Last time, we looked at numbers 10 and nine on our list of CPT® modifiers that create confusion and problems in coding and billing for medical services and procedures. This time, we look at four more as we count down to the number one misused CPT® code modifier.
How it’s misused: Previously, we discussed how 58 (Staged or related procedure or service by the same physician or other qualified healthcare professional during the postoperative period) can easily be confused with modifiers 76 (Repeat procedure or service by same physician or other qualified health care professional) or 78 (Unplanned return to the operating/procedure room by same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative period). As we saw, 76 describes a second, identical service after the first service did not significantly improve the patient’s condition, while 78 applies to a situation where complications arise from the first procedure.
How you should use it: Alternatively, you’ll use 58 for a second procedure that has been planned as a follow-up to an earlier procedure when the provider performs the second procedure during the global period assigned to the first. So, if your provider performs a diagnostic procedure that results in a service within the postoperative period, you will attach 58 to the diagnostic encounter.
Example: A patient has a malignant melanoma removed from his shoulder and the physician takes a lymph node biopsy (38510, Biopsy or excision of lymph node[s]; open, deep cervical node(s)). Pathology determines that the lymph node has metastatic malignancy, so the physician schedules the patient to come back for a lymph node dissection, which you would document with a code in the 38500-38555 (Biopsy or excision of lymph node(s); …) range, appending modifier 58 to the procedure code.
How it’s misused: This modifier can be the cause of several errors. First, some CPT® codes have laterality built into the code descriptor, rendering use of modifier 50 (Bilateral procedure) redundant. Second, some payers, including Medicare, prefer you to use Level II (HCPCS) modifiers RT (Right side) and LT (Left side) to specify the side of the body on which your provider performed the service.
How you should use it: Make sure you know your payer’s preference before using 50, RT, or LT. You can also check to see which CPT® codes will take 50 by
You should never attach 50 to codes with indicators 0, 2, and 9 in that column; however, you can use the modifier on codes with indicators 1 or 3.
Example: A physician performs removal of impacted cerumen with instrumentation on both ears. You report 69210 (Removal impacted cerumen requiring instrumentation, unilateral) for the procedure, and append modifier 50 to 69210 to show the procedure was bilateral as the 69210 descriptor contains the word “unilateral,” and is thus a modifier 50 opportunity.
How it’s misused: CPT® Appendix A identifies three problems you can encounter when using modifier 91 (Repeat clinical diagnostic laboratory test). The most common mistake is using it for services that require a provider to administer multiple, identical tests over a period of time as described by the particular CPT® code. Another error involves using the modifier on a subsequent test when the provider suspects a previous, identical test may have been performed inaccurately or has produced problematic results. Additionally, you cannot use the modifier for tests that are performed on different days or on different anatomic sites.
How you should use it: Modifier 91 is specifically for occasions when your provider repeats a test, such as a glucose tolerance test, to obtain different results over the course of the same day and gain a full understanding of a patient’s condition.
Example: A clinician orders 81000 (Urinalysis, by dip stick or tablet reagent for bilirubin, glucose, hemoglobin, ketones, leukocytes, nitrite, pH, protein, specific gravity, urobilinogen, any number of these constituents; non-automated, with microscopy) for a patient who is severely dehydrated and orders a second urinalysis later that day following intravenous treatment to determine whether the patient’s condition has improved. In this case, you should report 81000 and 81000-91.
How it’s misused: On the surface, appending modifier 26 (Professional component) to a service when your provider has simply contributed his professional expertise, such as interpreting test results, as opposed to providing the technological component to that test as well, seems fairly straightforward.
The problem comes in knowing when to apply it correctly. Some CPT® codes specify the professional component, making your use of 26 redundant. But some circumstances, such as services provided in a hospital setting, require you to report 26.
How you should use it: Look for words such as “interpretation and report only” in the CPT® code descriptor. If they are there, do not use the modifier. If your provider does the work in a facility that owns the testing technology, Medicare and payers who follow Medicare rules require you to use 26 when the CPT® code descriptor describes both a technical and a professional component. Payers will assume that the facility will append TC (Technical component) to the same code, and failure to append 26 on your side could result in an overpayment for the test.
Example: An ob-gyn physician performs an ultrasound for a patient in the labor and delivery (L&D) department of the hospital because the patient has stopped feeling fetal movement. You would code this service as 76811- 26 (Ultrasound, pregnant uterus, real time with image documentation, fetal and maternal evaluation plus detailed fetal anatomic examination, transabdominal approach; single or first gestation), as the hospital provided the equipment, or the technical component, of the test.
Contributing Editors: Chris Boucher, Ellen Garver
Join us in the next blog post for our last Misused Modifier post when we look at the final four modifiers on our list. Any guesses as to what they will be?
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