Health Information Management

Healthcare News: CMS issues transmittal to clarify use of modifiers -PA, -PB, and -PC

JustCoding News: Outpatient, December 30, 2009

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On December 4, CMS issued Transmittal 1867 in the Medicare Claims Processing Manual to advise providers regarding the proper use of modifiers -PA, -PB, and -PC. Some providers are incorrectly submitting claims using the -PC modifier to indicate the professional component of a service, according to related MedLearn Matters article MM6718.

Providers should use modifier -PC to indicate “wrong surgery on a patient.” Modifier -PA indicates “surgery wrong body part,” and modifier -PB indicates “surgery wrong patient.”

The incorrect use of modifier -PC has resulted in contractors incorrectly denying claims. Contractors will follow the requirements in Change Request 6718 to help prevent continued processing of claims on which providers have incorrectly submitted modifiers.

According to MedLearn Matters article MM6718:

Medicare contractors will:

  • Suspend, review, and develop all claim lines that are submitted with the -PA, -PB, or -PC modifiers
  • Contact the provider to determine whether the claims are related to one of the adverse events as described by the modifiers -PA, -PB, or -PC

If the contractor determines that the modifiers -PA, -PB, or -PC have been incorrectly submitted, they will:

  • Reject (return to provider) Part A outpatient claims
  • Return Part B claims as unprocessable with:
    • Claim adjustment reason Code 4 (The procedure code is inconsistent with the modifier used or a required modifier is missing.)
    • Remittance advice remark code MA130: Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information.

For additional guidance on the correct use of these modifiers, access MedLearn Matters article MM6405.

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