Orthopedic Coding Alert

Know the finger/toe assignments of F1-TA.

Most of the time you’ll use modifiers based on what type of service it is; some modifiers are for evaluation and management services (E/M) only, and others are reserved for surgical services. There are other modifiers that break down usage in other ways, however.

Anatomical modifiers and laboratory modifiers, while less frequently used than some of the other modifiers, are just as important to your claims. You’ll need to know how to use both of these modifier types correctly to ensure your claims get paid in full the first time.

So jump into this primer on anatomical and lab modifiers you might encounter in your coding, so you’ll be all set to code regardless of the type of modifier needed on your next claim.

Anatomical Modifiers Mark Surgery Spot

The first question about anatomical modifiers is also the most basic: What are anatomical modifiers used for?

Answer: “Anatomical modifiers designate the area or part of the body on which the procedure is performed and assist in prompt, accurate adjudication of claims,” explains Mary I. Falbo, MBA, CPC, CEO of Millennium Healthcare Consulting Inc. in Lansdale, Pennsylvania. There are specific anatomic modifiers for eyelids (E1-E4), fingers (FA-F9), toes (TA-T9), and coronary arteries (RC, LC, LD, RI, LM).

As an orthopedic coder, you’ll be most focused on the finger and toe modifiers, which break down thusly:

“These modifiers should always be used when a surgeon performs the same surgical procedure on more than one toe or finger,” explains Marcella Bucknam, CPC, CCS-P, COC, CCS, CPC-P, CPC-I, CCC, COBGC, revenue cycle analyst with Klickitat Valley Health in Goldendale, Washington. “They identify the exact location of the surgery and avoid denials that can occur when the insurance company thinks you are billing duplicate services.”

Remember: “Anatomical modifiers should only be utilized on procedures or supply codes. They should not be attached to E/M services, even if the chief complaint is specific to one side. These modifiers also should never be attached to a diagnostic code,” says Falbo.

Lab Modifiers Mark Testing Anomalies, Waivers

There are also three laboratory modifiers that you could run across in your daily coding: QW (CLIA Waived Test), 90 (Reference (Outside) Laboratory), and 91 (Repeat Clinical Diagnostic Laboratory Test). You’ll need to use these modifiers correctly to get your lab services paid out quickly and to eliminate any confusion on the payer’s part.

Modifier QW: “Modifier QW is used to indicate that the diagnostic lab service is a CLIA- [Clinical Laboratory Improvement Amendment] waived test and that the provider holds at least a Certificate of Waiver,” explains Bucknam. “The provider must be a certificate holder in order to legally perform clinical laboratory testing. CMS publishes a list of waived tests quarterly and this list indicates which codes must be accompanied by the QW modifier.” Check out the waived test list at: https://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/Downloads/waivetbl.pdf.

Modifier 90: “The modifier 90 is reported when a laboratory test was performed by a party other than the treating or reporting physician or other qualified healthcare professional,” says Bucknam. Coders beware: Some payers require direct billing by the laboratory, rather than the physician office billing on their behalf. “Knowing your particular payer rules will be important to be reimbursed. The modifier 90 may also be used when one laboratory references out a test to another laboratory,” continues Bucknam.

Modifier 91: “The modifier 91 is reported when a diagnostic test has been repeated on the same date of service because the physician needs comparative results. It is never used for a repeat lab procedure due to an inadequate sample, quality control or confirmation results,” explains Bucknam.