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AAHAM Conference
Part A Modifiers
Presented by
Provider Outreach and Education
April 2015
DISCLAIMER
This information release is the property of Noridian Healthcare Solutions, LLC. It
may be freely distributed in its entirety but may not be modified, sold for profit or
used in commercial documents.
The information is provided “as is” without any expressed or implied warranty.
While all information in this document is believed to be correct at the time of
writing, this document is for educational purposes only and does not purport to
provide legal advice.
All models, methodologies and guidelines are undergoing continuous
improvement and modification by Noridian and CMS. The most current edition of
the information contained in this release can be found on the Noridian website at
http://www.noridianmedicare.com and the CMS website at http://www.cms.gov
The identification of an organization or product in this information does not imply
any form of endorsement. CPT codes, descriptors, and other data only are
copyright 2015 American Medical Association. All rights reserved. Applicable
FARS/DFARS apply.
April 2015
2
Upcoming Part A Webinars
Date
Time (CT)
Webinar Title
4/28/15
1:00 PM
Rural Health Centers (RHC)
4/29/15
1:00 PM
Part A to Part B Rebilling
5/07/15
1:00 PM
Modifiers
5/12/15
1:00 PM
Utilizing the Benefit Period
5/19/15
1:00 PM
Modifiers
Register Now!
JE https://med.noridianmedicare.com/web/jea/education/training-events
JF https://www.noridianmedicare.com/parta/train/workshops/index.html
April 2015
3
Upcoming Part A Webinars
Date
Time (CT)
Webinar Title
5/20/15
1:00 PM
Comprehensive Outpatient Rehabilitation
Factor (CORF) Services
6/11/15
1:00 PM
Inpatient Psychiatric Facility (IPF) PPS
6/23/15
1:00 PM
Avoiding Common Claim Errors
6/25/15
1:00 PM
NCCI/OCE/MUE
Register Now!
JE https://med.noridianmedicare.com/web/jea/education/training-events
JF https://www.noridianmedicare.com/parta/train/workshops/index.html
April 2015
4
Agenda
•
•
•
•
•
•
•
Noridian Updates
ICD-10 Updates
Modifier Basics
Provider Specific Modifiers
Service Specific Modifiers
Other Modifiers
Resources
April 2015
5
Helpful Acronyms
CAH
Critical Access Hospital
CERT
CPT
CRNA
Common Error Rate Testing
Current Procedural Terminology
Certified Registered Nurse Anesthetist
E&M
Evaluation and Management
ER
Internet Only Manual
ESA
ESRD
HCPCS
Erythropoietin Stimulating Agent
End Stage Renal Disease
Healthcare Current Procedural Coding
System
April 2015
6
Helpful Acronyms
IOM
Internet Only Manual
MPFS
NCCI
OIG
Medicare Physician Fee Schedule
National Correct Coding Initiative
Office of Inspector General
OPPS
Outpatient Prospective Payment System
RA
Recovery Auditor
ZPIC
Zone Program Integrity Contractor
April 2015
7
Noridian Updates
Self-Paced Training
https://www.noridianmedicare.com/parta/train/workshops/archive.html
• Workshop Archive/Educational Tools
– Self-Paced Training/Tutorials
April 2015
9
Reason Code Guidance
https://www.noridianmedicare.com/parta/train/education_center/reason_code_guidance.html
April 2015
10
ICD-10 Update
Mapping ICD-9 to ICD-10 Codes for
Medical Policies
• NCDs are on CMS website, including related
Change Request
http://www.cms.gov/Medicare/Coverage/Coverage
GenInfo/ICD10.html
– Lab NCDs also updated
http://www.cms.gov/Medicare/Coverage/CoverageGe
nInfo/LabNCDsICD10.html
– CR 8348 instructed that all ICD-10 LCDs and
associated ICD-10 articles were to be published on
the Medicare Coverage Database (MCD) no later
than April 10, 2014
• Policies listed under Future Policies so public has plenty of
time to review mappings and provide feedback on concerns
April 2015
12
Claims Processing System Readiness
• Three standard systems used for claims
processing:
–
–
–
–
FISS-Part A
MCS-Part B
VMS-DME
Maintained by an outside entity that CMS hires as
a the standard system maintainer (SSM)
– Noridian tests all releases and changes, focusing
on local changes (another national contractor
also tests)
April 2015
13
Local Systems Are Ready
• Endeavor
– Diagnosis used in display under claims status
and appeals submission
April 2015
14
Provider Testing
• Two types of testing as outlined by CMS:
– Front-end (acknowledgement testing)
• Pass EDI front-end edits
• Determine if codes used are valid
– End-to-End
• End-to-end testing takes the testing a step further,
processing claims through all Medicare system edits to
produce and return an accurate Electronic Remittance
Advice (ERA)
– Testers should be verifying payment or denial
– Some are looking at payment amounts, especially on Part A
claims
April 2015
15
Front-End (Acknowledgement Testing)
•
Upcoming Testing
– June 1 - 5, 2015
– During the designated weeks, CMS is monitoring activities
and will report the results
– Testing can be completed before or after testing week
• Testing Guidelines:
– Test files must have the "T" in the ISA15 field to indicate
the file is a test file.
– Send ICD-10 coded test claims that closely resemble
claims currently submitted.
– Use valid submitter ID, NPI, and PTAN combinations.
– Use current dates of service on test claims
• Do not use future dates of service or the claim will be rejected
April 2015
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End-to-End Testing
• MLN Matters 8867
– Will receive remittance advice if claims pass front-end edits and
are not returned to provider (RTP) by FISS
– Had to volunteer and register and agree to certain testing
conditions
• Send 50 claims
• Provide list of provider numbers, Medicare numbers, etc…
• One week to send claims
– Contractors asked to choose a variety of provider types, provider
sizes
• Had to choose clearinghouses, at least 5, but no more than 15 for each
round
• 50 participants for each contractor will be selected from the volunteers
to represent a broad cross-section of provider types, claims types, and
submitter types
– CMS approves selected testers and all approved/non-approved
are informed by CEDI/EDI through an email
April 2015
17
Results From Round 1 End-to-End
Testing
• 661 participated
• Approximately 1,400 National Provider Identifiers (NPIs) were
registered to test, equally split between direct submitters and
clearinghouses/billing agencies
• Overall, participants in the January 26 to February 3 testing
were able to successfully submit ICD-10 claims and have
them processed through our billing systems:
• Reasons for rejected claims:
– 3% - Invalid submission of ICD-9 diagnosis or procedure code
– 3% - Invalid submission of ICD-10 diagnosis or procedure code
– 13% - Non-ICD-10 related errors, including issues setting up the
test claims (e.g., incorrect NPI, Health Insurance Claim Number,
Submitter ID, dates of service outside the range valid for testing,
invalid HCPCS codes, invalid place of service)
April 2015
18
Round 3 End-to-End Testing
• Volunteers must register by April 17, 2015
• Testing week will be July 20-24, 2015
• Announced on March 13, 2015
• Acceptance/non-acceptance notice will be
sent by May 8, 2015
April 2015
19
FAQ
• Will ICD-9 codes be accepted on claims with from
DOS of discharge/through dated on or after
October 1, 2015?
– No
• What will happen to claims containing ICD-9
codes for services on or after October 1, 2015?
– Direct data entry institutional claims – return to
provider
– Paper claims – reject as unprocessable
– Electronic claims – reject front-end or as
unprocessable
April 2015
20
FAQ
[2]
• Can a claim contain both ICD-9 & ICD-10
codes?
– No, however submitters can do a mix of ICD-9
and ICD-10 in the same electronic claim file
• Can ICD-10 codes be used on claims prior
to October 1, 2015?
– No.
April 2015
21
CMS ICD-10 Resources
• CMS
– www.cms.gov/ICD10
• CMS – ICD-10-CM/PCS the next generation
in coding
– www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10Overview.pdf
• ICD-10-CM Classification Enhancements
– www.cms.gov/Medicare/Coding/ICD10/Downloads/ICD10QuickRefer.pdf
• September 2013 ICD-10-CM/PCS billing and payment frequently
asked questions
– www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNProducts/Downloads/September-2013-ICD-10CM-PCS-Billing-Payment-FAQs-Fact-Sheet-ICN908974.pdf
April 2015
22
Noridian ICD-10 Resources
• Part A JF
– www.noridianmedicare.com/parta/news/docs/i
cd10_update.html
• EDISS ICD-10 web page
– http://www.edissweb.com/blue/news/icd10coming.html
• Road to 10
– http://www.roadto10.org/
April 2015
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Modifiers Basics
Modifier Basics
• Two digit codes appended to CPT/HCPCS
codes
• Provide additional information about
CPT/HCPCS codes
• Required on some services
• May Directly/indirectly affect payment
• May be Informational Only
April 2015
25
Ambulance Modifiers
Ambulance
Origin/Destination Modifiers
D
Diagnostic / therapeutic site (other than P / H) – ASC
and IDTF
E Residential, domiciliary, custodial facility, assisted
living
G Hospital-based dialysis facility (ESRD)
H
Hospital
I
Site of transfer (airport, helicopter pad)
J
Non hospital-based dialysis facility (ESRD)
April 2015
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Ambulance 2
Origin/Destination Modifiers
N
Skilled nursing facility (swing bed)
P Physician’s office (freestanding ER non-hospital
based, urgent care, clinics)
R Residence (private only)
S Scene of accident or acute event (origin only)
U Unclassified ambulance service
X Intermediate stop at physician’s office on way to
hospital (destination only)
April 2015
28
Ambulance 3
Additional Modifiers
QL
Patient pronounced dead after ambulance called
QM Ambulance service provided under arrangement by
a provider of services
QN Ambulance service provided directly by a provider
of services
TQ
April 2015
Basic life support transport by a volunteer
ambulance provider
29
Anatomical Modifiers
Eyelids
• Used when a surgical or diagnostic
procedure are performed:
E1
E2
E3
E4
April 2015
Service was performed on upper left eyelid
Service was performed on lower left eyelid
Service was performed on upper right eyelid
Service was performed on lower right eyelid
31
Hand Modifiers
• Left Hand
– FA – Left hand, thumb
– F1 – Left hand,
second digit
– F2 – Left hand, third
digit
– F3 – Left hand, fourth
digit
– F4 – Left hand, fifth
digit
April 2015
• Right Hand
– F6 – Right hand,
second digit
– F7 – Right hand, third
digit
– F8 – Right hand,
fourth digit
– F9 – Right hand, fifth
digit
32
Foot Modifiers
• Left Foot
– TA – Left foot, great
toe
– T1 – Left foot, second
digit
– T2 – Left foot, third
digit
– T3 – Left foot, fourth
digit
– T4 – Left foot, fifth digit
April 2015
• Right Foot
– T5 – Right foot, great
toe
– T6 – Right foot,
second digit
– T7 – Right foot, third
digit
– T8 – Right foot, fourth
digit
– T9 – Right foot, fifth
digit
33
Right vs. Left side modifiers
•
•
•
•
•
•
LC – Left circumflex coronary artery
LM – Left main coronary artery
LT – Left Side
RC – Right coronary artery
RI – Ramus intermedius coronary artery
RT – Right Side
April 2015
34
Critical Access Hospital (CAH)
Anesthesia
AA Anesthesia services performed personally by an
anesthesiologist
QY Medical direction of one CRNA/AA (Anesthesiologist's
Assistant) by an anesthesiologist
QK Medical direction by a physician of two, three, or four
concurrent anesthesia procedures
QZ CRNA service without medical direction by a physician.
April 2015
36
HPSA/PSA Modifiers
AQ
For dates of service on or after January 1, 2006,
physician providing a service in an unlisted health
professional shortage area (HPSA) should report this
modifier.
AR
For dates of service on or after January 1, 2005,
physician providing services in an unlisted physician
scarcity area (PSA) should report this modifier.
April 2015
37
PQRS Modifiers
1P
2P
Performance Measure Exclusion Modifier due to
Medical Reasons. Includes: Not Indicated
(absence of organ/limb, already
received/performed, other); Contraindicated
(patient allergic history, potential adverse drug
interaction, other).
Performance Measure Exclusion Modifier due to
Patient Reasons: Includes: Patient declined;
economic, social, or religious reasons; other
patient reasons.
http://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/PQRS/How_To_Get_Started.html
April 2015
38
PQRS Modifiers2
3P
8P
Performance Measure Exclusion Modifier due to
System Reasons includes. Includes: Resources to
perform the services not available; insurance
coverage/payer-related limitations; other reasons
attributable to health care delivery system.
Performance Measure Reporting Modifier. This
modifier facilitates reporting a case when the
patient is eligible but an action described in a
measure is not performed and the reason is not
specified or documented.
MLN 5640
April 2015
39
Practitioner Modifiers
AI
AE
AH
AK
GC
April 2015
Principal Physician of Record. CAHs report this
modifier to identify the primary physician
overseeing the patient's care from other
physicians who may be furnishing specialty care.
Services rendered in a CAH by a nutrition
professional/registered dietician.
Services rendered in a CAH by a clinical
psychologist.
For a non-participating physician service, a CAH
must place modifier AK on the claim.
This service has been performed in part by a resident
under the direction of a teaching physician.
40
Practitioner Modifiers2
GF
Services rendered in a CAH by a nurse practitioner (NP),
clinical nurse specialist (CNS), certified registered nurse
(CRN) or physician assistant (PA). (The “GF” modifier is not
to be used for certified registered nurse anesthetist (CRNA)
services. If a claim is received and it has the “GF” modifier
for CRNA services, the claim is returned to the provider.)
Also, while this national “GF” modifier includes CRNs, there
is no benefit under Medicare law that authorizes payment to
CRNs for their services. Accordingly, if a claim is received
and it has the “GF” modifier for CRN services, no Medicare
payment should be made.
SB
For dates of service prior to January 1, 2011, bill this modifier
to represent services by a certified nurse-midwife.
April 2015
41
Practitioner Modifiers3
62
April 2015
Two surgeons. When two surgeons work together as primary
surgeons performing distinct part(s) of a single reportable
procedure, each surgeon should report his/her distinct
operative work by adding the modifier 62 to the single
distinct procedure code. Each surgeon should report the cosurgery once using the same procedure code. If additional
procedure(s) (including add-on procedures) are performed
during the same surgical session, separate codes may be
reported without the modifier 62 added. Note: If a co-surgeon
acts as an assistant in the performance of additional
procedure(s) during the same surgical session, those
services may be reported using separate procedure code(s),
with modifier 80 or modifier 81 added, as appropriate.
42
Practitioner Modifiers4
80
Assistant surgeon
81
Minimum Assistant Surgeon
82
Assistant Surgeon (when qualified resident surgeon not
available)
AS
Physician Assistant, Nurse Practitioner, or Clinical
Nurse Specialist services for assistant-at-surgery, nonteam member.
April 2015
43
Telehealth
• Telehealth codes – G0108, G0109, G0420,
G0421, 96153, 96154, 97804, 99231 – 99233,
99307 – 99310
• GQ – Telehealth service rendered via
asynchronous telecommunications system
• GT – Telehealth service rendered via
interactive audio and video
telecommunications system
• Change Request 7049
April 2015
44
Clinical Trail, Device and Drug
Modifiers
Clinical Trail Modifiers
Q0 (zero) Investigational clinical service provided in a clinical
research study that is in an approved clinical research
study. Report Modifier Q0 (zero) on Category B
Investigational Device Exemption (IDE) code along with
the IDE number on the claim.
Q1
April 2015
Routine clinical service provided in a clinical research
study that is in an approved clinical research study. The
Q1 modifier must be billed in conjunction with diagnosis
code ICD-9 code V70.7 or ICD-10 code Z00.6, effective
September, 28, 2009.
46
Device Modifiers
FB
Item provided without cost to provider, supplier or
practitioner, or credit received for replaced device (e.g. under
warranty, replaced due to defect, free samples) FB cannot
be submitted with FC.
FC
Partial credit received for replacement device. FC cannot be
submitted with FB.
April 2015
47
Drug Modifier
JW
April 2015
Drug amount discarded/not administered to any patient. JW
modifier is required for any claims with discarded drugs.
48
End Stage Renal Disease
(ESRD)
ESRD Modifiers
AY
Item or service furnished to an ESRD patient that is not for the
treatment of ESRD.
EM
Emergency reserve supply for ESRD benefit only. In the event that
the schedule was changed, the provider should note the changes in
the medical record and bill according to the revised schedule. For
patients beginning to self-administer an Erythropoietin Stimulating
Agent (ESA) at home receiving an extra month supply of the drug,
bill the one month reserve supply on one claim line and include
modifier EM.
ED
Hematocrit level has exceeded 39% (or hemoglobin level has not
exceeded 13.0 g/dl) for 3 or more consecutive billing cycles
immediately prior to and including the current cycle
EE
Hematocrit level has not exceeded 39% (or hemoglobin level has
not exceeded 13.0 g/dl) for 3 or more consecutive billing cycles
immediately prior to and including the current cycle
April 2015
50
ESRD Modifiers2
GS
Dosage of Epoetin Alfa (EPO) or Darbepoietin Alfa has been
reduced and maintained in response to hematocrit or hemoglobin
level.
G1
Most recent Urea Reduction Ration (URR) reading of less than
60%
G2
Most recent URR reading of 60% to 64.9%
G3
Most recent URR reading of 65% to 69.9%
G4
Most recent URR reading of 70% to 74.9%
G5
Most recent URR reading of 75% or greater
G6
ESRD patient for whom less than seven dialysis sessions have
been provided in a month.
April 2015
51
ESRD Modifiers3
JA
Effective for claims with dates of services on or after January 1,
2012, all facilities billing for injections of ESA for ESRD
beneficiaries administered intravenously.
JB
Effective for claims with dates of services on or after January 1,
2012, all facilities billing for injections of ESA for ESRD
beneficiaries administered subcutaneously
JE
Administered via dialysate - Append the JE modifier to all ESRD
claims where drugs and biologicals are furnished to ESRD
beneficiaries via the dialysate solution on claims with dates of
service on or after July 1, 2013.
April 2015
52
ESRD Modifiers4
Q3
Liver Kidney Donor Surgery and Related Services. All covered
services (both institutional and professional) for complications from
a Medicare covered transplant that arise after the date of the
donor’s transplant discharge will be billed under the recipient’s
health insurance claim number and are billed to the Medicare
program in the same manner as all Medicare Part B services are
billed.
Internet Only Manual (IOM), Medicare Claims Processing Manual,
Publication 100-04, Chapter 3, Section 90
April 2015
53
ESRD Modifiers5
V5
Vascular catheter (alone or with any other vascular access)
V6
Arteriovenous graft (or other vascular access not including a vascular catheter
in use with two needles)
V7
Arteriovenous Fistula Only (in use with two needles)
V8
Dialysis access - related infection present (documented and treated) during
the billing month. Reportable dialysis access-related infection is limited to
peritonitis for peritoneal dialysis patients or bacteremia for hemodialysis
patients. Facilities must report any peritonitis related to a peritoneal dialysis
catheter, and any bacteremia related to hemodialysis access (including
arteriovenous fistula, arteriovenous graft, or vascular catheter) if identified
during the billing month. For individuals that receive different modalities of
dialysis during the billing month and an infection is identified, the V8 code
should only be indicated on the claim for the patient’s primary dialysis modality
at the time the infection was first suspected. Non-access related infections
should not be coded as V8. If no dialysis-access related infection is present
during the billing month by this definition, providers should instead report
modifier V9.
April 2015
54
ESRD Modifiers6
V9
April 2015
No dialysis-access related infection, as defined for modifier V8,
present during the billing month. Dialysis access-related infection,
defined as peritonitis for peritoneal dialysis patients or bacteremia
for hemodialysis patients must be reported using modifier V8.
Providers must report any peritonitis related to a peritoneal dialysis
catheter, and any bacteremia related to hemodialysis access
(including arteriovenous fistula, arteriovenous graft, or vascular
catheter) using modifier V8.
55
Evaluation & Management
(E&M) Modifiers
E&M Modifiers
25
Significant, separately identifiable – E&M service by the same physician on
the same day as the procedure or other service. The physician may need to
indicate that on the day a procedure or service was performed, the patient’s
condition required a significant, separately identifiable E&M service above and
beyond the other service provided or beyond the usual preoperative and
postoperative care associated with the procedure that was performed. The
E&M service may be prompted by the symptom or condition for which the
procedure and/or service was provided. As such, different diagnoses are not
required for reporting of the E&M services on the same date. This
circumstance may be reported by adding the modifier 25 to the appropriate
level of E&M service.
27
Multiple Outpatient Hospital E&M Encounters on the Same Day. Hospitals
may append modifier 27 to the second and subsequent E&M code when more
than one E&M service is provided to indicate that the E&M service is
"separate and distinct E&M encounter" from the service previously provided
that same day in the same or different hospital outpatient setting. When
reporting modifier 27, report with condition code G0 (zero) when multiple
medical visits occur on the same day in the same revenue centers.
April 2015
57
Laboratory Modifiers
Medicare Claims Processing Manual, Publication 100-04, Chapter
16
Laboratory Modifiers
90
Reference lab. Used to indicate a lab test was sent to a referral
(outside) lab, e.g., lab procedure performed by a party other than
the treating or reporting laboratory.
91
Repeat clinical diagnostic laboratory test. In the course of treatment
of the patient, it may be necessary to repeat the same laboratory
test on the same day to obtain subsequent (multiple) test results.
Under these circumstances, the laboratory test performed can be
identified by its usual procedure number and the addition of the
modifier 91. Note: This modifier may not be used when test are
rerun to confirm initial results; due to testing problems with
specimens or equipment; or for any other reason when a normal,
one-time, reportable result is all that is required. This modifier may
not be used when other code(s) describe a series of test results
(e.g., glucose tolerance test, evocative/suppression testing). This
modifier may only be used for laboratory test(s) performed more
than once on the same day on the same patient.
April 2015
59
Laboratory Modifiers
ET
April 2015
Attestation that the laboratory test(s) were ordered in conjunction
with emergency treatment. For hospital claims with dates of service
on or after April 1, 2012, for services rendered to ESRD
beneficiaries that include an emergency room service with revenue
code 04Xx on a line item date that differs from the line item date of
service for the related laboratory test(s) the hospital must include
the modifier ET to attest that the laboratory test(s) were ordered in
conjunction with the emergency services. This is necessary to
recognize that emergency services often span two calendar days.
For hospital claims for services rendered to beneficiaries in a
Skilled Nursing Facility (SNF) where services related to the
Emergency Room (ER) encounter span more than one service
date, hospitals must identify those services by appending a
modifier ET to those line items. The reporting of the ET modifier will
alert Common Working File (CWF) that these are related ER
services performed on subsequent dates so the SNF Consolidated
Billing (CB) edits in CWF will be bypassed.
60
Laboratory Modifiers
L1
Provider Attestation that the Hospital Laboratory test(s) is not
packaged under Outpatient Prospective Payment System (OPPS).
QP
Panel test. Documentation is on file showing that the laboratory
test(s) was ordered individually or ordered as a CPT recognized
panel other than automated profile codes 80002-80019, G0058,
G0059, and G0060.
Medicare Claims Processing Manual, Publication 10004, Chapter 16
April 2015
61
Outpatient Rehabilitation
(Therapy) Modifiers
Outpatient Therapy
Service delivered under an outpatient speech
language pathology plan of care
Service delivered under an outpatient occupational
GO
therapy plan of care
GN
Service delivered under an outpatient physical
GP
therapy plan of care
1 percent impaired, limited or restricted. Therapy
CH Severity/Complexity Modifiers. Therapy
Severity/Complexity Modifier.
At least 1 percent but less than 20 percent
CI impaired, limited or restricted. Therapy
Severity/Complexity Modifier.
April 2015
63
Outpatient Therapy
CJ
At least 20 percent but less than 40 percent impaired,
limited or restricted. Therapy Severity/Complexity Modifier.
CK
At least 40 percent but less than 60 percent impaired,
limited or restricted. Therapy Severity/Complexity Modifier.
CL
At least 60 percent but less than 80 percent impaired,
limited or restricted. Therapy Severity/Complexity Modifier.
At least 80 percent but less than 100 percent impaired,
CM limited or restricted. Therapy Severity/Complexity Modifier.
CN
At least 100 percent limited or restricted. Therapy
Severity/Complexity Modifier.
April 2015
64
Outpatient Therapy
KX
Therapy exceeds the therapy financial limitation or therapy
cap and qualifies for the therapy cap exception. Providers
should add the KX modifier to each claim line for an
outpatient therapy service procedure when the beneficiary
is qualified for exception to the therapy caps through
either the automatic process or the manual process of
exception. Providers should not add the KX modifier to
line items that would not be eligible for exception if the
service was provided after the cap is reached. That is, if
the services would require a manual exception if the cap is
exceeded and that exception has not yet been approved,
providers should not bill for that service using the KX
modifier.
April 2015
65
Surgery Modifiers
Modifier 50
• Used when billing bilateral procedure
– Bill on 1 line
April 2015
67
Modifier 51
• Multiple procedures other than E&M
performed at same session, by same
physician on same patient on same day
– Do not use with add on codes
– Do not use on all claim lines of service
– Not required for billing, Noridian will append if
necessary
April 2015
68
Modifier 52
• Partially Reduced or Eliminated Services
• Should be used:
– When charge is reduced
– Not performing all services indicated in CPT description
– Services were modified from normal service due to
physician’s decision
– When documentation supports normal complete service
was not provided
• Should not be used:
–
–
–
–
April 2015
For discontinued services
When patient can not afford full services
On time based codes
With E&M services
69
Modifier 59 - Clarification
• Distinct procedural service on same DOS
by same physician
–
–
–
–
Different anatomical sites
Different sides of body
Different procedure, or
Different session
• Still valid modifier but not as repeat modifier
– Refer to IOM Pub. 100-04, Ch. 1, Sec. 120
• Check CCI-Edits list
– Indicator 1 - allows for unbundling
– Indicator 0 – cannot unbundle codes
April 2015
70
Example of Modifier 59
• Column 1 CPT 17000, Column 2 CPT 11000
• Modifier indicator lists 1 (allowed)
Column1/Column 2 Edits
Column 1
17000
Column 2
11000
* = In
existence
prior to
1996
Effective
Date
19980401
Deletion Date
*=no data
*
Modifier
0=not allowed
1=allowed
9=not applicable
1
• Modifier 59 is appended to Column 2 CPT code
April 2015
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X Modifier Subset of 59 Modifier
XE
XP
XS
XU
April 2015
Separate Encounter, A Service That Is Distinct
Because It Occurred During A Separate
Encounter.
Separate Practitioner, A Service That Is Distinct
Because It Was Performed By A Different
Practitioner.
Separate Structure, A Service That Is Distinct
Because It Was Performed On A Separate
Organ/Structure.
Unusual Non-Overlapping Service, The Use Of A
Service That Is Distinct Because It Does Not
Overlap Usual Components Of The Main Service.
72
Modifier 73
• Discontinued out-patient hospital procedure prior to the
administration of anesthesia
• Used to indicate a procedure requiring anesthesia was
terminated due to extenuating circumstances or do to
circumstances that threatened the well-being of patient
after patient had been prepared for procedure (including
procedural pre-medication when provided), and been taken
to the room where procedure was to be performed, but
prior to administration of anesthesia.
• CMS Internet Only Manual (IOM), Medicare Claims
Processing Manual, Publication 100-04, Chapter 4,
Section 20.6.4
April 2015
73
Modifier 74
• Discontinued out-patient hospital procedure after
administration of anesthesia.
• Used by facility to indicate that a procedure requiring
anesthesia was terminated after the induction of
anesthesia or after the procedure was started (e.g.,
incision made, intubation started, scope inserted) due
to extenuating circumstances or circumstances that
threatened the well-being of the patient.
• This modifier may also be used to indicate that a
planned surgical or diagnostic procedure was
discontinued, partially reduced or cancelled at the
physician's discretion after the administration of
anesthesia.
• CMS Internet Only Manual (IOM), Medicare Claims
Processing Manual, Publication 100-04, Chapter 4,
Section 20.6.4
April 2015
74
Modifier 76
• Repeat procedure by same physician
• Can be used for x-rays and Injections
• Does not replace modifiers:
– RT, LT, 50, E1-E4, FA, F1-F9, TA, T1-T9
• If billing procedure code two or more times
for same date of service:
– First line – CPT with no modifier
– Second and subsequent lines – CPT with
modifier 76
April 2015
75
Modifiers 77
• 77 – Repeat procedure by another
physician
– Add modifier to repeated service
– Can also be used for x-rays and injections
• Does not replace modifiers:
– RT, LT, 50, E1-E4, FA, F1-F9, TA, T1-T9
April 2015
76
Modifier 78
• Return to operating room for a related
procedure during postoperative period
– Original surgery code can only be used when
identical procedure is repeated
• Complications must be documented
Example 1:
Date of Service
1/24/15
2/5/15
Treatment
Coronary artery bypass
Explore chest wall
CPT/Modifier
33514
35820-78
Example 2:
Date of Service
Treatment
CPT/Modifier
1/10/15
Fractured femur repair
27470
1/12/15
Bone Abscess or Osteomyelitis
27303-78
April 2015
77
Other Modifiers
Hospital-Based Providers
PO
April 2015
Services, procedures, and/or surgeries furnished at off-campus
provider-based outpatient departments
79
Erythropoiesis Stimulating Agents
(ESAs)
• All non-ESRD claims billing HCPCS J0881
and J0885 must begin reporting one (and
only one) of the following modifiers on
same claim as ESA HCPCS:
– EA – ESA, anemia, chemotherapy induced
– EB – ESA, anemia, radiotherapy induced
– EC – ESA, anemia, non-chemo/radio
• MLN 5699
April 2015
80
Other Modifiers
CA
Procedure payable only in the inpatient setting when
performed emergently on an outpatient who expires prior
to admission. The presence of modifier CA on the
inpatient-only procedure line assigns the specified
payment Ambulatory Payment Classification (APC) and
associated status and payment indicators to the line. The
packaging flag is turned on for all other lines on that day.
Payment is only allowed for one procedure with modifier
CA. If multiple inpatient-only procedures are submitted
with the modifier CA, the claim is returned to the provider.
If modifier CA is submitted with an inpatient-only
procedure for a patient who did not expire (patient status
code is not 20), the claim is returned to the provider.
April 2015
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Blood Modifier and Incorrect
Procedure Modifiers
BL
PA
PB
PC
April 2015
Special acquisition of blood and blood products.
Surgical or other invasive procedure on wrong
body part
Surgical or other invasive procedure on wrong
patient
Wrong surgery or other invasive procedure on
patient
82
Disaster Modifier
CR
April 2015
Catastrophe/disaster related. It is required when
an item or service is impacted by an emergency or
disaster and Medicare payment for such item or
service is conditioned on the presence of a “formal
waiver”.
83
Incarcerated Beneficiary Modifier
QJ
April 2015
Services/items provided to a prisoner or patient in
state or local custody, however the State or Local
government, as applicable, meets the
requirements in 42 CFR 411.4(B). For outpatient
claims, providers shall append a modifier QJ on all
lines with a line item date of service during the
incarceration period. All associated charges
should be billed as non-covered.
84
PET/CT Modifiers
PI
Positron Emission Tomography (PET) or PET/Computed
Tomography (CT) to inform the initial treatment strategy of
tumors that are biopsy proven or strongly suspected of being
cancerous based on other diagnostic testing.
PS
PET or PET/CT to inform the subsequent treatment strategy
of cancerous tumors when the beneficiary’s treating
physician determines that the PET study is needed to inform
subsequent anti-tumor strategy.
MLN 6632
April 2015
85
Preventive Service Modifiers
GG
GH
PT
33
April 2015
Diagnostic Mammography – Performance and
payment of a screening mammography and
diagnostic mammography on same patient, same
day.
Diagnostic mammogram converted from screening
mammogram on same day
Colorectal cancer screening test; converted to
diagnostic test or other procedure
Preventive Services
86
Waiver of Liability
Liability Modifiers
Waiver of liability Statement Issues, as Required by
Payer Policy. Advanced Beneficiary Notice (ABN) of
Liability required. Modifier is used to signify a line
item is linked to the mandatory use of an ABN when
GA
charged both related to and not related to an ABN
must be submitted on the claim. Line item must be
submitted as covered and Medicare will make the
determination for payment.
Notice of Liability Issued, Voluntary Under Payer
Policy. This modifier should be used to report when
GX a voluntary ABN was issued for a service. Lines
submitted as non-covered and will be denied as
beneficiary liable.
April 2015
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Liability Modifiers
Item or service is statutorily excluded or does not
GY meet the definition of any Medicare benefit. Lines
submitted as non-covered and will be denied.
Item or service expected to be denied as not
reasonable and necessary. Cannot be used when
GZ
ABN is given, this will deny provider liable. Lines
submitted as non-covered and will deny.
Publication 100-04, the Medicare Claims Processing
Manual, Chapter 1, section 60.4
April 2015
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RESOURCES
References
• Noridian Modifier Web pages
JE –
https://med.noridianmedicare.com/web/jea/topic
s/modifiers;jsessionid=42F49F255ECC4EDE9B
E472608BADEA18
JF –
https://www.noridianmedicare.com/parta/train/e
ducation_center/modifiers.html
April 2015
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References
• CMS Internet Only Manuals, Medicare
Claims Processing Manual http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/InternetOnly-Manuals-IOMsItems/CMS018912.html?DLPage=1&DLSo
rt=0&DLSortDir=ascending
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References
• Centers for Medicare & Medicaid Services
(CMS) National Correct Coding Initiative
(NCCI)
• CMS Medically Unlikely Edits (MUEs)
• CMS Addendum A and Addendum B
Updates
April 2015
93
CMS Educational Materials
•
•
•
•
•
MLN products downloadable
– Free of charge/free shipping
Brochures
Fact sheets
Quick reference charts
Web-based training
MLN dedicated web pages
•
•
•
•
MLN General Information
http://www.cms.gov/MLNGenInfo
MLN Matters Articles
http://www.cms.gov/MLNMattersArticles
MLN Products
http://www.cms.gov/MLNProducts
MLN Web Guides
http://www.cms.gov/MLNEdWebGuide
April 2015
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Questions?
Thank you!