Part B Insider (Multispecialty) Coding Alert

Don't throw away money using modifier 81 for NPPs

If your practice is routinely using modifier 81 (Minimal assistance at surgery) when a non-physician practitioner helps a physician during surgery, it's time for you to review correct modifier use.

When an NPP is providing services, Medicare requires you to use the modifier AS (Assistant at surgery service), experts say. But other payors will require other modifiers. Some large private payors will request  modifier 80 (Full assistance at
surgery) when an NPP works as an assistant at surgery, notes Marcella Bucknam, HIM program coordinator at Clarkson College in Omaha, NE.

However, some payors will request the the 81 modifier for all NPP surgery assistant services. But the American Medical Association designed modifier 81 for situations where a provider helps for a short time only, insists consultant Quinten Buechner with ProActive Consultants in Cumberland, WI.

For example, when inserting a feeding tube through the stomach, a surgeon will need an additional provider in charge of the pressure tube for a few minutes, Buechner explains. For such short-term assistance, the 81 modifier is perfect.

Modifier 81 doesn't address the professional certification required of the assistant at surgery, say experts. There are no guidelines as to which type of provider can use the 80 or 81 modifiers. "They just describe services," says Michael Powe, director of reimbursement with the American Academy of Physician Assistants.

So payors shouldn't try to prevent NPPs from billing the higher-paying 80 modifier instead of the 81 modifier. If they do, you should appeal and get them to change their policy to allow NPPs to use the 80 modifier, Buechner adds. He's created a form letter arguing that NPPs should be allowed to use the 80 modifier, and has won a large number of appeals using it.

The amount you'll receive for using the 80 and 81 modifiers varies by payor, but the 80 modifier is supposed to guarantee the "full assistant rate" for a procedure while the 81 will provide a reduced rate.