General Surgery Coding Alert

The following supplement to General Surgery Coding Alert is the transcript of a teleconference presented by The Coding Institute. To obtain the slides for the conference, please log on to our Online Subscription System at http://codinginstitute.com/login and download the current issue, and the slides will be contained therein. If you're not sure how to use the Online Subscription System or need help downloading the issue, please contact our customer service department at 1-800-508-2582 or service@medville.com, and one of our representatives will be able to assist you.

The speaker for the teleconference, Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS is a leading national authority on medical coding and reimbursement. Ms. Jandroep ran a successful practice, which billed over $1.6 million per year with less than .06% rejection rate. She currently owns A+ Medical Management & Education, a prestigious national provider of coding and reimbursement training, research and consulting. Ms. Jandroep founded the South Jersey Chapter of the American Academy of Professional Coders and is an active supporter of this and other chapters. She also formed the Coding and Reimbursement Network, a national online community of medical coders, billers and office managers that delivers education via computers and telephones.

Welcome everyone.  My name is Laureen Jandroep and basically I thought I was going to be an occupational therapist when I grow up.  That is why I went to school for and I ran a therapy practice for about ten years where I kind of got very involved in the clinical world and the management aspect of healthcare.  When prospective payment came to the arena, pretty much my rehab business was over because nursing homes, which were my prime clients, no longer wanted to outsource the therapy services. So I got into billing because we were doing 1.6 million in billing a year on our own and we really were doing well - we had less than a 0.06% rejection rate so we thought wow, we are really good at billing so let us do that.  And I did that for a little bit, found out really quick that to be a good biller, you really needed to know coding, and I took a course and became a certified coder and in the process was teaching on the side and fell in love with teaching.  I absolutely love it, much better than the other career path I was in.  So this is what I do now full time.  I teach people how to become certified coders and do teleconferences like this, talk at local chapter meetings and things like that so I hope you will enjoy today's presentation on modifiers.  It is one that I cut my teeth on many years ago, my very first public speaking so it is near and dear to my heart.  If you have any questions that you do not get answered at the end, please, take advantage of e-mailing and I will do my best to research it and get the answer back to you.

What I would like you to do is in your handout packet, if you could take it out and I want you to pull out the modifier grid.  It is a two page form.  On the top, it says "Modifiers-It's All About The Money" and then modifier grid.  It is two pages, pull that out from the rest of the packet because we are going to be really using this throughout most of the presentation.  Then what I would like you to do is to separate out the power point slides.  There are 20 pages of them and if you could just quickly take a minute to just number them, 1-20 so that as I am going through the presentation, when I say what page I am on, you can make notes there and see where I am. 
One of the recommendations I make as well is if you are the type of coder where you use your manuals a lot, then I would actually grab your CPT book, if you have it handy and make notes in the margin in appendix A where all of these modifiers are actually located and today's presentation is going to focus on the modifiers in CPT.  We are not going to get into HCPCS modifiers other than a general overview.  Modifiers really apply to all specialties and what I am going to teach you today is the correct coding use of modifiers.  Of course when you use them in the real world, payers sometimes change what we are taught as being a correct coding principle so just be aware that Medicare might tell you to do it a little differently than another payer or workers comp.  We had someone write in that, that is their specialty.  So just be aware that the presentation today is focusing on correct coding using modifiers across the board but you might find variations in your own specialty and of course at the end of the call you can ask me your specialty-specific questions.

Okay looking at page 1 of the power point where it says, modifiers-it's all about the money!

The second slide is basically explaining why I name it this way, thinking about the money.  And when you think of a CPT code, a five digit CPT code or HCPCS code, it is normally attached to a fee unless it is an unlisted one.  And when you append the modifier to it, it is going to do something to the money normally.  That is normally what the main use for modifiers is for.  They can also just be factual, just to let us know it was on the right side or left side, it might not affect the money so throughout think about that if you are battling between, well, do I use this one or do I use that one, they both seem to fit.  If you think about what it does to money, the fee, then that should help you in your selection.

It is important to know that there are actually there levels of coding modifiers.  Level I is what we are going to be talking about today.  These are the ones in appendix A, they are the CPT modifiers.  So in the coding world when we say HCPCS codes or HCPCS modifiers, that is basically the government's - CMS's - coding system and what they decided to do is they did not want to recreate the wheel so they said okay level I will be CPT.  That was one of the biggest things that confused me when I was a rehab biller because they would say HCPCS code and then they mentioned a CPT code, and I'm like okay wait a minute, is it HCPCS or the CPT?  So that in itself is just helpful to know that.  So when they are talking about level I modifiers, they are talking about the ones in CPT.  Level II modifiers are the alphanumeric ones that you do find in your HCPCS manual on the front cover or back cover and they have an appendix in the back of most of them that list them all out.  There are tons of them so I normally have my students memorize the ones in CPT, but not HCPCS for that reason and it really is a good skill if you can get those modifiers memorized from CPT.  It will really go a long way in your billing and coding.  There is also a cheat sheet in the front of the CPT manual where they list all of the modifiers with a real brief description, but the full description of them is in appendix A in the back of your manual. 

The level III HCPCS modifiers are really going by the wayside because these are modifiers that are normally told to us by our regional carriers.  The government is really trying to do away with it.  They want everything done on a national scale and with HIPAA and standardization, you are going to probably find out you are not going to see too many level III modifiers.

Okay moving on to the second page of the power point what do modifiers do?  Well basically they are going to modify the code description.  Coders are storytellers, hopefully factual storytellers.  We do not want to be committing fraud, so whenever we put a five digit CPT code on a claim form and a modifier, we are saying we have the back-up or the proof back at the office for what we are billing or claiming payment for.  So the modifiers just help round out the story to make it more clear and therefore they are very important part of coding and we are giving a lot of attention to.  There are actually a couple of ways you can report them on the claim form.  You can report them as a single line item.  For example, if you have a CPT code 12345, you could just put 22 next to it on the claim form.  The dash really is just, you do not really actually put that on the claim form, that is what is used just visually when we look at it and report in newsletters and things like that to make it more visible, but you actually would stick it on the end.  Or you could actually report it as two line items.  This is not done too much anymore.  It used to be done because the computer system on the payer side or on our side, could not handle modifiers so you would actually put a line below it and start with 099 and then put whatever two digit modifier you wanted to use.  So in the example I have on the slide it is just 09922, rather than putting the 22 right after the five digit CPT code, but you probably would not see that too much because our computers are more sophisticated now and can handle multiple modifiers on the line item for the procedure.

Then the next couple of slides are just showing you a print-out of a 1500 form, with it listed as one line item, where that would go on the claim form.  Another one, kind of tiny, but you can see it is actually two line items, five digits
each.

As far as general tips for using modifiers before we get into talking about them individually, if you have an unbundling situation where you know that the payer is going to think that two codes, one should be bundled into the other, but your situation is such that they should not be.  Maybe they are done at a separate time of day, separate site and you know what I am talking about - modifier 59 - you are going to put that first.  So maybe your are an assistant surgeon and you also did it on the right side and you have like three modifiers you want to put on there.  Put 59 first because if you put the other ones first, the claim might get stopped and sent back to you, it would not even get to the point of analyzing that other one.  So the next thing I want to think about after you put any unbundling modifiers first, is ones that affect payment.  So if you have a situation where you expect the money to go down like modifier 52, you do not want to reduce your fee because they are going to reduce the fee.  You do not want them to reduce the reduction, so leave the fee as it is.  Now if you expect the modifier to make the money go up, then the opposite is true.  You should increase the fee because they are not going to do it for you.  That being said, typically modifiers like 52 and 22 are going to require that you send in the documentation and sometimes you might be agonizing over which modifier to use.  The bottom line is they are probably going to need documentation, do not agonize over it because you are going to be basically sending in a cover letter and they are going to be determining what to pay you, so do not sweat those if you have send in documentation.  And of course the last point, you really need to know your payer and your setting, so if you are dealing with workers comp, I understand that that is very different from state to state, then you need to know the workers comp rules for using modifiers in your state and for your particular payer.  Medicare is pretty clear and what they want in all of the transmittals and memoranda that we get from them so that is pretty clear.  The best thing to do is take your top three or even possibly your tope five payers and make a little chart of how they want you to handle certain situations.  You might even want to just augment this modifier chart you have here.

Okay let us take a look at that modifier chart.  Basically what I did was rather than teach modifiers in numerical order, which did not make sense to me, I tried to find commonalities with them and kind of group them into families of modifiers or types.  So there is a key in the upper left-hand corner of your modifier grid and basically whenever you see GP next to it, it is letting you to know that it is a global package modifier and we will talk about that in a little bit.  BUN means that the modifier is related to bundling or CCI edits.  E/M only, self-explanatory.  The # sign means it is a modifier that has something to do with the number of physicians involved.  Anesthesia, self explanatory.  Labs, lab related and Oth is all other modifiers that just did not fit into one of those families real neatly.  So we kind of group it that way, it really helps us to put the pieces together.  Then in the upper right hand corner of this form is the money key.  Basically if you see an arrow that goes up, then it indicates that you would expect when you append that modifier that the fee should go up.  If the arrow just kind of goes up into the right, you are not expecting to get paid more but if you did not put it on, the claim when it get through the door, it will not even be considered.  Arrow going down, you expect the money to go down and the arrow just going to the right, this means that it is informational only.  Okay this is a general guideline and what I recommend that you do is, do use your CPT book in appendix A.  Just transfer those symbols right in the margin so that will help you.  For example, the very first one we are going to talk about, modifier 24.  You will see the short description right next to it, unrelated E/M by the same physician during postop period.  In the type column, it is a global package modifier as well as an E/M only modifier so you could just put that right in the margin next to -24 and then the arrow going up into the right.  So real quick that kind of tells you the story about how to use that modifier.  Okay, that just kind of orients you a little bit to the form. 

The first thing we are going to talk about is a global package family of modifiers so you can see basically -24 down to -56 there.  But what we have to understand first is what is this global package concept?  On page 4 of the power point you will see the last slide talking about the global package concept and it in essence includes three things: preop, the operation itself and postop.  And so the modifiers that we call global package modifiers are related to those three pieces.

On page five, we have what is preop?  Basically, it is now defined as the day of the procedure or the day before the procedure, that little E/M visit that they do where the decision has already been made to have the surgery and they are just having that conversation with the patient before they actually do the surgery.  So that is preop.  Before the AMA in the CPT manual would just say that it was the preop visit prior to surgery, it did not give a timeframe, where CMS said clearly the day of or the day before.  Now CPT has adopted that same definition.  You will see that change in there.  The second piece is the operation.  Normally we all get that.  We see that in the CPT manual and when we turn to the five-digit code for the surgery, it is clear that is what is being done.  And along with that any prep like, local infiltration, topical anesthesia.  If it is anesthesia from the wrist or like ankles down metacarpal, metatarsal and finger blocks, digital blocks - that is all bundled in.  That is part of the operation piece.  Then the last part, this is the one where most of the modifier issues come into play is the postop follow-up care.  Now CMS gives us a Medicare fee schedule database and I recommend that you to go check it out.  I gave you the link there on that third slide and you will see you can download an Excel spreadsheet and it has got columns.  The first column is every single CPT and HCPCS level II code, and then you have got all theses other columns.  Many of them having to do with modifier usage.  Okay so one of the columns is talking about the follow-up days.  They have got 000 if there is no follow-up days for that particular code, 010 if there is 10, and 090 if there is 90.  Sometimes they have XXX like it does not apply, maybe it is an add-on code.  The add-on code is being added on to a principle procedure, that is the one that was going to carry the global day so it is not applicable or MMM if it is a maternity code, things like that.  Your software probably has this information built into it.  I use code correct, it is on the Web, it is always updated and I just pop in my codes and I have a little icon where it can tell me what modifiers apply.  So just be aware of that.  This is where most of these billing software companies are getting the information from right from the Medicare fee schedule database.  Now of course not all payers follow Medicare but many do.  So that is why I said that you do kind of an analysis of your top 3-5 payers and you find out how they want you to tell that it was a co-surgery.  How do they want you to tell that it was a reduced service.  Just make sure that it is in line with what your understanding is.

Now in talking about the global package, it is important to mention about starred procedures which no longer exist, page 6 of the power point slide there.  They used to tell the story that that particular code if it was starred was not subject to the global package.  The global pack did not apply.  Therefore the follow-up days were zero.  The problem was Medicare never recognized the star.  So you are a biller and you bill out a claim and you see the star on CPT and you think, hey, the patient came in three days later, I am going to bill the E/M because there is no follow-up days.  Well Medicare for that particular code, especially if there is an incision in the skin, gave it a 10 day global so it kind of confused everything.  So CPT now has adopted the same definition as Medicare and just eliminated the star.  So now it is really up to us to find out from the payer what the global days are.  And with Medicare they give us that fee schedule database.  With your other payers, find out - in your contract ask, do you go by in Medicare guidelines or do you have your own?

Now the first modifier we are going to talk about in this family, modifier 24, unrelated E/M by the same physician during the postop period,  we see that it is an E/M only modifier and it is also in this global package family, so right away if it is not an E/M code, it does not apply and if you are not in a global period, it does not apply.  So the arrow is pointing up into the right hand corner.  We are not expecting the fee to go up just because we put 24 on it but we are expecting it to get paid.  We might have a situation where the patient had a hysterectomy 4-5 weeks ago and now they are coming in to the same specialty and they have another problem that is unrelated.  They have different diagnoses and you would think that would be enough to tell the story that this is unrelated, but we have to remember that our computers are talking to the payers' computers and it is not a human review we are looking at it, at least not initially when it is performing all of these edits.  So they rely on the modifiers in the procedure codes not the diagnoses.  They will use diagnoses to see if it supports the procedure but not, 'hey is this a different diagnosis?  Okay let us let this clam go through.'  So we have to do that by putting 24 on it and also makes us responsible.  If we append -24 we are telling the payer we have proof on file that this is a different reason that this physician is seeing the patient within the follow-up period.  And so you just expect to get paid as normal.

Modifier 57 is the next one.  This is more having to do with the preop side of the global package.  If your physician happens to see you the day of this procedure, the day before and that is when he says, 'oh my goodness, this is serious.  You need to get his done right away.'  And therefore when the claim is dropped it looks like there is an E/M on the day of or the day before the surgery - what is the payer going to think?  He will think, 'oh that is preop, that is bundled in, we are not paying it' - unless you put modifier 57 on it.  Modifier 57 tells the story that 'I know I look like the preop visit but I am not, so pay me.'  The day that the physician decides to do the surgery that is the visit that deserves to get paid because that is not a preop visit.  So that is why I like the definition in CPT that says about the global package, it is subsequent to the decision for surgery, the visit on which the decision for surgery was made.  Now I have had people say, 'but Laureen, I never used modifier 57 and I always get paid.'  Well it is a probably a function of your billing.  Let us say, you dropped you claims on Wednesday and the E/M visit was separate from the surgery code, so if the E/M visit was on Wednesday and that's when you dropped your claim and the surgery was done on Thursday or Friday, that will be on two separate claim forms.  So the payer's system does not even know yet that a surgery has occurred to put the block up, so that might be why.  And the bottom line is when in doubt, if it is definitely decision for surgery, it does not hurt to put it on.

Next we have modifier-58 so kind of leaving discussing E/M and we are talking about another procedure.  The patient is within, lets just say within a 90 day global period of a major surgery, and now they have something additional done, so that 58 is what you would use to tell the story that it is staged which means they knew ahead, or for example a cleft palate surgery, typically that is going to require two surgeries - not always - so if they know that ahead of time, they will bill stage 1 and then may be 4-6 weeks later when they come to do stage 2 they will append modifier-58 to tell the story that it was a staged procedure, but it does not always have to be known ahead.  A lot of people make that mistake, they could actually do a procedure and think that is going to be enough and then they got to bring the patient back to do some more, and it is staged or related to it, they just did not know it ahead, and you still use 58.  One of the interesting things to note with 58 is that it resets the global period, so if you were in a 90 day global period and you are four weeks into it and then you do stage 2 which also has a 90 day global, well then 90 days starts all over again.  Sometimes that helps for the deciding factor, so it would definitely make that note stand out that a new postoperative period began.  58 sometimes gets confused with 78 which we will talk about in just a few minutes, but 78 is more for when there is a return to the OR, more for like a complication and 78 does not reset the global, so you know, if it is something major being done it is going to be 58.

Next we have modifier-76 repeat procedure by the same physician.  The key here is that it is going to be the same CPT code and often times when the payers see the same CPT code they think it is a duplicate, even if it is on a different date of service.  Sometimes they think that it is a billing error or something, so we want to put - 76 to just let them know it is a repeat.  This one I have the arrow going down because Medicare will reduce the fee on that one.
Where as modifier-77, the next one, is repeat procedure by another physician, so again same CPT code but now we are going to have a different doctor represented by different U pin number, and that one they do not reduce the fee, but you do need it to get the claims through the door because the patient is in a global period from the first time it was done, and with both of these you are going to need to send in documentation more than likely, so be prepared for that.

You see the repeat procedure -76 in radiology a lot when they have to do the same x-ray twice, they do two views of a fracture, they set the fracture and they do the same two views again so - 76 is used quite often for that.  By the way, on the modifier grid you probably noticed to the right of these type key and money key the different areas of CPT that you'll actually see these modifiers being used.  So with - 76 you see it is being used in the surgery section but also radiology, medicine, and ASC and hospital.

Page 8 of the power points, we are now talking about modifier-78 return to the operating room, so right there that is a variable that has to be met and there must be an operating room involved in order to even consider using this code and it has to be for a related procedure typically - I do not want you to think it is a hard and fast rule - but typically it is for complications after surgery.  It is normally going to happen you know pretty soon after they just had a surgery, may be they are having you know bleeding from the site or something come unstapled and they've got to go back in and fix it.  They will have a different diagnosis here but still you need to put the modifier on to get the claims through the door.  Think of it as a key that unlocks its.  This one does not reset the global so that normally helps you in determining whether or not you should put 58 or 78, and this is paid at 70-80% of the fee schedule.  It is good to know which modifiers actually apply a mathematical formula and which ones you probably going to have to send in documentation so this is one that applies a mathematical formula.

Modifier-79, this is unrelated procedure or service by the same physician during the postop period so it is very similar to modifier-24 that was for E/M - this is for procedures, so it has nothing to do with the original procedure.  You are going to use modifier-79.  Again you would think that the diagnosis would tell that story but that is not what the computer uses to look at, it uses the modifiers on the CPT code.  And then we have 54, 55, and 56, typically when I tell colleagues that I am doing a presentation where I group modifiers by type, for example the global package family, they think of these three modifiers.  And this really takes the package apart.  So if you have one CPT code and by appending these modifiers you are actually breaking up the fee.  So okay 54 will pay for the surgical part only, 55 will pay for the postop part only maybe those 90 days of follow-up, and 56 will pay for the preop.  Now pretty much you will probably never see 56 used because now preop is bundled into surgery.  So in essence we are really talking about 54 and 55 and this is designed where there is a transfer of care. so maybe one the patient lives in a very rural area and there GP sends them to a specialist.  They go to the city and the specialist says you need this surgery but it would be a hardship for the patient to drive into the city every time she needed a follow-up visit, so he makes arrangements for the GP to handle the follow up part of the package.  So they agree they are going to use the same CPT code, but the surgeon is going to append 54 and general practitioner is going to append 55 and that will split the fee accordingly. And that Medicare fee schedule data base I mentioned at the beginning, you could consult that and see how that split would work and it is recommended that in that freeform text box in your claim form you just indicate the date that your physician turned over care, if you are billing for the surgeon, or the date the physician took over care if you are doing the postoperative part.  I think this is an area that eventually payers are going to start to crack down on for people like, when you are on vacation, you break your ankle and fracture care is done, and fracture care is subject to the global package.  It actually carries normally a 90 day global period.  The patient is going to go home and their general practitioner is going to actually see them for the follow-up stuff.  So the doctor down in Florida - not necessarily where you are on your vacation, no offense to the Florida people on the call - is going to call the doctor in New Jersey like where I am and say let's split that CPT code.  So it is just an area to be careful of.  Technically good coding would dictate that they will bill the CPT code with 54 because they are really only doing that part of the package.  Alright that was the global package family, I hope that was helpful looking at it that way because if you are in a situation like where you have got a situation that is definitely related to follow-up, the patient being in the follow up period.  Look at this chart and shop your list of global package modifiers - which one fits your situation the best?  Chances are you are going to find one that is better than the other, that tells the story better and most of these global package modifiers just simply unlock the door to get you through.  I did want to make one note about modifier-24 it is also used, when we talked about the follow-up period, it is for normal follow-up, no complications.  But say the patient comes in and they are having an unusual complication.  It is related to the surgery but it is not related to the reason they had the surgery. You can use modifier-24 for that situation.  If you look at the footnote that I provided on the bottom of page 2 of the grid, there is little foot note next to - 24 for unrelated E/M, it says per the CPT assisted of 05/97 you can look this up, modifier-24 is used when a physician provides a surgical service related to one problem and then during the period of follow-up care, provides an E/M service unrelated to the problem requiring the surgery.  It does not say 'related to the surgery itself' because of course it is related to the surgery.  Bottom line, if you did not view it that way what modifier would you use to get paid for E/Ms that you do that are related to surgery but are a complication, and per the definition are not subject to the global package?  It is the modifier-24.

Alright lets move on and we are going to talk about the next family of modifiers.  There are only three, these are the bundling modifiers 25, 26, 59.  Modifier-25 is also an E/M-only modifier.  I used to have it in the global package family as well, I will talk about that a little bit because this modifier really fits many different definitions but the key is that you need to have an E/M note that is significant and separate from whatever else you are trying to tell the payer it is significant and separate from, so consultants at different conferences I have attended have given me advice and I agree and share it now, just picture the note.  Do you see clearly a separate history, a separate exam, separate medical decision making.  If you do, then you can bill it with -25.  My little thing is, if you do not have a HEM - history, exam, medical decision-making - you cannot bill an E/M, as far as making it separate and significant.  So it is recommended that the procedure note or maybe it is a preventative medicine note, is written separately, literally on a separate piece of paper from this other E/M note, or at least separated with a line, something to make them clearly distinct.  #1.  It will make it really easy if either of the payers are requesting the documentation if you are dealing with the preventative medicine with an E/M.  You just send in which ever page they need and it does really prove that it is separate and significant.  Now when we are talking about modifier-57, decision for surgery, what Medicare has you do if it is a minor surgery like say with a global days of 10, they will have you use -25 instead of -57 because the procedure will be done on the same day like right in the office type of thing.  So just kind of consider modifier-25 decision for minor surgery as far as how Medicare views it.  That is one way to think of it.  The other way to think of it is if a patient comes in and all they are having done is maybe some lesions removed.  They had the E/M visit previously and now they are coming in just for that procedure.  You are not going to bill an E/M because every procedure has many pre and post procedure E/M component built into it and the payers know this.  You do not just jump in and start whacking off the lesions, you actually assess it.  The physician is going to look at it and they are going to decide okay, I am going to use this type of suture material and I am going to this type of stitch, I am going to remove it this way, so there is some history, some exam and medical decision making done related to providing that procedure, that is bundled in.  But if you end up doing a separate E/M or a significant one, it is way more then what you would typically do related to the procedure, then go ahead and bill an E/M based on how much history exam and medical decision making you have, and append modifier-25 so it gets paid.  Very important that you realize when you append 25 and E/M you are telling the payers that you have proof, you have back-up on file that you have a separate E/M from the procedure.  So if your physician likes to kind of lump that procedure note right in the middle, try to get them out of that habit if you can because it will really make it much better - in case that chart gets pulled - in proving your case.  Otherwise if you have to photocopy a note like that just kind of underline the part that it is the procedure note and say the rest is E/M, or vice versa, so they can clearly see that it is significant and separate. 

Sometimes you have it the other way around, you actually have the patient coming in for an E/M and then lo and behold, they find something that needs to be taken care of. So they have you put the 25 because they do not know the situation, they do not know which came first, the visit and then the procedure or procedure and then, 'oh hey we got to do an E/M on this problem we discovered.'  The bottom line is if they see an E/M and a procedure note, and basically procedure being something that starts with 1-6 in CPT, like from the surgery section.  They are not going to pay the E/M, so you have to put the 25 on it.  I am sure some of the questions you are getting ready to ask at the end of the call, 'yeah but my payers does not pay it even when I put 25 on it.'  That is an appeal situation.  If you truly have a significant and separate E/M then you have to appeal it because E/Ms are a major, major part of every physician's practice so we have to appeal and say this is separate and significant, here is my proof and yes, it is pain but that is what you have to do to establish the practice and hopefully they will take care of whatever computer edit is automatically built in and kicking those out.

Modifier-26, so when you are dealing with radiology codes or codes that involve equipment, there are many that are in medicine section.  When you bill that code with no modifier, you are saying 'pay me for the technical and professional component.'  Technical is reimbursement for the overhead, the staff, the technologist that run the equipment, and the professional component is for the doctor to maybe interpret and read the data that these tests are spitting out or if it is x-ray image, looking at that on a lighted box and dictating a report.  Okay so you have two pieces to it, technical and professional.  It is called a global code, when you bill that you are going to get paid the full fee.  Often at times what you really want to report is just the physician's part, the professional component, you have to put a modifier-26 to tell that piece of the story.  It will reduce the fee because you didn't deserve to get paid for the technical because it was not the physician's equipment, it was the hospital's or wherever else they were using it.  In some situations, you might have an outpatient biller that is billing for the hospital side of the use of the equipment and then the pro fee, the professional side, for the actual radiologist who might happen to be an employee.  You are still going to end up putting a 26 on the radiologist because the facility side is billed on the different billing form, the UB-92 or the CMS 1450.  By nature of using that form and billing it to the part A program, or whatever, they know that that is a facility fee and they are going to pay you the portion of that code accordingly.  Therefore, that leaves okay how do we get paid for the rest of it, the professional fee, you have to bill that on a 1500 form.  Really the only situation where you probably will not use modifier-26 is when it is a free standing type of radiology clinic like we have here locally, community radiology.  And the radiologists are on staff, so they do own the equipment and they have the radiologists on staff.  They want the total code, they want to be paid for the whole things, so they would bill it with no modifier. 

There are some codes you need to be careful of in the medicine section where it is basically a parent code and a couple of indented codes and the parent code is really for the total procedure and then indented underneath it, you have got one that represents the professional component and one underneath it that presents the technical component, and maybe even two pieces of the technical component.  In that situation you would never put a 26 on that top code because there are available codes to tell the story that this was just a professional component, so be aware of those.  You only want to put it on global codes.  If you use that Medicare fee schedule data base, it will let you know which codes have a professional and technical component, so use that to help you with that.

Modifier-59, this is the un-bundling modifier and it is one that is getting the most attention these days.  It is actually the most overused one.  We need to talk a little bit about the correct coding initiative to really understand this modifier which is now available for free.  We do not have to pay a mint for it, it comes out every quarter.  I do not have the exact link but if you go to www.cms.gov and you type in the little search box CCI it will bring you to the page where you can look at these edits.  And basically what they are in a nutshell is just picture of one comprehensive code, like may be a hysterectomy.  You have got your 5 digit CPT code in one column then in the column next you have got all these series of CPT codes that they consider bundled into that procedure, so if it is an abdominal hysterectomy then the laparotomy code 49000, is going to be bundled into the hysterectomy code.  It is part and parcel, the approach is bundled into the procedure, those we can almost figure it out.  But many, many, many other things, unless you are a surgeon and you know every signal thing that is included, you would not know, as you are preparing these claims, which is bundled into what.  So we use the CCI edits.  What will happen is if you bill a pair where one is bundled into the other and you have claims scrubber, which hopefully you do, it will put up a flag and then you have to go look at it.  Now in the CCI edits, they have a superscript next to these codes in column 2, if you have 0 it means we do not care what modifier you put on, it is not getting paid.  But if it has a 1 then there are some modifiers, which is modifier-59 99% of the time, under certain circumstances that you could use that would apply.  So in using the exploratory laparotomy code 49000, if that is all you do then that is why the code exits, go ahead and report it.  But say your are doing an exploratory lap and you find something and, 'oh, this ovary needs to come out,' you do an oophorectomy.  You do not bill the laparotomy, you only bill the oophorectomy.  But what if they did the oophorectomy earlier in the day and something went wrong and you have to go back in and open the patient up.  You did two laparotomies, you deserve to get paid for that second laparotomy.  You put modifier-59 on to unbundle it.  Or could have been you did the exploratory laparotomy in the morning did not find anything, close them up, later on that you had to go in - the appendix burst or whatever -and then that has to be removed, so in that case you have got a reason and use 59 and that will allow it to go through.  The thing to keep in mind with 59 is that it is considered the modifier of last resort so if there is another modifier that will tell your story, you are to use that instead of modifier-59, and basically you will see language in CPT (separate procedure) like that exploratory laparotomy code we are talking about, that is just like a heads up that this is normally a component code, it is part of other comprehensive procedures, just make sure if you are reporting me with something else that I am not considered bundled into it.  It is just a heads up.  And that is really it as far as the bundling family of modifiers.

Evaluation and only modifiers, those are pretty self explanatory.  Really we have talked about all almost all of them already except for modifier-21 and 27, so let's talk about a little bit about modifier-21.  You will notice that arrow goes up and I also put it to the right.  Medicare kind of considers this informational only, they will not increase the fee, but other payers might, so that is why it is kind of either situation depending on your payer.  The key with this one is that you are only to report it when you are already at the highest level within an E/M category.  So if you are talking about a new office patient.  The highest code for that is 99205, if you are already billing that, and you need to report extra time, you cannot bill anything higher, so use - 21.  I will say in discussing this to consider, and you might want to make a note in your hand outs, to consider prolonged care first.  Prolonged care codes in the E/M section, if you have over 30 minutes of extra time regardless of what level E/M you are at, you can probably report prolonged services as long as the payer recognizes it, which Medicare does.  So consider that.  That is 2 ways get paid for extra time: prolonged care or modifier-21.  And the 3rd way is by bumping up a level, it is not really the scope of this presentation, but if you want to make a note, review page 7 in your CPT manual.  There is paragraph 3 there that talks about time if counseling or coordination of care is more than half of session, we are told we can bill by total time, so if you had a 20 minute E/M on a new patient that will probably be a level 2.  But if you ended up doing 40 minutes of counseling on whatever this problem is that this new patient comes in with, well counseling definitely dominated this session because 40 minutes is definitely more than half, so you add the 40 minute counseling to the 20 minute E/M, you have got a total session of 60 minutes that when you look at the bottom paragraph of the each of the code descriptors between 99201-99205, so you can bump up a level or a couple as in this case, but 21 comes into place when there is no way to bump up to, you are already at the highest level, and you can use modifier -21.

Modifier-27 is only used for outpatient hospital use.  There are a lot of outpatient clinics, a patient might in the same day go to a pulmonary clinic, a diabetic clinic, so to tell that story they cannot have one E/M on the same day, which is a general rule of thumb that we have because they are different specialties. So you put - 27 on it, but if you are a physician based coder, do not even worry about that one.

Moving on to the number of surgeons involved section, the # sign.  We have got modifier-62, 66, 80, 81 and 82, so this is a situation where it is just related to reporting the surgery and you have got some other players involved.  You might actually have the assistant surgeon in the same practice and are billing for both of them, which is kind of an advantage because you can remember to use the modifiers correctly in the same CPT code.  The first one is modifier-62, this is for two surgeons, a co-surgery.  The key to remembering when to use this is when the surgeons needs to share a CPT code.  If they can find the CPT code in the CPT book that represents their work and then there is another CPT code to represent the other surgeon's work, then they do not need to use modifier-62.  It is only when they have to share the code.  There is a misconception out there that if there are two surgeons in the room every single code they do we put a 62 on.  No. it is only when you have to share a CPT code and that does apply mathematical formula.  Medicare will actually multiply it times 125% and then divide it in half for each of the surgeons.  Now if these two surgeons are in different practices and practice A submits their claim and forgets to put modifier-62 they are going to get paid for the whole thing and when Dr. B submits their claim it is not going to get paid, its going to get kicked back, so communication and coordination between the two offices is very important. and that of course that they are using the same CPT code, because if one coder in one office says 'I thought it was this code' - you really need to coordinate your efforts there.  The Medicare fee schedule data base also has a column regarding this.  It will let you know which procedure codes they consider even applicable to having a co-surgeon, again this is a Medicare thing you might have other payers that do not agree with it all but at least you have a starting point.

Modifier-66 is the same thing except you have three or more surgeons, we have seen these things on TV with the separating of the conjoined twins or delivery of sextuplets and you have a team involved.  This one is going to be a 'got to send in documentation,' so it is not really anything you have to sweat too much because they are going to have to decide what the fee is and how to divvy it up among all the players, but that is when you are to use that code.

Modifier-80, we are on page 13 of the power point.  This is the assistant surgeon modifier.  Now in this situation, the primary surgeon does not put any modifiers on their CPT code, but the assistant surgeon does.  They report the same CPT code and they put modifier-80 first and then any other modifiers that the primary surgeon used.  So if they used RT or 50, then the assistant surgeon would as well, but they are going to lead with the modifier-80.  This one will obviously decrease the fee.  I do not know the exact percentage but it definitely applies a mathematical formula.  Again you can check the Medicare fee schedule data base to see what CPT codes they even consider applicable to having an assistant surgeon.  Modifier-81, kind of going down to the packing order as far as the hierarchy of assistants in the operating suite, a minimum assistant surgeon.  Sometime they call them the second assist, third assist, fourth assist, they are going to be paid a very, very small amount, I think it is like 5% or something really tiny.  It does have a mathematical formula applied to it.  Now Medicare does not even recognize this one, they do not pay for it.  If you have other payers that do, then you can go-ahead and use this modifier.  This has been explained to be as used typically for your openers and closers during the surgery.  Maybe they come in and get the patient started, move the organs to the side and then they let the primary surgeon take over and they leave or they might come in and finish up a surgery, close it up, the co-surgeon or the other surgeon had a grueling surgery 6 hours, 7 hours, and they let this assistant surgeon close.  So that is how that story would be told. 

Modifier-82 is the same thing as modifier-80 but when it is done in a teaching facility.  So if your physician that you are billing for works in a teaching facility and they are an assistant, then you are probably going to be using this modifier because teaching facilities supposedly get paid more because they are supposed to use residents as their assistants at surgery.  And there are some situations where there are no residents currently at that hospital that are trained in being an assistant for that specialty.  If that is the case and you have to bring in a nonresident physician to be the assistant surgeon they have to use modifier -82 because 80 will not be recognized.  And 82 again is putting responsibility on us that we are saying we have proof, documentation that there was not a qualified resident available and it does not mean they are down the hall getting a Coke, on rounds, it is just they did not have the training, they did not have the skills to be able to be an assistant surgeon so that is modifier-82.

Next we have the anesthesia family, just two little codes.  I used to actually have these grouped in 'others' and I said well two modifiers still make a family so 23 is unusual anesthesia.  This is basically going to be used on anesthesia codes by anesthesiologists and it might be a situation, maybe you have got a patient who is mentally retarded and they need a procedure done and they do not understand, they are thrashing about and they need to be put under, so the anesthesiologists are going to do that and they are going to put a -23 on that to tell that story.  These do not go on surgery codes and it is not necessarily going to increase the fee or anything it just helps get it through the door, explain that story.  Modifier-47 is the opposite, it is reported by surgeons and it is where the surgeon not only does the surgery but they also do the anesthesia.  I do not know how advisable that is and I do not think that it is actually done that often because Medicare does not pay for it.  If the surgeon decides to do the anesthesia, of course I am not going to get paid for it then I am not going to take that risk.  I will bring an anesthesiologist to do it.  So thinking of situations maybe like for a carpal tunnel surgery where they do kind of a tourniquet and it is more of a regional type thing, that surgeon could probably handle both with obviously having a co-surgeon and nursing staff in the room.  But like I said you are not going to see this too much and if you do it does get appended to the surgery code not the anesthesia code and it is reported by surgeons. Sometimes I am asked, 'do I just put that on one line item and that will increase the fee or do I report the surgery on line 1 and then the same surgery code with -47 on the second line?'  And the answer is it depends on your payer.  So if you have that rare situation occurring, call your payers first and see how they want it reported so you do not get any surprises when the bill comes back.

Lab modifiers, again this is another two modifier family, 90 and 91.  Modifier-90 is an old one 91 is a new one.  I think you are going to see modifier-90 kind of disappearing soon.  This is saying reference outside lab.  In the good old days, the doctors office will draw the blood and send it off to the lab and the lab would run the test and send the report back with the bill, and the physician's office would bill that lab and path code, the one that starts with an 8, and they would append 90 on it to tell the payer that they had sent that lab work out.  And there is a little box on the 1500 form, you have probably seen it, it says, 'outside lab yes or no.'  You would check yes, and on the bottom of the claim from in that middle box where you put addresses for like hospitals or different entities, that is where the address would go for the lab.  It is just really not that any more because Medicare came along and said no, we want the entity doing the work and billing us directly.  So labs have to do their own billing since they are doing it for Medicare, they just do it for everything.  It is very rare nowadays to find a physician's office that is actually billing for labs that they do not do - they bill for their own labs - but outside labs, they are not normally doing that anymore.  Modifier-91 is a fairly new code, the labs are so happy to get this because what happens when you have the same CPT code with the same date of service on the same claim form, it is going to kicked out as a duplicate and labs are always having to repeat tests per the physician order - they want to see what it looks like in beginning of the day, maybe towards the end of the day.  So they were having to appeal things that really in essence ended up being like $2 or $ 3 charges, so it was very frustrating.  So now they have modifier-91, that tells the story that this is a repeat test.  We are only going to use it when you have the same CPT code and we are cautioned to not use it if we have a code like a glucose tolerance test which inherently has multiple tests within it.  We do not put a 91 on that, we only put it on tests that we are running individually, and it also not to be used because of error on the lab's part in running these tests.

Next up we have all the rest, all the other modifiers that did not fit neatly into any of these families.  Modifier-22 is the first one, with this one we are expecting the fee to go up.  This is a documentation guideline one, you are going to have to send in documentation so just be prepared for that.  What you are saying is that there is some extra work that was beyond the normal.  Every single CPT code has a RVU, a value attached to it that is based on the average amount of time, the average skill, the average amount of equipment needed.  So what you are saying is something was beyond the average and we deserve to get paid for it.  The recommendation is when you send in that documentation and you have your copy of the operative report, underline neatly the area of the operative report you feel warrants the use of -22.  Do not highlight it because when the payer gets it sometimes they scan it in and depending on the color highlighter or the type, it will either turn that line to black or it will drop off completely, so just underline it, and that would be a big time saver to them and will hopefully help to get that paid.  But really make sure before you append -22 because you have to send in documentation.  It is not an 'if' it is a definite.  That used to be the most over used modifier before 59 came along, but it is still looked at.

Next we have modifier-32, mandated services.  This is one where your are not really going to see the money go up or down, it just helps support why the procedure was done, it is telling the payer that this was required by either them, maybe the insurance company themselves, or maybe it was a legal thing that was required to put -32 on it.  Some examples that I have heard, one we see all the time in E/M is, 'required 2nd or 3rd opinion' so you put your -32 on that consult code.  Ingenix Coding Lab has a really great book, Understanding Modifiers, it used to be called Modifiers Made Easy I think, and in it was an example of repeat pedophile that the courts ordered to be chemically castrated.  So I guess that physician will put a - 32 to say hey, they may be do it.  I do not know if that really happens, I thought that was an interesting one.

Modifier-50, page 17 of the power point handout.  This one we expect the money to go up and for most payers this does apply mathematical formula of paying the fee at a 150%, which makes sense, because when you have multiple surgical procedures the payer will normally pay a 100% of the first one and 50% for the subsequent one, so if you had two procedures, you would be getting paid in essence 150%s, so the question is do I put this on two line items, one line item?  If you are dealing with Medicare and payers that follow their techniques, you put it on one line item, because when you put 50 on that code, it is going to apply a mathematical formula and pay you 150%.  I have heard stories of practices that pay back a lot of money because, they were getting paid, the biller would put line one, the first code, thinking in their mind, okay this is telling you I did the right side, and then on line two they put it again with - 50 thinking okay I did this on the other side.  Well they got paid 100% of the first code and a 150% of the second code, so they obviously were way overpaid.  So be very, very careful of that, really check your EOBs when they are coming in.  The phrases in CPT where you see 'one or both' obviously that means it could be bilateral, if you do not put a -50 on it. 50 is not an informational modifier.  It applies a formula, so you have to be careful with that.  Some payers want you to use RT and LT, you really have to find out, but what I have found and what has been told to me by people that are billing on a full time basis is that the -50 on one line item is the preferred method.  But really monitor your EOBs for that and that is definitely one you should find out from your top 3-5 payers, how they want bilateral procedures reported.

Modifier-51 multiple procedure; this one is kind of going by the wayside, I know the Medicare carrier here in Jersey and I heard a lot of colleagues discuss it - they do not want it anymore because their computer programs are sophisticated enough to determine when it is a multiple surgery procedure and they will gladly reduce the subsequent surgeries, so if you are trying to adhere to good coding guidelines, what we were told to do - and I always view this in my mind not as multiple line items, but multiple surgical procedures is typically what we are talking about here - and what they are looking for is some shared work.  If there is shared work, then the second code should be reduced, because if you think of the value of every single CPT code, they all have a relative value, which takes into consideration the prep time, the clean up time, the use of all that overhead, the skill, the equipment needed.  If there is a component to two codes that is shared and you do not get one reduced, then you are actually being overpaid.  Okay, it is kind of like volume discounting, so think of it that way.  Not all payers view the definition that way, they just say 'no, multiple procedures'.  Even if in your mind, you know there is no shared component with this procedure to that one, they are going to try and reduce it.  You might have to appeal those.  To me it is a very arbitrary modifier, so just be aware of that, know what your payers want and you might be fortunate enough where most of them do not want it, so you do not have to worry about that.  And yes, I am often asked can you use modifier -59 with 51?  Yes in my opinion, you can, because you might have a situation where you are simply trying to say for a CCI bundling situation, hey this one looks like it is bundled in, but it is not, it was done at a separate time of day.  But it might be, let me pick a different situation, a separate site, but it is in the same operative session, so -51 would also apply because it is a multiple procedure within that session, so that can happen.  What I typically do and recommend is I will just put the -59 on and see what happens, because typically if it is in a separate site, there probably is not shared work, based on the RVUs use for those codes and therefore it should be paid separately.

Modifier-52 reduced services, this is one that does not apply a mathematical formula, because they do not know how much you reduced it.  You maybe just reduced it a little bit, maybe reduced it a lot, you are going to have to send in paper work, so you know, do not really sweat whether or not to use this one, just send in your documentation.  And you can use it for things like maybe a bilateral procedure that you only did on one side for various reasons.  Maybe it is an eye procedure and the patient has a glass eye, and you only did it on one side, use a 52 and that of course is going to decrease the fee, but that will be determined later on.

Modifier-53 discontinued procedure, is going to decrease the fee, again, they do not know how much to decrease it by, see you are going to have to send in paper work and as soon as you thing of 53, think of extenuating circumstances.  There is something serious going on that is leading the physician to say hey, we need to stop this surgery or whatever the procedure may be, use -53.  52 and 53 get confused sometimes and you have a procedure that was stopped and you are like what was it reduced or was it discontinued?  And you kind of go back and forth and back and forth, and basically when I have been interviewed on this topic by the Coding Institute, I say for the most part you really do not want to worry about it because you have to send in documentation, so put whatever you think works, because you have to send in documentation for either of those situations.  But I do have a little decision matrix on page 18 of the power point handout and it says 52 versus 53.  This will kind of help you, if you are kind of battling that.  If anesthesia is involved - 'if' because obviously not all procedures require anesthesia - and the procedure is stopped before it is given, then you are dealing with a 52 situation.  If it is stopped after anesthesia has been given, then you are dealing with the 53 situation.  If there is a cancelation and it is electively done by the patient or the physician it is a 52, but if it is canceled because the physician said, 'to continue would put the patient at risk' then it is a 53, that is extenuating circumstances.  And results - if you did some of the procedure and you accomplished something, you removed a couple of polyps, but you could not continue because the patient's blood pressure went crazy, you are probably dealing with a 52; with 53 there are no benefits.  You try to get that catheter going and it just was not going and you had to stop, you did not accomplish anything.  So hopefully, those variables will kind of help you, but like I said it is really a moot point since you have to send in paper work anyway.

Okay, modifier-63, this is a new modifier since 2003 procedures preformed on infants less than 4 grams because smaller bodies mean more work involved.  What you have to be careful of is there are many codes that are already for kids, for infants, so be alert to parenthetical notes in CPT that tell you to not use modifier-63 in that circumstance.  Some of them spell it out, some do not, you have to be careful.  You do not want to be redundant because if there is a code in CPT that exists for an infant versus an adult, then the value of that code is increased because it is a smaller body.  Basically 63 is like a 22 but more specific, so be aware of that, and basically per the AMA, these codes are to be used for the 20,000 to 60,000 series of codes in the surgery section.  Modifier-73 and 74, these are only for outpatient and ASC use, so if you are a physician-based coder, plug your ears.  But you know how we were dealing with 52 and 53 versus anesthesia being involved, if it is outpatient side, they actually give you the modifiers.  73 is the modifier for when it is stopped prior to anesthesia, you are going to use 73, and 74 is when the procedure stopped after, nice and clear.

And finally modifier-99 multiple modifiers, this is one that is going to be a little more rare, because our computer systems are much more sophisticated then they used to be.  So if you have a situation where you need to report the digits in the finger and use all those HCPCS level 2 modifiers and you need to say that it was a multiple procedure, you could have 5+ modifiers going on.  So what happens sometimes, you might have to put a 99 and just say refer to box 19 on the 1500 form and I will tell you all the modifiers that apply.  But most computer systems can handle, I think up to 4 modifiers, and then what I recommend you do before you try and use modifier-99, use that method, we learned about in the beginning and putting 099 on the next line item and putting that leftover modifier on there.  So hopefully that will help.  And just real quick before I take questions, I just wanted to mention: did you notice in the new 2005 CPT book, there is an appendix I, genetic testing modifiers, obviously that is not going to apply to a whole huge subset of people on the call, but it is just a kind of need to be aware of changes that are coming out in our CPT manuals.  And if you have the professional version, that is on page 438 genetic testing code modifiers, so I would encourage you to just kind of take a look at them they are kind of interesting.  The way they organize it is the first digit is kind of indicating the disease category and second digit is telling us the gene types, so it is kind of neat how they put them together.
So okay, what wold I like to do now is open it up for questions, so Mandy if you can give them the instructions on how to do that.

Thank you, Ms. Jandroep.

Ladies and gentlemen, I would like to remind you that this portion of the teleconference is also being recorded.  If you have a question at this time please press *1 on your touchtone telephone.  If your question has been answered or your wish to remove yourself from the queue please press #, please limit your self to one question at a time so that everyone may have a chance to participate.  If you have another question you may reenter the queue by pressing *1.  Our first question comes Nicole Bartley of The Coding Institute, please state your question.

Q & A Session:

Question:  I have some questions that were e-mailed to me before the conference, and I am just going to go ahead and read them for you, the first one states, I direct occupational clinic, can you point out, if the rules vary or if there is something special regarding coding for workers compensation?

Answer: Okay, yeah, basically, I have got a copy of that in the beginning and what I have found out is that this is very state specific.  I talk to a colleague and she said for example in Texas, when you are dealing with the radiology codes, -26, and if you were trying to get paid for the global, you would normally not put any modifier, but that particular worker's comp carrier wants you to put a WC.  So the answer is that you really have to actually go to them to find out what modifier situations affect you in that state so I would use the modifiers just as described in this presentation, unless you get a claim back where it looks like they are denying it for a reason - it is probably for a different way that they use modifiers. Find it out ahead in that research of your top, you know, five payers.

Comment:  Great and another question that I have reads how can you get an ER visit paid, when the patient goes into observation for example for abdominal pain, the surgeon is called in, into the observation room and they decide to do emergency surgery?

Answer:  Okay, so for that one, it sounds like there is a decision for surgery and they are worried that that E/M visit in the ER is not going to get paid, so what you would do is you would append that 57-modifier on that and that should get paid, and if it does not, you should appeal it, if they are trying to bundle it into the surgery.

Question:  Thank you, and another one asks if the lesion removal is done at the same time as skin tag removal, would this need a modifier-59 or a 51?

Answer:  Okay, this is a situation where if you actually looked up these codes, which I did, because this is a question provided to me ahead of time, 11200 and 11400, this is what I run through my program to see if it flags any CCI edits, and it did indicate that code 11400 is mutually exclusive to code 11200, but a modifier is allowed.  This is a situation with a superscript of a one, so that modifier would be 59.  As far as the 51 it is a multiple procedure, you could put it on, but like I was saying in the presentation, chances are you do not need to append it, they will reduce it automatically, if that is how they have it set up in their system.

Question:  Great and the last question I have for you is what modifiers are used for newborn in nursery or NICU seen for another condition or disease by a NICU physician and have a circumcision and nerve block done on the same day by the same physician?

Answer:  Okay, if I am understanding that question correctly, it is looks like, the concern is billing two procedures on the same day.  You are probably going to use a 51-modifier, first of all saying it is a multiple procedure and if you put that through the CCI edits I really doubt that circumcision or nerve block is bundled into each other, if so then you probably have to use modifier-59 for that one.

To view slides, please refer to issue pdf.