Medicare Compliance & Reimbursement

Hint: Documentation is key to utilize modifier 22.

The appropriate use of modifiers can make or break your Medicare claim, so if your modifier knowledge hasn’t been updated in a few years, you may be cutting your own pay.

Check out this handy Q-and-A for advice on the five most commonly used modifiers.

Question 1: Seven years ago, a patient had a lung resection due to cancer and made a full recovery. However, she now requires a bronchoscopy due to a questionable spot on a CT scan that a pulmonologist believes requires further exploration. Because of the unusual shape of her resected lung, the doctor must make two bronchoscopic attempts during the session with increasingly larger bronchoscopes that finally result in a therapeutic bronchoscopy (31646, Bronchoscopy, rigid or flexible, including fluoroscopic guidance, when performed; with therapeutic aspiration of tracheobronchial tree, subsequent). What modifier works in this scenario?

Answer: Because the pulmonologist was medically justified in making several attempts, which added an exceptional amount of time to the session, you can append modifier 22 (Increased procedural services) to 31646. You should include a statement in your documentation, for instance, “this bronchoscopy took an hour and 45 minutes longer than the typical repeat therapeutic bronchoscopy” with the corresponding details.

CPT^® codes describe a range of services. Sometimes a procedure may go smoothly, and another procedure of the same type may take longer. The fee schedule amounts assigned to individual codes assume that the easy and difficult procedures will average out over time. However, if the procedure requires significant extra time or effort that falls outside the range of services described by a particular CPT^® code, you should bring out modifier 22.

Important: A diagnosis alone does not support the medical necessity of reporting modifier 22. The documentation must clearly indicate that the procedure was more complex than the normal and detailing why, says Suzan Hauptman, MPM, CPC, CEMC, CEDC, AAPC Fellow, senior principal of ACE Med in Pittsburgh.

Question 2: A patient comes to the office a few days after a 90-day global procedure for the biopsy results/report. The doctor talks to the patient for 15 minutes about results and different types of new treatments required. You should report the appropriate office visit code, such as 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity ...), based on the time spent reviewing the results face-to-face with the patient. What modifier do you append?

Answer: Since this visit does not constitute a true postoperative follow up examination or care of a recent surgical wound but rather a visit to review the biopsy results with the patient, you can report the E/M service with modifier 24 (Unrelated evaluation and management service by the same physician or other qualified healthcare professional during a postoperative period).

Tip: Before considering modifier 24, ensure that the same physician who performed the original surgical procedure or one of his associates sees the patient during the postoperative period for an E/M service unrelated to the postoperative surgical care.

In fact, if the patient reports for any unrelated E/M that occurs during a postop global period — including hospital visits, office visits, etc. — you may append modifier 24, according to Celia Forde, CPC, CPCH, coding specialist for Florida’s Centra Care, in the Orlando area.

Question 3: An ob-gyn sees a patient with vaginal bleeding. During the exam, the ob-gyn identifies polyps in the cervical os and decides to remove the polyps today instead of requesting that the patient return. What modifier should you use?

Answer: You would report the visit code (9921X) with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified healthcare professional on the same day of the procedure or other service) appended in addition to 57500 (Biopsy of cervix, single or multiple, or local excision of lesion, with or without fulguration [separate procedure]) linked to N84.1 (Polyp of cervix uteri).

Remember: Since the ob-gyn provided a separate and significant E/M service at the same time as a minor procedure, modifier 25 is the best choice. Modifier 25 should not signify the decision to do a minor surgery at the time of the visit, which is integral to that minor surgery, but rather that the physician documented a separate significant E/M service. Appropriately appending modifier 25 means that your practice will receive a separate payment for an E/M service that the ob-gyn performed on the same day as a procedure or other service.

Question 4: A patient presents to the emergency room (ER) with nausea and severe lower-right abdominal pain. The surgeon examines the patient and orders labs and radiology services to rule out appendicitis. Based on the test results, the surgeon makes the decision for surgery, performs an open appendectomy, and admits the patient to the hospital. What is the best modifier for this example?

Answer: Firstly, despite the fact that the first patient encounter was in the ER, you should not use one of the codes from the range 99281-99285 (Emergency department visit …). Because the surgeon admitted the patient the same day, you’ll need to report a single E/M code for initial hospital inpatient services for the day.

Do this: Instead, choose the appropriate code from the range 99221-99223 (Initial hospital care …) based on the level of history, examination, and medical decision making (HEM). You should base the HEM level on all the encounters with the patient during the day (except for the surgery), including the ER encounter. You can append modifier 57 (Decision for surgery) and additionally report the surgery with 44950 (Appendectomy) in this situation.

Reminder: When the provider performs an E/M service for a patient that leads to surgery that day (or in the near future), you’ll likely append modifier 57 to the E/M code, relays Catherine Brink, BS, CMM, CPC, president of Healthcare Resource Management in Spring Lake, New Jersey.

Never apply modifier 57 to a procedure code; it’s for E/Ms only, and only in specific circumstances.

Question 5: A physician performs a computed tomography (CT) abdomen/pelvis with contrast and a CT abdomen/pelvis without contrast at different encounters on the same day. What modifier fits this coding situation?

Answer: In the case of 74176 (Computed tomography, abdomen and pelvis; without contrast material) and 74177 (Computed tomography, abdomen and pelvis; with contrast material[s]), the first point of reference you want to check is the National Correct Coding Initiative (NCCI) edit between these two codes. NCCI edits automatically bundle 74176 into 74177 under a modifier “1” status — meaning that the bundle can be overridden with a modifier under the appropriate circumstances.

Your decision to either use a modifier or bundle 74176 into 74177 depends on the circumstances of the patient encounter. If each exam is performed for separate diagnostic reasons, the answer is as simple as applying modifier 59 (Distinct Procedural Service) to 74176 (column 2 code).

However, it’s not just diagnostic criteria that allow for the use of modifier 59. CMS states the following as valid reasons to report a claim with modifier 59: “Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual.”

Since the provider performs the second scan at a different session than the first in this example, you are eligible to apply modifier 59 to 74176.

Tip: Depending on your payer policies, you may want to consider the use of the X{EPSU} modifier set in place of modifier 59. Modifier XE (Separate Encounter), for instance, is specifically designated to distinguish separately performed services on the same day.