Practice Management Alert

1. False: You should append modifier -22 (Unusual procedural services) only to your primary service, if it is greater than what is normally performed. The primary service can have any length of global surgical period. For instance, you can append -22 to services like endoscopies. You can also use them with assistant surgeon services.

You shouldn't, however, append modifier -22 to secondary services.

2. False: You can append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to E/M codes when your physician also performs a physical exam, as long as the E/M service performed and documented was a separately identifiable evaluation.

For a service to qualify as separate, your physician should identify a medical condition, and evaluate, manage and treat the patient. Make sure you match an ICD-9 code to the E/M level of care for the medical problem. Report this separate diagnosis for your E/M code in addition to the preventive V code for the physical exam and the procedure code. Use a sign and symptom code for the diagnosis, in the absence of a confirmed diagnosis. Though this answer is correct coding, you may not get paid. Refer to the January 2003 Medical Office Billing & Collections Alert for more on Medicare's payment for preventive exams.

3. True: Modifier -21 (Prolonged evaluation and management services) is used when a face-to-face or floor/unit service is provided. If the time spent was greater than usually required for the highest-level E/M service within a given category, you should append the E/M code with modifier -21.

4. False: Not necessarily: Modifier -51 (Multiple procedures) covers related multiple procedures during the same provider session, not including those captured by add-on codes. Always check with your payer before using modifier -51.

If, on the other hand, you're reporting unrelated procedures that were in the same session as your primary service, you should report these "distinct" services with modifier -59 (Distinct procedural service). Distinct procedures are those not normally reported with the other procedure listed, for example a separate incision or a different anatomic site. Modifier -59 on CPT codes other than your primary service says to the payer, "These are totally unrelated," Brink says.

You should use modifier -59 with caution. The CPT states, "Only if no more descriptive modifier is available, and the modifier -59 best explains the circumstances, should modifier -59 be used." Beware, especially, of using modifier -59 with bundled codes. Always check the NCCI (the National Correct Coding Initiative) to make sure the codes are not bundled or mutually exclusive codes. You should not append modifier -59 to a mutually exclusive code, that is, one that can't possibly be unbundled.

However, modifier -59 is useful for those codes normally bundled that can be unbundled under unusual circumstances, as when your physician had to perform a stress test when an EKG test indicated a problem. Normally, stress test and EKG test codes are bundled together, but if the physician did the EKG without planning to do a stress test, and the results of the EKG led to the stress test, then modifier -59 will justify coding for two distinct services.

5. True: You would use modifier -52 (Reduced services) for a procedure the physician aborted when he determined that the full procedure wasn't needed; the physician effectively reduced the original service. But if the physician stops performing the procedure because medical necessity requires it which is usually the reason why a procedure is prematurely ended you would use modifier -53 (Discontinued procedure).

6. False: The assistant surgeon modifier -80 (Assistant surgeon) does not accurately capture the plastic surgeon's work because he performed a separate procedure and did not assist. Use instead modifier -62 (Two surgeons). You should use this modifier when two surgeons with different skills work together on two distinct parts of a single service.