3C Complications of Modifiers -...

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3C – Complications of Modifiers


Katherine Abel, CPC, CPB, CPMA, CPPM, CPC-I


• Review ways to analyze modifier use

• Learn the proper usage of the most common

modifiers

• Identify the correct way to utilize modifiers

• Understand the most common mistakes being

made with modifiers and how to fix them

• Review tough case examples and how modifiers

can affect your bottom line

Objectives


Patient's Name Med

Rec#

DOS Doctor CPT Code Modifier ICD-9

Code

$

Charged

Ins Co. Corrected

/Refiled

Denial

Reason/Additional

Coments1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

Denial Tracking

2


3%

17%

3%

3%

8%

49%

3%

14%

Didn't Indicate if Medicare is Primary

Inclusive Procedure

Incomplete/Invalid Place of Service

Incorrect Entitlement Number or Name

Need Home Health Name and Upin #

Not Medically Necessary

Starred Procedure Performed as the Major

Service During a Subsequent Visit

UCR-Exced Claim Limit

Analyze


Reports from practice management systems:

– Do all in-office procedures have an E/M with a

modifier 25?

– Is there a high use of modifier 59?

– Is modifier 22 used every time a certain procedure is

performed?

– Are there numerous denials for inclusive procedures?

Analyze


• Adding modifiers 24, 25, 26, 58, 59, 76, 78, or 79 to a denied

service continues to be one of the top reasons for requesting

a review.

• Calling to add a modifier just because the service was

denied is not appropriate.

• Be prepared before calling in for a review. We have

experienced providers calling and asking to add a modifier.

Then when that modifier did not get the claim paid, they want

to try another one. This is inappropriate.

WPS Medicare Modifier Review Facts

6 Source: http://wpsmedicare.com/j8macpartb/resources/modifiers/modifier-25.shtml

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• 25 – Separately, identifiable E/M

• 57 – Decision for surgery

• 59 – Distinct procedural service

• 22 – Increased procedural service

• 52 – Reduced services

• 53 – Discontinued procedure

• 58 – Staged or related procedure

Problem Modifiers


• 25 – Significant, separately identifiable E/M service

by the same physician on the same day of the

procedure or other service.

• 57 – Decision for surgery

Evaluation & Management Modifiers


Significant, separately identifiable evaluation and management service by

the same physician on the same day of the procedure or other service

What is significant and separately identifiable?

Modifier 25

Source: https://oig.hhs.gov/compliance/physician-education/02payers.asp

4


Q1. Please clarify whether a visit by the physician on the same day

as a screening colonoscopy is separately payable. Is a visit

always included in the reimbursement for the screening

colonoscopy?

A1. A visit is only payable if the documentation shows a significant,

separately identifiable service and meets the qualifications for modifier

25. This means the physician performed a great amount of additional

work above and beyond that normally performed prior to the procedure.

In addition, an auditor must be able to identify the significant amount of

additional work separately from that normally performed prior to the

procedure.

Modifier 25 – WPS Medicare

10 Source: http://www.wpsmedicare.com/j8macpartb/resources/provider_types/2009_0810_emglobpkg.shtml


Typical pre-operative work included in Colonoscopy:

– Symptoms reviewed with patient

– Patient’s history reviewed

– Patient’s allergies and medications reviewed

– Pre-anesthetic exam with airway assessment and

cardiopulmonary evaluation

– Lab & X-ray studies reviewed

– Risks and benefits of the procedure are reviewed

– Informed consent obtained

Modifier 25

11


HCPCS Descriptio

n

Global

Days

Pre

Op

Intra

Op

Post

Op 11400 Exc tr-ext b9+marg

0.5 cm<

010 0.10 0.80 0.10

11401 Exc tr-ext b9+marg

0.6-1 cm

010 0.10 0.80 0.10


1.1-2 cm

010 0.10 0.80 0.10


2.1-3cm/<

010 0.10 0.80 0.10


3.1-4 cm

010 0.10 0.80 0.10

Modifier 25

12

5


Office of Inspector General (OIG):

“Another example of upcoding related to E&M codes is misuse of Modifier

25. Modifier 25 allows additional payment for a separate E&M service

rendered on the same day as a procedure. Upcoding occurs if a

provider uses Modifier 25 to claim payment for an E&M service when

the patient care rendered was not significant, was not separately

identifiable, and was not above and beyond the care usually associated

with the procedure.”

Modifier 25

Source: https://oig.hhs.gov/compliance/physician-education/02payers.asp


November 2005 OIG Report

“Thirty-five percent of claims using modifier 25 that

Medicare allowed in 2002 did not meet program

requirements, resulting in $538 million in improper

payments .”

Modifier 25

14 Source: https://oig.hhs.gov/oei/reports/oei-07-03-00470.pdf


September 2013 – Hospital refunded $64,526

“Specifically, during a change in the billing system,

modifier 25 was automatically being added to the

E&M code when charges other than an E&M or

clinic lab service were provided for the same patient

on the same date of services.”

Modifier 25

15 Source: https://oig.hhs.gov/oas/reports/region7/71205031.pdf

6


2013 OIG Workplan:

“Evaluation and Management Services—Use of Modifiers During the Global Surgery

Period

We will review the appropriateness of the use of certain claims modifier codes during the

global surgery period and determine whether Medicare payments for claims with

modifiers used during such a period were in accordance with Medicare requirements.

Prior OIG work found that improper use of modifiers during the global surgery period

resulted in inappropriate payments. The global surgery payment includes a surgical

service and related preoperative and postoperative E/M services provided during the

global surgery period. (CMS’s Medicare Claims Processing Manual, Pub. 100 -04,

ch. 12,§40.1.) Guidance for the use of modifiers for global surgeries is in CMS’s

Medicare Claims Processing Manual, Pub. 100-04, ch. 12,§30. (OAS; W-00-13-

35607; various reviews; expected issue date: FY2013; new start)

Modifier 25

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• Used to indicate the patient’s condition required a significant,

separately identifiable E/M service, above and beyond the usual pre-

and post-operative care associated with the procedure or service

performed.

• Should not be applied if only a scheduled procedure is performed.

Example: Patient presents for a scheduled cryosurgery of the cervix as

a result of an abnormal pap smear from a previous visit.

• Per Medicare, the procedure and office visit do not require a different

diagnosis codes.

Modifier 25


• What about new patient visits?

• WPS Medicare list of false statements:

– I can always use this modifier for a new patient.

– I can always use this modifier when I did not plan a procedure.

– I can always use this modifier when the diagnoses are different.

– I can never use the modifier when the diagnoses are the same.

Modifier 25

Source: http://wpsmedicare.com/j8macpartb/resources/modifiers/modifier-25.shtml

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• Failure to append modifier 25 when appropriate will result in the denial of the E/M service

Examples for appropriate use:

• Patient presents for management of hypertension and diabetes. The patient also complains of a painful abscess located behind his ear. In addition to the E/M service for his chronic illnesses, the physician performs an incision and drainage of the abscess.

• Problem focused visit performed on the same day as a preventive medicine visit. The documentation must support a separate E/M service.

Modifier 25


NHIC, Corp. J14 A/B Mac:

“NOTE: The most common cause for claim denial of

an unrelated E/M service billed on the same day as

another procedure or during the post operative

period for a non-surgery related reason is due to

the omission of

modifier -25”

Modifier 25

20 Source: http://www.medicarenhic.com/providers/pubs/REF-EDO-0058%20Modifier%20Billing%20Guide.pdf


• NCCI – “Since minor surgical procedures and XXX procedures include pre-procedure, intra-procedure, and post-procedure work inherent in the procedure, the provider should not report an E&M service for this work. Furthermore, Medicare Global Surgery rules prevent the reporting of a separate E&M service for the work associated with the decision to perform a minor surgical procedure whether the patient is a new or established patient.“

• MCM (IOM) – “Carriers pay for an E/M service provided on the day of a procedure with a global fee period if the physician indicates that the service is for a significant, separately identifiable E/M service that is above and beyond the usual pre- and post-operative work of the procedure. “

Modifier 25

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Blue Cross Blue Shield of Alabama

• Criteria – E/M involves separate and unique conditions, services, procedures, incisions, excisions or

anatomical sites;

– Procedure and medically necessary E/M occur on the same day by the same provider;

– A decision is made to perform a minor procedure;

– The E/M service is above the usual preoperative, intraoperative, or postoperative care associated with the procedure that was performed and is no way related to the procedure code submitted;

– E/M visit is problem oriented and stands alone as a billable service

• Items that do not meet criteria – An E/M code is billed with major surgical procedures, chiropractic manipulations, or

polysomnography; or

– Lab or x-ray services are the only other services provided in additional to the E/M; or

– The sole reason of the visit was for the procedure; or

– The E/M service is not above and beyond the primary purpose of the patient encounter; or

– Documentation does not support the definition of the modifier; or

– To bypass a fragmented coding edit.

Modifier 25

Source: https://www.bcbsal.org/providers/policies/final/330.pdf


Blue Cross Blue Shield of Tennessee

• Criteria – There is documentation of a significant, separately identifiable E/M service which must

contain the required number of key elements for the E&M service reported;

– The E/M service is provided beyond usual pre-operative, intraoperative, or postoperative care associated with a procedure performed on the same day;

– A symptom or procedure presents that prompts the E/M service (may not require a separate diagnosis);

– An initial hospital visit, an initial inpatient consultation, and a hospital discharge service is billed for the same date of service as an inpatient dialysis service;

– Critical care codes are billed within a global surgical period; or

– A medically necessary visit is performed on the same day as routine foot care.

• Items that do not meet criteria – E/M service that resulted in a decision for surgery;

– Ventilation management in addition to E/M services;

– Use on surgical codes;

– Use on same day of minor procedure;

– Use within global surgical period (pre- or postoperative care)

Modifier 25

Source: http://www.bcbst.com/providers/manuals/bcbstPAM.pdf


• Appeal

– Does the documentation support two services?

– If I remove all of the documentation for one service,

do I still have enough documentation to support the

second service?

– Appeal letter –separate documentation into two

services and send with letter.

Modifier 25

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Pt comes in for FU of her HTN, hyperlipidemia, depression and has some musculoskeletal pain she is concerned about. She would like a skin lesion removed. She also requests a tetanus shot. She has some left shoulder pain that started about two weeks ago. It is not related to any increased activity, however. She points between her scapula and her spine when she brings her elbows back. No weakness in the upper extremities or numbness. No cough, no chest pain, no SOB.

Review of Systems: Essentially negative other than she has a lesion on her belly she would like looked at and removed if possible.

PHYSICAL EXAMINATION: Weight 241 #. BP 134/82. Pulse 68. Respiratory rate 16. Temperature 97. Eyes: anicteric. Ears: clear. Throat: normal. Neck: no JVD, no bruits. Abdomen reveals a flesh-colored lesion along the bra line, which is slightly irritated and erythematous. Extremities: no cyanosis, clubbing or edema. Shoulder reveals good ROM, some tenderness and spasm along the medial scapula on the left compared to the right. Distal neuro and vascular supply is grossly intact.

ASSESSMENT: HTN, hypercholesterolemia, musculoskeletal strain and depression.

PLAN: We will increase her Zoloft to 100 mg per pt request and have her stay on this for at least one year and wean off in the spring of next year. Today her lipids revealed LDL of 131, total cholesterol 220. We will continue with the Zocor given her two risk factors and her age. For HTN, continue Uniretic. Her abdomen was prepped and draped, and I cc of 1% Lidocame was administered subcutaneously. A sharp excision was performed on the lesion, which measured approximately ,5 cm, Hemostasis was achieved without any suture. Pt tolerated procedure well. Specimen was not sent because it is flesh-colored. Pt will FU as needed. Instructions were given for wound care.

Modifier 25?


FoIIow-Up Note: The patient is a female with a long history of chronic intractable pain secondary to myofascial pain syndrome, scoliosis, four back surgeries, and greater trocanteric bursitis. She also has piriformis muscle syndrome. She has undergone trigger-point injections for quite some time. Her last set was about four months ago. She is getting married tomorrow and flying off to Kauai and would like to have some good pain relief for this. She comes back at this time for repeat trigger point injections.

Physical Exam reveals multiple trigger points throughout her lower back and buttocks and over the greater trocanteric bursa.

My Impression remains myofascial pain syndrome and left greater trocanteric bursitis.

My Recommendations included multiple trigger point injections for her.

Procedure: TRIGGER POINT INJECTION X 11

The patient agrees with the plan and accepts the risks. The patient was injected with eleven trigger points using a total of 33 cc. of 0.25% Marcaine and 40 mg. Depomedrol equally divided amongst the eleven trigger points. The ones injected were in the greater trocanteric bursa bilaterally in two places each, then four places on the right side in her lumbar paraspinous muscles, and three places on the left side in the lumbar paraspinous muscles, including the piriformis muscle bilaterally. The patient tolerated the procedures well without complications and was discharged to home. She was instructed to contact my office in about two weeks for follow-up.

Modifier 25?


• Modifier 25 – Significant, separately identifiable EM service

by the same physician or other qualified health care provider

on the same day of the procedure or other service

– Minor procedure

– 0-10 global days

• Modifier 57 – Decision for Surgery

– Major procedure

– 90 global days

Modifier 25 vs 57

10


HCPCS Mod Description Global Days

20612 Aspirate/inj ganglion cyst 000

20615 Treatment of bone cyst 010

20650 Insert and remove bone pin 010

20660 Apply, rem fixation device 000

20661 Application of head brace 090

Global Days National Physician Fee Schedule Relative Value File

Source: http://www.cms.gov/PhysicianFeeSched/01_Overview.asp#TopOfPage


BlueCross BlueShield of Tennessee

• May not be valid when the E/M service is associated with a minor surgical procedure. Because the decision to perform a minor procedure is typically done immediately before the service, it is considered a routine pre-operative service and therefore not separately reimbursable.

• May be recognized as valid when used appropriately and there is documentation that the E/M service resulted in the initial decision to perform the service.

• Will not be recognized when the decision to perform the surgery was made in advance of the E/M visit.

• Is not appropriate when reported with non-E/M codes.

• Is not appropriate to report with the E/M service when performed for the pre-operative evaluation.

• Use of modifier 57 merely to bypass a bundling edit is inappropriate and will result in recoupment of erroneous reimbursement.

Modifier 57



Palmetto GBA:

“This modifier should not be submitted with E/M codes that are

explicitly for new patients only: CPT codes 92002, 92004, 99201-

99205, 99324 through 99328, 99281-99285, 99321-99323 and 99341-

99345. These codes are 'new patient' codes and are automatically

excluded from the global surgery package. This means that they are

reimbursed separately from surgical procedures. No modifier is

required in order for these codes to be separately reimbursed. These

codes are also automatically excluded from the global surgery

package.”

Modifier 57

30 Source: http://

http://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~Jurisdiction%2011%20Part%20B~Browse%20by%20Topic~Modifier%20Lookup~8EELFB4718?open&navmen

u=navmenu||

11


WPS Medicare:

Append to Procedure codes:

– 92002-92014 E/M Ophthalmology Services

– 99201-99499 E/M all locations

Modifier 57

31 Source: http://wpsmedicare.com/j5macpartb/resources/modifiers/modifier-57.shtml


DOS: January 31

CC: Follow up tibial osteomyelitis

PI: Patient is a 58-year-old male. He has had the tiial osteomyelitis treated with sterile

debridement and irrigation. He has a vac. He has been on IV Vancomycin and po

Levaquin.

PE: The vac is removed. He has gross purulence in the tibia calcaneal and in the

wound. There is draining puss.

IMP: Left tibial osteomyelitis

Plan: He is admitted to the hospital today. We essentially failed limb salvage with this

patient. He has had five or six debridements. He looked great at the time of

discharge last week. Apparently his wound looked good on Saturday and it has

worsened just over the last several days. We are going to recommend amputation at

this point. Please see H&P and hospital notes for further details. We will proceed

tomorrow.

Modifier 57?

32


• 59 – Distinct Procedural Service

• 22 – Increased Procedural Service

• 52 – Reduced Services

• 53 – Discontinued Procedure

Surgical Modifiers

12


• Distinct procedural service

• Used to indicate:

– Different surgical session

– Different procedure or surgery

– Different site or organ system

– Separate excision or incision

– Separate lesion or injury

Modifier 59


Column

1

Column

2

Effective Date Deletion Date Modifier

11006 64550 20090401 20090401 9

11006 69990 20050101 * 0

11006 93000 20090401 * 1

Modifier 59

• Do not use modifier 59 if there is a more appropriate modifier

• Review NCCI edits for Medicare and payers who use CCI Edits

Source: http://www.cms.gov/NationalCorrectCodInitEd/NCCIEP/list.asp#TopOfPage


• Example: Column 1 Code/Column 2 Code 45385/45380

– CPT Code 45385 - Colonoscopy, flexible, proximal to splenic

flexure; with removal of tumor(s), polyp(s), or other lesion(s) by

snare technique

– CPT Code 45380 - Colonoscopy, flexible, proximal to splenic

flexure; with biopsy, single or multiple

• Policy: More extensive procedure

• Modifier -59 is:

1) Only appropriate if the two procedures are performed on

separate lesions or at separate patient encounters.

NCCI Edits Example

Source: http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Downloads/modifier59.pdf

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Example of proper use:

A provider destroys 1 pre-malignant lesion on the

patient’s left forearm (17000) and performs a biopsy

of 1 lesion on the patient’s left shoulder (11100).

Modifier 59 is appropriate because there are separate

lesions.

Modifier 59



Modifier 59 will only be recognized as valid to bypass edits when: – Combination of procedure codes represent procedures that would

not normally be performed at the same time;

– Different session or patient encounter is documented in patient’s medical record;

– Surgical procedures performed are not through the same incisional site (Note: doesn’t matter if instrumentation changes if incision or presentation is the same);

– Surgical knee procedures involving multiple compartments of the same knee; or

– Another modifier is not more appropriate.

Modifier 59




Questions to ask regarding Modifier 59: – What is the rationale for the existing edit?

– Is the edit a NCCI edit with an indicator ‘0’? If so, there is no appropriate modifier to allow edit bypass.

– Was the procedure performed in a separate setting, different time, or different encounter?

– Is there sufficient documentation to support the separateness and distinction of the two procedures?

– Was the procedure truly separate and/or is it unusual to perform these procedures at the same session?

Modifier 59


14


Regence BCBS - Invalid use of modifier -59:

– Procedures in the same ipsilateral joint (including differing compartments)

performed by open, scope, or combined open/scope technique, including added

port or incisional sites. [Per Regence reimbursement policy the edits are

applicable per entire joint and not per compartment within a joint]

– Procedures in the same anatomical site (e.g. digit, breast, etc), even with incision

lengthening or contiguous incision.

– CPT identified “separate” procedures performed in the same session, same

anatomic site, or orifice.

– Scope procedure converted to open procedure.

– Incisional repairs are part of the global surgical package, including deliveries.

– Contiguous structures in the same anatomic site, organ system, or joint.

40 Source: http://www.or.regence.com/provider/library/policies/reimbursement-policies/modifiers/modifier-59-distinct-procedural-service.html


Horizon Blue Cross and Blue Shield of New Jersey

• Incorrect use of Modifier 59 is NOT appropriate when:

– Appending modifier 59 with E/M codes

– Used in lieu of Modifier 25

– Another modifier is more appropriate

– Horizon BCBSNJ’s Medical Policy deems that the service is not

medically appropriate

Modifier 59

Source: https://services5.horizon-bcbsnj.com/eprise/main/horizon/content/homepage/GeneralMsgnew/gen_2008.12.23_14.

37.06


OPERATION:

Excision of right posterolateral lesion 6 mm, left hairline lesion 7 mm, and anterior midline lesion 6 mm with intermediate defect closure 9 mm, 11 mm, and 9 mm.

DESCRIPTION OF PROCEDURE:

The patient was brought to the procedure room. Using loupe magnification, lesions were all examined with the patient's cooperation and participation. The lesions were then outlined as elliptical excisions and the areas infiltrated with lidocaine-epinephrine solution. The lesions were then excised to the level of subcutaneous tissue. The wounds were then closed by slight undermining the wound edges with re-approximation with 4-0 PDS deep dermal subcutaneous closure and 5-0 Prolene suture.

Modifier 59?

15


PROCEDURE:

Excision of skin cancers x 2 right leg.

DESCRIPTION OF PROCEDURE:

The patient was prepped and draped in the usual fashion in the supine position under local anesthesia. IV sedation was given. Prior to incision, 1 gram of Ancef was given IV piggy back. An elliptical incision was made around the anterior skin lesion and mass and the full thickness skin was taken down past the subcutaneous tissues to the muscle layer and was excised circumferentially. A short suture was marked superiorly and the long suture laterally. Hemostasis was acquired. The wound was then closed using interrupted, 3-0 Vicryl sutures of the subcutaneous tissues and 3-0 Nylon suture for the skin. Of note, the second lesion was also excised using elliptical incision. This was on the inferior medal aspect of the right leg. This was taken down and removed full thickness of skin. A short suture marked the area superiorly and the long suture laterally. Hemostasis was acquired and was good. This wound was then closed using interrupted 3-0 Nylon sutures in an interrupted fashion. Dressings were applied. At the end of the operation, the sponge and needle count were correct X 2. Estimated blood loss was less than 5 cc.

The patient was then transported to the recovery room in stable condition. The patient tolerated the procedure well.

Modifier 59?


Increased Procedural service

Used to indicate the service provided required

substantially greater work than typically required for

a service of the same type.

Modifier 22


Examples:

• Excessive blood loss during the particular procedure

• Excessively large surgical specimen

• Trauma extensive enough to complicate the particular

procedure and not billed as additional procedure codes

• Other pathologies, tumors, malformations (genetic,

traumatic, surgical) that interfere directly with the procedure

but are not billed separately.

Modifier 22

16


WPS Medicare - Reimbursement will required review of documentation including:

– The unusual circumstances of the procedure

“The ease or difficulty of a procedure generally falls within a bell curve with the lowest 2.5% of cases being extremely easy and the highest 2.5% of cases being substantially more difficult.”

– How the procedure differs from the “typical” service normally provided.

Modifier 22

Source: http://wpsmedicare.com/j5macpartb/resources/modifiers/clarification-use_modifier22.shtml


WPS Medicare

• When the modifier 22 is used, two separate documents will

be required to support the claim.

– An operative report and

– A separate statement indicating how the service differs from the

usual

• Please note - on April 28, 2012, if a separate statement

describing the very unusual difficulty is not with the operative

report, the 22 modifier will not be considered.

Modifier 22

47 Source: http://wpsmedicare.com/j5macpartb/resources/modifiers/modifier22-billing-documentation.shtml


WPS Medicare

“When developing a separate statement avoid using a

generalized statement. Comments like "patient was obese"

or "surgery took longer than usual" or "multiple adhesions"

lack specific details which identify why the procedure was

beyond the normal difficulties that could be encountered with

the procedure. Further, it is important that your operative

note supports the statement on why the surgical procedure

was beyond the ordinary range of difficulty.”

Modifier 22

48 Source: http://wpsmedicare.com/j5macpartb/resources/modifiers/modifier22-billing-documentation.shtml

17

3C – Complications of Modifiers 49


NCCI

• Occasionally a provider may perform two procedures that should not be reported together based on an NCCI edit. If the edit allows use of NCCI-associated modifiers to bypass it and the clinical circumstances justify use of one of these modifiers, both services may be reported with the NCCI-associated modifier. However, if the NCCI edit does not allow use of NCCI-associated modifiers to bypass it and the procedure qualifies as an unusual procedural service, the physician may report the column one HCPCS/CPT code of the NCCI edit with modifier 22. The Carrier (A/B MAC processing practitioner service claims) may then evaluate the unusual procedural service to determine whether additional payment is justified.

Modifier 22


Regence BCBS:

“In order to be considered for increased

reimbursement, documentation from the patient’s

record that will support the significantly greater effort

performed must be submitted with the claim. It is not

sufficient to simply document the extent of the

patient’s illness or comorbid conditions that caused

additional work. The documentation must describe

additional work performed. “

Modifier 22

51 Source: http://www.or.regence.com/provider/library/policies/reimbursement-policies/modifiers/modifier22-increased-procedural-services.html

18


Procedure:

Gastrostomy revision.

T-tube change.

History: This is 7-year-old male who is admitted to the GI service. Patient has a prolapse of what appears to be large amount of gastric mucosa out of G-tube site. Because of this, changing of his G-tube was felt indicated. He currently has a Foley in place.

Procedure: The patient was taken to the operating room, laid in supine position while general anesthesia was induced. The Foley was used to measure the tract length and the tract length was felt to be about 3.5 cm. A Foley was removed and abdomen was prepped and draped in usual sterile fashion. A large mass on the superior portion of the G-tube was excised along with a large amount of scar tissue. This was followed down to the gastric mucosa and the mucosa was sutured in a 180 degree fashion on the superior side to the skin. This made a nice gastrostomy tract. 8 ML 25% Marcaine was injected as a local block. Next, a 16 X 4.0 Boston Scientific G-tube was placed and the balloon filled. This seemed to fit fairly well. Antibiotic was placed on the wound. Patient tolerated procedure well, awoke in the recovery room in stable condition.

Modifier 22?


Procedure:

The patient was brought to the Operating Room and placed on the operating table in the supine position. General anesthesia was induced and she was prepped and draped in sterile fashion. Her ileal conduit was instrumented with silicone 14-Frech Foley catheter with return of yellow urine. The abdomen was then prepped with Betadine and latex allergy precautions were maintained throughout the procedure. Initial 3-cm incision was made superior to her previous lower midline scar and blunt dissection and Bovie electrocautery was down to the level of the anterior rectus fascia in the midline. Once this was identified, there was an obvious hernia, and this was incised. Two hours were spent in lysis of adhesions and to identify the point of obstruction, and the limits of the hernia. After the hernia defect had been identified in its entirety, there was no gross evidence of ischemic bowel, however, there was obvious obstruction, which went beyond on what was visible. Her incision was opened both inferiorly and superiorly and the lysis of adhesions continued. Pneumatosis was identified in several locations in the mid small bowel and along with copious adhesions…..

Modifier 22?


Reduced services – Used to indicate a procedure was partially

reduced or eliminated at the discretion of the provider.

• Do not use for procedures that are terminated

• Do not use on time based codes

• Do not use to reduce the fee for the service

• Fee should be calculated by the percentage of the procedure

performed

Example: When a bilateral procedure is performed on one side

only. If the code description includes “unilateral or bilateral”

do not append modifier 52.

Modifier 52

19


Railroad Medicare

• Radiology

– Used when the ‘supervision’ and ‘interpretation’

components are performed by different providers.

CPT should be submitted with modifier 26 followed by

modifier 52.

– Used when a bilateral code is performed unilaterally or

when the available code describes more than was

captured on the film.

Modifier 52

Source: http://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~Railroad%20Med

icare~Articles~Modifier%20Lookup~8HKT225577


Railroad Medicare

• Documentation must include:

– A concise statement that explains the nature of the reduced service

along with any other supporting documentation that the provider

deems relevant

– The concise statement may appear on the operative report, but it

must be clearly identified. You may circle, underline, highlight or

write the concise statement on the operative report. Failure to

submit the appropriate information will result in a denial of the claim.

Modifier 52

56 Source: http://www.palmettogba.com/palmetto/providers.nsf/DocsCat/Providers~Railroad%20Med

icare~Articles~Modifier%20Lookup~8HKT225577


PROCEDURE: Limited colonoscopy to 45 cm. It could not be done further because of poor bowel prep and stool proximal to this area.

DESCRIPTION OF PROCEDURE: The patient had bowel prep the day prior and was brought to the operating room with sedation. He was placed m the left lateral descubitus position. Rectal examination showed that the rectum was clear. The colonoscope was then advanced into the anal/rectal area and advanced slowly up to 45 cm, At 45 cm. I encountered a large amount of stool and a large amount of fluid. I removed some of the stool in this area but proximal to this there was a large amount of stool and I could not advance the colonoscope any further. Because of poor bowel prep and I could not see the colonoscope was then removed from 45 cm back to the anal verge. There were no tumors, polyps, cancers identified. It was normal to 46 cm, I will need a barium enema to complete his evaluation of his colon. I will schedule this at a later date. The patient was then transported to the recovery room In stable condition. The patient tolerated the procedure well.

Modifier 52?

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I have discussed the risks, benefits and alternatives of the procedural sedation with the patient. She requests analgesia for the reduction. I have obtained pre procedural vital signs. I pre-oxygenated the patient utilizing a non-rebreather. I had airway equipment at bedside. I had the patient with constant cardiopulmonary monitoring during the procedure. Utilizing 100 mcg of fentanyl, I was able to with reasonable anesthetic effect reduce her ankle dislocation. However, the ankle dislocation was unstable- I am unable to stabilize it sufficiently, and it has re-dislocated. I have irrigated the area again under pressure with sterile saline. 1 have once again placed a sterile dressing soaked with sterile saline on it. I re-examined the pulses including DP and PT pulses and they are intact. Her nerve function is intact. I have watched her for approximately 45 minutes after the procedure, and she has recovered completely from the fentanyl. Her blood pressure did not drop. Her oxygenation did not drop. Her recheck vital signs are 151/78, pulse of 75, respiratory rate of 18, 98% on room air. I have also discussed the risks, benefits and alternatives of joint reduction with her, and these include neurovascular injury, worsening fracture among multiple others, but she agreed to pursue this. I have obtained written consent for both procedures. At this time, the patient is comfortable. Her lab studies are still pending at this time. Chest x-ray is pending at this time, and she will be admitted to Dr. P for emergency surgery for irrigation and debridement of her open wound.

Modifier 52?


Discontinued procedure – Used to indicate that

circumstances existed that were a threat to the

patient’s well being and the procedure was

discounted.

• Do not use for an elective cancellation

• Fee determined by the percentage of the procedure

completed.

Modifier 53


WPS Medicare

• Documentation should:

– Be available upon request

– State the procedure was started

– State why the procedure was discontinued

– State the percentage of the procedure that was performed

• Facts:

– 45378-53, G0105-53, and G0121-53 have their own fee schedule

amounts

Modifier 53

Source: http://wpsmedicare.com/j8macpartb/resources/modifiers/modifier-53.shtml

21


CT-GUIDED LIVER CORE BIOPSY

FINDINGS: Prior to the procedure I explained the procedure, benefits and risks to the patient and his wife via a translator. They expressed their understanding of this information and wished to proceed. A detailed written informed consent was obtained and witnessed. The patient was brought to the CAT scan suite and laid in the supine position. Limited CT images of the upper abdomen were performed. These were viewed for scouting purposes only. The appropriate site for liver core biopsy was chosen. The patient's skin was then marked with the computer coordinates. Patient's skin was then prepped and draped in the usual sterile fashion. 1% lidocaine was used for local anesthesia. At this point, repeat limited CT scans of the upper abdomen were performed. This demonstrates the needle in satisfactory position. Therefore it was elected to proceed with liver core biopsy. I then utilized 1% lidocaine to numb the liver capsule. Throughout this procedure the patient was given instructions for breathing. A small incision was then made. Then an 18-gauge core biopsy device was advanced into the appropriate site and a sample was obtained. The first pass had limited sample. Therefore I did a second pass. The sample was small. At that point in time, due to the patient's respiratory variability and inability to follow breathing instructions it was elected to proceed with this biopsy under ultrasound guidance. Followup CT images of the upper abdomen and lung were obtained in order to rule out pneumothorax. Followup chest x-rays were ordered as well. The patient was then transferred to the holding area for monitoring and if stable, to undergo an ultrasound-guided liver core biopsy. All of this information was discussed with Dr. at the time of attempted CT-guided liver core biopsy. This information was also translated to the patient via a translator .

Modifier 53?


OPERATIVE PROCEDURE:

1. Transmastoid approach to middle and posterior fossa.

2. Definitive resection of middle and posterior fossa intra and extradural resection of mass off clivus.

3. Microsurgical resection of brain.

4. Frameless stereotactic-craniotomy.

CLINICAL HISTORY:

The patient is a 41-year-old female who presented with difficulty walking and a large petroclival hemangioma. She was scheduled for resection. The risks of the operation, including bleeding, infection, paralysis, coma and death were explained to the patient and family, and they wished to proceed with surgery.

OPERATION IN DETAIL:

The patient was brought to the operating room; induced anesthesia in a smooth fashion. A curvilinear incision was made behind the right ear. We had the frameless stereotactic set up. We then put in three burr holes and removed a 5 cm of bone flap. We went above and below the transverse sinus and went to the middle fossa, as well. The transverse sinus was identified. We then opened the dura and tacked it up with 4-0 Nurolon; then went to the posterior fossa first and a supracerebral infratentorial tumor appeared. This was an extremely vascular tumor. Under the microscope, we were able to get it debulked and it had torrential bleeding. We lost over a liter of blood. We decided to be more cautious. We used the frameless stereotactic to resect. More than 50% of the tumor had been debulked. There was persistent bleeding and the brain was getting swollen and I figured we did not want to cause any unnecessary morbidity. So, we decided we would stop the procedure and then consider a gamma knife. The dura was closed with continuous 4-0 Nurolon. Glue was put over the bone flaps to pat together plates. Interrupted Vicryls was used on muscle and fascia, and locked Nylon was put on the skin. A sterile dressing was applied. Patient tolerated the procedure well and was taken to the recovery room in a stable condition.

Modifier 53?


• 58 – Staged or related procedure or service by the same physician during the postoperative period

• 78 – Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period.

Post-Operative Surgical Modifiers

22


• Staged or related procedure or service by the same

physician during the postoperative period.

• Used when:

– The service is planned or staged

– The service is more extensive than the original service

– Therapy following a surgical procedure

• Not used when:

– Reporting the treatment of a complication from the original

surgery

Modifier 58


• A new postoperative period begins when the staged or related procedure is performed.

Example: A breast biopsy is performed on 3/2/13. The patient is diagnosed with breast cancer and the same physician performs a modified radical mastectomy on the right breast on 3/6/13. The modified radical mastectomy would be submitted with modifier 58.

Modifier 58


NCCI

“If a diagnostic endoscopic procedure results in the decision to

perform an open procedure, both procedures may be

reported with modifier 58 appended to the HCPCS/CPT code

for the open procedure.

However, if the endoscopic procedure preceding an open

procedure is a “scout” procedure to assess anatomic

landmarks and/or extent of disease, it is not separately

reportable. “

Modifier 58

23


Indication: This 44-year-old female with history of status post left upper extremity hand decompressive fasciotomy due to compartment syndrome. The patient has been brought previously for left upper extremity wound debridement and surgical bed preparation and preparation for application of full thickness skin graft to expedite wound closure and to allow earlier physiotherapy and return of function. The patient was planned to have a wound closure either in delayed fashion or with split-thickness skin graft during this operative encounter. The procedure was explained in full to the patient. She understands the risks include, but not limited to bleeding, infection, failure of the skin graft, need for further reconstructive surgery, loss of function, possible loss of limn, Informed consent was obtained.

Modifier 58?


• Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period.

• Failure to submit the procedure with modifier 78 will result in claim denial

• Example: Patient has a liver transplant on 3/2/13, on 3/3/13 the patient is returned to the OR and the physician re-opens the abdomen to control bleeding. Modifier 78 is appended to the procedure performed on 3/3/13.

Modifier 78


OPERATIVE INDICATIONS: The patient is a 51 year old gentleman who yesterday I tried to revise his AV graft. I did a thrombectomy and balloon angioplasty and intraoperative arteriogram and it failed right away.

OPERATIVE PROCEDURE: The patient was placed in supine position, underwent uncomplicated general endotracheal anesthesia. I reopened his old incision, I then opened up the graftotomy and did a thrombectomy both sides, got good back bleeding, good inflow. I went ahead and shot an arteriogram. There was a small amount of what looked like pseudo-intima in the distal anastomosis of the venous that was causing a flow defect, I finally got that out with a Fogarty catheter and then I ballooned it up again with a 6 millimeter and a 7 millimeter Conquest balloon up to 30 atmospheres and then reshot the arteriogram in both directions. The arterial anastomosis looked fine as did the venous anastomosis except it was a little bit narrowed still but certainly much bigger than it was at the time of the first revision. I closed up the graftotomy with 5-0 Prolene, restored flow. There was a modest thrill but of course his blood pressure was only 90 so hopefully it will get better with time. We closed the wound with Vicryl and Dermabond and turned the patient over to anesthesia for wake up.

Modifier 78?

24


PROCEDURE: Exploratory laparotomy and removal of 2 liters of blood clots; ligation of omental bleeding vessel; removal of 6 lap pads and reapplication of wound VAC.

FINDINGS: Six lap pads that could be easily removed, large amount of hematoma and a small bleeding arterial in his omentum.

FLUIDS REPLACED: I5OO crystalloid. DRAINS: Wound VAC.

INDICATIONS FOR PROCEDURE: The above patient was admitted following a head-on motor vehicle crash. He sustained multiple interabdominal injuries including a liver laceration and multiple bowel injuries. He had small bowel resection and was left in discontinuity. The patient was on Coumadin preoperatively and had significant bleeding intraoperatively. Additionally, his gonadal vein was avulsed from his inferior vena cava. Postoperatively the patient required massive fluid resuscitations of crystalloid and blood products. He required pressure release of his wound VAC earlier in the day and earlier in the afternoon he partially eviscerated from the bottom portion of his wound along the pelvis. We could only see purplish material underneath; it was unclear whether it was blood clots or ischemic bowel.

DESCRIPTION OF PROCEDURE: We removed his wound VAC, sterilely prepped and draped him in the usual manner. We encountered a large amount of hematoma and evacuated approximately a total of 2 liters. The bowel was still protuberant but viable. We were able to identify at least one area that was in discontinuity. We removed 6 laparotomy pads from his bilateral pelvis; there was no bleeding in the area. We left the lap pads surrounding the liver. Additionally, there was one small artery in his omentum that had pulsatile bleeding and we ligated that with a vicryl tie. We then irrigated the abdomen and reapplied a fenestrated bowel bag taking care to have the bowel bag extend into the gutters. We also applied an open abdomen wound VAC device and attained a good seal. The patient was taken back to the trauma ICU in still critical but hemodynamically stable condition. He tolerated the procedure well. Counts were correct during the case. He still has retained laparotomy pads. I do not know the exact number that are retained. We did however take 6 laparotomy pads out of his abdomen. I was scrubbed and present during this procedure.

Modifier 78?


• Intent of modifier

• Documentation

• Payer Guidelines

Wrap Up


Questions?

Thank you!

Date post:	30-Sep-2020
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