reason for the procedure is performed (e.g., patient presents with complaint of irritated skin tags, which the provider removes. Prior to leaving, patient mentions in passing a lesion related to a recent burn. After evaluating the lesion, the provider prescribes a topical treatment for the burn. In this case, the E/M related to the burn can be billed with a modifier 25 to separate that work from the removal of the skin tags)
  • A significant E/M service above and beyond the other service provided on the same day is performed (e.g., a patient comes with complaints of a sore throat. The condition is evaluated and treated. Later the same day, the patient presents for treatment after stepping on a nail.)
  • E/M work above and beyond the typical pre- and post-op work associated with the procedure is performed (e.g., patient becomes dizzy, falls resulting in a laceration to the head. During the visit, the provider repairs the laceration and evaluates the reasons for the patient's dizziness.)

Inappropriate circumstances:

  • Do not use modifier 25 on the procedure code.
  • Do not use modifier 25 when the E/M resulted in a decision to perform major surgery.
  • Do not use modifier 25 when the E/M is mainly related to the procedure (e.g., patient presents for follow-up for ongoing acne treatment. During the visit, acne cysts are injected. In this case, the E/M would be included in the acne surgery.)

Modifier 59 continues to be used to report services as distinct from each other, and aids in communicating to the payer that both services should be paid even though they normally are considered part of each other. While using modifier 59 may seem like the magic ticket to unbundling CCI edits to get paid, be careful. Inappropriate use of this modifier can be interpreted as fraudulent behavior. The key with this modifier is to ensure the documentation clearly supports a distinct procedure within the parameter of the modifier's description.

Modifier 58 and 78
Prior to 2008, modifier 58 and 78 were being used interchangeably; therefore, both definitions were changed to distinguish appropriate use.

The descriptor for modifier 58 was changed to expand its application to other billing providers instead of limiting use to physicians. Additionally, the phrase "planned prospectively" has been changed to "planned or anticipated." This allows for a broader application in situations where the subsequent procedure is dependent on the outcome of the surgery. We are no longer limited to using this modifier only in situations where the additional procedures were planned ahead of time. For example, during the post-op period, a re-amputation is performed to raise the level of amputation on a diabetic foot. The second procedure would be coded with a 58 modifier. This tells the payer that it was hoped the original surgery would be sufficient, yet the need for additional surgery was anticipated if the patient didn't progress well enough.

Modifier 78, on the other hand, is reserved for those unplanned returns to the operating/procedure room. In these cases, the patient undergoes the surgery or procedure with no expectations of additional surgeries/procedures. Note that the expansion of this modifier description to include "procedure room" allowed for this modifier to be used outside the inpatient setting. A common scenario for using modifier 78 is a return to the OR to control post-op bleeding.

For 2011, the phrase "or other qualified health care professional" as been added to the descriptor of Modifiers 76, 77 and 78 to expand the scope of these modifiers to more than just physicians.

As you can see, if you've ignored the changes to the modifiers over the past few years, you may have missed some key billing opportunities. When you dive into the treasure of the new CPT manuals, it's important to explore every aspect -- even the smallest of details can make a difference for you!

Melissa Brown is vice chair of AAPC Chapter Association Board of Directors.

CPT is registered trademark of the American Medical Association

January 2011 Coding Tips

This update is a contribution from our “Coding Guru Gail” Thanks so much for allowing me to send out… Also, be sure to check out the Cigna website at the end of this post for webinars and free education regarding medicare services.... HAPPY CODING!

Starting Jan 1, 2011 you may now bill your patients for one annual wellness exam each year. The annual wellness exam is a service separate from other preventative services such as smoking cessation and breast and pelvic exams. You are free to bill all covered preventative services along with the annual wellness exam. You are also free to bill an additional E&M on the same day, however it must be separately identifiable and must be due to the need of an acute problem. It needs to fall outside the scope of long term issues that need addressed.

G0438- Billed for the patients first ever annual wellness visit (AWV) RVU's = 99204

G0439- Billed for every subsequent annual wellness visit (AWV) RVU's = 99214

There are nine required criteria that need to be performed and documented

  1. Establish/update individual medical and family history

  1. Create/update a list of current providers and suppliers, and medications including supplements such as vitamins

  1. Measure height, weight, body mass index or weight circumference, blood pressure and heart rate

  1. Check for signs of any cognitive impairment ( CMS has declined to provide any standardized tool and suggests providers rely on there "best clinical judgement")

  1. Screen for depression and functional status ( only required to be done on the first ever exam G0438)

  1. Establish/update schedule of screening services for the next 5-10 years

  1. Establish/update a list of risk factors

  1. Furnish personalized health advice and referral where needed to health education or prevention counseling services or programs

CPT changes 2011

Evaluation and Management

New CPT codes for Observation Subsequent Care codes. These codes are used for all subsequent days following an admission to Observation status prior to discharge

99224- Subsequent observation care- per day- requires 2 out of 3 components

-problem focused history

-problem focused exam

-Medical decision making straightforward or low complexity

99225- Subsequent observation care- per day- requires 2 out of 3 components

- expanded problem focused history

- expanded problem focused exam

- Medical decision making moderate complexity

99226- Subsequent observation care- per day- requires 2 out of 3 components

- detailed history

- detailed exam

- Medical decision making high complexity

New Medicare specific wellness codes

G0438- Annual wellness visit (AWV) First AWF (billable 1 year after Welcome to Medicare exam if performed on first year of Medicare)

G0439- Annual wellness visit (AWV) Subsequent years AWF

See above for the required documentation components.

G0436- Smoking and tobacco cessation counseling visit for asymptomatic patient 3-10 minutes

G0437- Smoking and tobacco cessation counseling visit for asymptomatic patient greater than 10 minutes

99406 and 99407 will still be used for symptomatic patients


Two skin debridement codes have been deleted. 11040 and 11041. Providers are instructed to use

97597 sharp selective skin debridement for ongoing care- 1st 20 sq cm

Other debridement codes 11010-11044 have new language to clarify how many square centimeters of subcutaneous, muscle, fascia or bone were debrided. Codes 11045, 11046, 11047 and 97598 have been added to capture each additional 20 sq cm of debridement.

Providers should now document how many square centimeters of debridement was performed in their procedure note


Two new spinal arthrodesis codes

20551- Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; cervical below C-2

20552- - Arthrodesis, anterior interbody, including disc space preparation, discectomy, osteophytectomy and decompression of spinal cord and/or nerve roots; each additional interspace


Lower leg Vascular intervention codes 37720-37235 have been deleted. New CPT codes 37720-37235 have been added to encompass catherizing the vessel, interventions and radiologic supervision and interpretation related to the intervention performed.

Heart Catherization codes 93501-93556 have been deleted and replaced with new Heart Catherization codes 93451-93533. The new cath codes encompass right, coronary artery or right and left into one code that includes the injection and the imaging supervision.

Cardiac testing changes includes deletion of Holter codes 93230-93237. New codes 93224-93227 have been added with new language that states up to 48 hours instead of for 24 hours.

General Surgery

New codes 43327-43338 for laparotomy paraesophageal hiatal hernia repairs

New codes 43753-43757 for gastric intubation procedures

Nervous System Surgery

There are some code description revisions for transforminal epidural injections to include imaging guidance

New code 64611 Chemodenervation of parotid and submandibular salivary glands


Immunization administration with counseling codes 90465-90468 have been deleted.

New codes added

90460-Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; 1st vaccine or toxoid

+ 90461- add on code- each additional vaccine or toxoid

New Vaccine codes (all pending FDA approval)

90644 Meningococcal conjugate vaccine,seroproups C&Y and Hemophilus influenza B, tetnus toxoid conjugate (Hib-MenCY-TT) 4 dose schedule children 2-15 mos of age

90644- Influenza virus vaccine, pandemic formula, live, for intranasal

90666- Influenza virus vaccine, pandemic formula, split virus, preservative free for intramuscular use

90667- Influenza virus vaccine, pandemic formula, split virus, adjuvanted for intramuscular use

90668- Influenza virus vaccine, pandemic formula, split virus for intramuscular use

New Medicare code

Q2037- for influenza vaccine-90658 no longer payable


Deleted codes J0170-adrenaline epinephrine- Use code J0171

J0559-Penicillin G benzathine and Penicillin G Procaine 2500 units

- use code J0558

J0560- Penicillin G benzathine, up to 600, 000 units – Use code J0561

J0570- Penicillin G benzathine, up to 1,200, 000 units- Use code J0561

J0580- Penicillin G benzathine, up to 2,400, 000 units- Use code J0561

New code J0561- Penicillin G benzathine, 100,000 units

J0558- Penicillin G benzathine and Pencillin G procaine 100, 000 units

Referring Page:

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