Modifier Mania

Presented by: Pat Cox, COC, CPC, CPMA, CPC-I, CEMC

Lisa Deel, CPC, CEMC, COBGCDenise Taylor, CPC, CEMC, CGSC

Modifier 22

Increased Procedural Services

Modifier 22

• Use this modifier when the work required to provide a service is substantially greater than typically required.– It may be identified by adding modifier 22 to the usual

procedure code• Documentation must support the– Substantial additional work and reason for the additional

work– ie, increased intensity, time, technical difficulty of the

procedure, severity of patient’s condition, physical and mental effort required

Modifier 22

• May be used in these CPT code set sections– Anesthesia– Surgery– Radiology– Laboratory and pathology– Medicine– Not on E&M

Guidelines

• Use only when work factors requiring the physician’s technical skill involve significantly more– Work– Time– Complexity

• For surgical and nonsurgical procedures

Guidelines

• Relative value units for services represent average work effort and practice expenses for a service

• Increased or decreased payment only under unusual circumstances and after medical records and documentation review

• Claim submission requirements– Written report - concise statement about how the service

differs from the usual (Kiss letter)– Operative report

KISS Letter

• “Kiss Letter”– I am requesting special consideration for the

operative procedure performed on Patient X on January 12, 2015. I am requesting a payment increase of 25 percent above my usual fee for this procedure, which is proportionate with the extra work effort due to (indicate special condition here)

KISS Letter

• Example Letter (Continued):– Then, briefly describe the difficult nature of the

service– Include typical average circumstances vs. actual

circumstance– Compare to normal time to complete procedure– End letter by referencing the OP note

Modifier 22: Example

• Laminotomy with decompression of nerve root with a partial facetectomy, foraminotomy, and excision of herniated disk

• During surgery, difficult-to-control hemorrhage requiring 60 additional minutes

• CPT Code(s) Billed: 63020 22—Laminotomy (hemilaminectomy), with decompression of nerve root(s), including partial facetectomy, foraminotomy and/or excision of herniated intervertebral disk; one interspace, cervical

Modifier 22: Example

• Using an example of a gallbladder surgery, if a patient has a BMI of 48.4 and had previous upper abdominal surgery such that adhesions in the upper abdomen were extremely dense, the gallbladder was densely adherent to the gallbladder bed on the liver and the surgery time was two and one-half hours, that would be a case where the surgeon is justified in using the 22 modifier and asking for extra reimbursement.

Modifier 22

Don’t assign the modifier if:• There is not supportive documentation• There is an existing “add on” code available• Append to secondary procedures• Use for re-operations• Unlisted procedures

Tips

• The physician’s documentation should be thorough. If it does not indicate the substantial additional work, carriers will not increase the fee.

• The additional work must be significant. Most carrier say that unless 25% more work was performed, then modifier 22 should not be appended.

• When possible, use the diagnosis codes that further describe the circumstances warranting the use of modifier 22.

Tips

• Modifier 22 should not be overused. Abuse of this modifier will attract unwanted scrutiny by an insurance carrier and may trigger an audit.

• Medicare has suggested that modifier 22 should be used with fewer than 5 percent of all surgical cases.

Tips

• Remember not every difficult case merits a modifier 22. The procedure must be unusually difficult in relation to other procedures of the same type.

• Per the AMA-”Only rare, outlying cases-those that are far beyond the average difficulty-call for modifier 22”

• Check with your carrier regarding any special requirements.

So what’s not a 22?

Modifier 51

• Use modifier 51 Multiple procedures to show that the same provider performed multiple procedures (other than E/M services, Physical Medicine and Rehabilitation services or provision of supplies) during the same session.

Modifier 51

• Modifier 51 indicates: The same procedure performed on different sites;

• Multiple operations during the same session; or

• One procedure performed multiple times.

Modifier 51

• Used to identify the secondary procedure, or additional procedures. It is not appended to the primary code.

• Not appended to “add-on codes” or modifier 51 exempt codes (found in Appendix E of CPT).

• Refer to the 'Mult Surg' indicator in the Medicare Physician Fee Schedule database (MPFSDB) to determine if CPT modifier 51 is applicable to a particular procedure code.

Reimbursement

• Rank codes according to the highest relative value unit using the total RVU not wRVU.

• The primary procedure will be reimbursed at 100% of the allowable

• 50% of the fee schedule amount for the remaining procedures.

• Surgical procedures beyond the 5th may priced differently depending on the circumstances and/or carrier.

Multiple Surgery Reduction Rule• Multiple endoscopy payment rules apply for procedure

billed with another endoscopy in the same family

• Endoscopy includes arthroscopy• For endoscopy performed on the same day as another in

the same family, the payment for the procedure with the highest RVUs is 100% of the maximum allowed fee

• The maximum allowed fee for every other procedure in the family is reduced by the value of the base code for the family

• No separate payment for a base procedure when other endoscopies in the same family are performed on the same day

Example of Modifier 51

• The patient presents for removal of a 3.5 cm benign skin lesion on the face. A layered closure of the resulting wound is performed in the same operative session.

The procedure would be coded as follows: 12052 Repair, intermediate, wounds of face, ears, eyelids, nose, lips and/or mucous membranes; 2.6 cm to 5.0 cm

• 11444-51 Excision, other benign lesion including margins, except skin tag (unless listed elsewhere), face, ears, eyelids, nose, lips, mucous membrane; excised diameter 3.1 to 4.0 cm.

Modifier 59

• Modifier 59 Distinct procedural service indicates a: – Different encounter or session; – Different procedure; – Different site; or – Separate incision, excision, injury, lesion, or body

part.

Modifier 59

• Modifier 59 should be used only if no more descriptive modifier is available and the use of modifier 59 best explains the circumstances should it be used. “Modifier of last resort.”

• Appending modifier 59 indicates that the procedure is not considered a component of another procedure but is a distinct, independent procedure.

Modifier 59

• Some payers do not accept modifiers 51 or 59• Coders should avoid using modifier 59 to

simply override a payer edit. • Should be used with caution. As a modifier

that affects payment and “unbundling”, it is watched closely by payers.

• Documentation needs to be specific and easy to identify.

Example from NCCI Book-Surgery:

• A patient underwent placement of a flow-directed pulmonary artery catheter for hemodynamic monitoring via the subclavian vein (93503). Later in the day, the catheter had to be removed and a central venous catheter was inserted through the femoral vein.

• CPT Code(s) Billed: 93503-Insertion and placement of flow directed catheter (eg, Swan-Ganz) for monitoring purposes 36010 59-Introduction of catheter, superior or inferior vena cava

Which to use…51 or 59

• Were the services performed at separate encounters? – append “59”

• Did the services involve different sites or organ systems?• Separate incisions, excisions?• Separate lesions or injuries?– Append “59” to the second code, if not append “51

Modifier -59 Subsets• New HCPCS modifiers;

– XE - Separate Encounter, a service that is distinct because it occurred during a separate encounter;

– XS - Separate Structure, a service that is distinct because it was performed on a separate organ/structure;

– XP - Separate Practitioner, a service that is distinct because it was performed by a different practitioner; and

– XU - Unusual Non-Overlapping Service, the use of a service that is distinct because it does not overlap usual components of the main service.