Health Information Management

Master modifiers to ensure accurate reimbursement

JustCoding News: Outpatient, December 2, 2009

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Proper modifier use is a critical part of coding, billing, and reimbursement. Currently, coders can choose among 13 CPT modifiers and 39 HCPCS Level II modifiers. With so many choices, even experienced coders can run into problems when assigning modifiers.

Modifiers allow facilities to indicate that a specific circumstance altered a performed service or procedure without changing the procedure’s definition or code, says Kim LeBlanc, MS, RHIA, CPC, coding manager at Lafayette (LA) Health Ventures, Inc.

Coders use modifiers to clarify CPT codes, distinguish separately billable procedures, properly unbundle National Correct Coding Initiative (NCCI) edits, prevent denials, and ensure accurate reimbursement.

Coders don’t always see denied claims, making it even more important for them to correctly code the services provided the first time. When a payer denies a claim, the facility must review it and try to correct the problem, which requires additional resources and expense.

Every part of CPT is its own little world, LeBlanc says. Each section of the CPT Manual is formatted differently, and code use varies from section to section, which can present significant problems for coders who code procedures from multiple areas. “You should put together a modifier manual for each specialty so coders know what they’re up against,” LeBlanc says.

Procedural modifiers

Procedural modifiers can provide a wealth of information to further describe the services provided, LeBlanc says. Coders apply these modifiers to non-evaluation and management (E/M) codes.

Coders should use anatomic modifiers to specify location. “These modifiers are useful in differentiating separate procedures at separate sites and should usually be used instead of modifier -59. Check with payers for guidance,” LeBlanc says.

Anatomical modifiers include:

  • -T1 through -T9 for each toe
  • -F1 through -F9 for each finger
  • -E1 through -E4 for each eyelid
  • -LC, -LD, and -RC for coronary arteries 
  • -LT (left) and -RT (right)

Use modifiers -LT and -RT to identify procedures that can be performed on paired organs but were only performed on one side.

Bilateral procedures are performed on mirror-image organs or body parts during the same operating session. Assume all CPT procedures to be unilateral unless the description specifies bilateral.

Modifier -50 (bilateral procedure) is one of the most frequently used anatomical modifiers, LeBlanc says. Appending modifier -50 can affect reimbursement, so always check the list of bilateral procedures by payer.

Staged, repeat procedures and return to the OR

In some cases, a physician will decide to perform surgery in stages. These situations involve a planned return to the operating room (OR). Append modifier -58 (staged or related procedure or service by the same physician during the postoperative period) to:

  • Staged procedures planned prospectively at the time of initial surgery
  • Subsequent surgery that is more extensive than the original procedure
  • Therapeutic surgery following a diagnostic surgical procedure

For example, if the physician leaves an incision and drainage open and plans fracture debridements, append modifier -58 to the code(s) for the additional debridements.

Do not use modifier -58 when the patient’s return to the OR is unplanned. For example, a surgeon removes polyps from a patient’s colon. Several hours later, the physician returns the patient to the OR and performs a colonoscopy with electrocautery to control postoperative bleeding. In this case, append modifier -78 (return to the OR for related procedure during the postoperative period [same day]).

When the patient has a repeated procedure or has returned for another procedure on the same day, consider modifiers -76 through -79. If the same physician repeats the same procedure on the patient, append modifier -76 to the code for the second procedure. Use modifier -77 when another physician repeats the same procedure.

When the patient returns to the OR for a related procedure that was unplanned, use modifier -78. These unplanned procedures are usually complications or unforeseen events. Use modifier -79 to identify unrelated procedures by the same physician on the same day.

Reduced, discontinued procedures

In some cases, a physician may decide to partially reduce or eliminate a service or procedure. In such a case, append modifier -52 (reduced services). “Documentation must support how the procedure is different than a typical procedure,” LeBlanc says.

Modifiers -73 and -74 are designated for use for discontinued procedures. The distinguishing factor is whether the patient received anesthesia. Use modifier -73 when surgery is cancelled prior to the administration of anesthesia, even when the patient has already been taken to the OR. Append modifier -74 to the procedure code when the patient received anesthesia but the physician terminates the procedure due to extenuating circumstances after the procedure started.

When the surgeon elects to terminate a surgical or diagnostic procedure after starting the procedure, assign modifier -53 (discontinued procedure).

NCCI edits

CMS created the NCCI edits to prevent inappropriate payment of services that coders should not report together, LeBlanc says. The edits, which CMS updates quarterly, are based mainly on rules in the CPT Manual.

The NCCI edits contain a general introduction that identifies the correct use of modifiers and edits. In addition, the introduction contains CPT chapter–specific guidelines.

NCCI contains mutually exclusive edits, which refer to procedures that cannot occur during the same operative session, and unbundling edits. Unbundling is breaking down a comprehensive procedure into its component procedures. Unbundling modifiers, anatomical modifiers, and modifier -59 (distinct procedural service) are used to break down comprehensive procedures into their component procedures. Providers should generally not unbundle procedures, although it may be appropriate in some cases.

For the NCCI, the primary purpose of modifier -59 is to indicate that a provider performed two or more procedures at different anatomic sites or during different patient encounters, according to CMS.

CMS defines different anatomic sites as different organs or different lesions in the same organ. However, treatment of contiguous structures of the same organ is not treatment at different sites. For example, treatment of the nail, nail bed, and adjacent soft tissue constitutes a single anatomic site. For more information about the use of modifier -59, access MedLearn Matters article SE0175.

“Only use modifier -59 if no other modifier is more appropriate,” LeBlanc says.
When a physician performs multiple procedures at the same anatomic site, the coder should append modifier -51 (multiple procedures). Appending modifier -51 is different than billing multiple units of one procedure.

Coders should not use modifier -51 with add-on codes, E/M codes, or codes designated as modifier -51 exempt. Consult the list of modifier -51 exempt codes in appendices D and E of the CPT Manual.

Because modifiers are complex, coders should always use the most up-to-date coding manuals and guidelines, as well as national and local coverage determinations for each payer. Written procedures or flow charts are “extremely important to ensure proper coding and billing,” LeBlanc says. “Taking the time to do research up front will ensure proper payment and prevent denials that can cripple [your facility’s] financial health.”

Editor’s note: E-mail LeBlanc at kimleblanc@lgmc.com.

This story was originally published in the December issue of Briefings on APCs.

Interested in learning more about modifier -59? Susan E. Garrison, CHC, CHCA, PCS, FCS, CCS-P, CPAR, CPC, CPC-H, and Peggy S. Blue, MPH, CPC, CCS-P, discuss specific, common scenarios for which it is appropriate to report modifier -59 in the June 23, 2009 HCPro audio conference, "Modifier -59: Manage Pre- and Post-Payment Audits to Reduce Denials."



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