What are Medical Coding Modifiers? Examples of CPT, HCPCS and Anesthesia Modifiers and When to Use Them
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Using CPT, HCPCS and anesthesia modifiers correctly is critical to communicate details regarding the performance of a medical procedure or service to payers. Modifiers are two-character codes that provide more meaning to the procedure code’s original definition. By using modifiers correctly and communicating specific information to the insurance carriers, medical billing and coding companies ensure that physicians get paid appropriately for services rendered
Features of Modifier Codes Modifier codes can be two digit numbers, two character modifiers, or alpha-numeric indicators They are a tool to provide more detail to the performance of a medical procedure or service They are always placed at the end of a CPT code, separated with a hyphen Up to 4 modifiers may be stated on a claim Functional modifiers affect reimbursement and informational modifiers provide information about the procedure HCPCS Level II modifiers are used to provide additional information about services provided to patients covered by a payer that accepts HCPCS Level II codes. www.outsourcestrategies.com
Code Modifiers Clarify the Following Whether a service or procedure has a professional component or a technical component If multiple procedures were performed or only part of a service was performed Why a procedure was necessary The location on the body where the procedure was performed Whether the service or procedure was performed by more than one physician Whether a service or procedure was provided more than once Unusual events occurred An add-on or additional service was performed Other information that may be vital to a claim’s specific reimbursement status
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Commonly Used CPT and HCPCS Modifiers CPT Modifiers 22 Unusual procedural services 23 Unusual anesthesia 24 Unrelated evaluation and management service by the same physician during a postoperative period 25 Significant, separately identifiable E&M service by the same physician on the same day of the procedure or service 26 Professional component 27 Multiple outpatient hospital E&M encounters on the same date 32 Mandated services 47 Anesthesia by surgeons 50 Bilateral procedure 51 Multiple procedures Indicates that multiple procedures (other than E/M services) 52 Reduced services 53 Discontinued procedure 54 Surgical care only www.outsourcestrategies.com
57 Decision for Surgery - Indicates an E/M service that resulted in the initial decision to perform a surgery 58 Staged or related procedure or service by the same physician during the postoperative period 59 Distinct Procedural Service - Indicates that a non-E/M procedure or service was distinct or independent from other non-E/M services performed on the same day: XE-Separate Encounter XP-Separate Practitioner XS-Separate Organ/Structure XU- Unusual Non-overlapping Service 76 Repeat procedure or service by same physician or other qualified healthcare professional 77 Repeat procedure by another physician or other qualified healthcare professional 95 Synchronous telemedicine service rendered via real-time interactive audio and video telecommunications system
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HCPCS Modifiers Anatomical Modifiers: Anatomical modifiers indicate the area or part of the body on which the procedure is performed on different sites during the same session. Examples: • • • • • • • • • •
E1–E4 Eyelids FA–F9 Fingers TA–T9 Toes RT Right LT Left LC Left circumflex, coronary artery LD Left anterior descending coronary artery LM Left main coronary artery RI Ramus intermedius RC Right coronary artery
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Modifiers for Anesthesia Claims Correct use of anesthesia modifiers is necessary for proper claims payment. AA Anesthesia services performed personally by anesthesiologist – informs the payer that the anesthesiologist provided care to the patient alone, and not alongside a certified registered nurse anesthetist (CRNA). AD Medical supervision by a physician; more than four concurrent anesthesia procedures QZ CRNA service: without medical direction by a physician QY Medical direction of one certified registered nurse anesthetist by an anesthesiologist QK Medical direction of two, three or four concurrent anesthesia procedures involving qualified individuals QX CRNA service: with medical direction by a physician QS Monitored anesthesia care (MAC) provided by an anesthesiologist P1–P6 Anesthesia Physical Status Modifiers www.outsourcestrategies.com
Use of Modifiers - Key Points to Note There are strict rules and regulations to using modifiers that must be followed at all times When two or more modifiers are used, the functional modifier should be listed first, followed by all the other modifiers The documentation within the medical record to support the use of each modifier should be clear While some modifiers can be used only with Evaluation and Management (E&M) codes, there are several modifiers that are not compatible with E&M codes Incorrect use of modifiers prevents the provider from receiving the full reimbursement for the services performed and vice versa Repeated misuse of modifiers will attract scrutiny and trigger audits www.outsourcestrategies.com
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