Do you know? Many federal, state, and private payers report incorrect modifier use as one of the top billing errors — one that results in denials, reductions in payment, or delays in reimbursement. These claims are missing a modifier or they have an incomplete or invalid modifier appended to the CPT® code.
Correct modifier use is critical to comply with the rules set forth by the Office of Inspector General (OIG) to avoid fraud and abuse charges and to ensure that payers correctly reimburse your practice or facility. Some modifiers are informational only, while other modifiers can directly affect the facility’s reimbursement.
Let’s take a look at 5 modifiers you will use often.
Payers typically define a procedure as beginning with administration of anesthesia and/or preparation of the patient for the procedure in the area where the physician will perform the procedure, such as a hospital operating room (OR), clinic, or physician’s office. They consider a procedure discontinued when a physician begins the surgical or diagnostic service but elects to stop the procedure because continuing would threaten the patient’s well-being. You append modifier 53 to the CPT® code for the service when this occurs.
There are many reasons why a physician may elect to terminate or discontinue a procedure, such as:
You do not append modifier 53 to procedures, however, when they are electively canceled before administration of anesthesia and/or the patient’s surgical preparation in the operating suite.
Documentation should again be made in the patient’s record indicating the reason(s) for discontinuing the procedure.
Exception: Refer to modifiers 73 and 74 to code hospital outpatient procedures that are reduced or canceled prior to and after the administration of anesthesia to the patient.
When you have procedures or services that are distinct or independent from other non-E/M services rendered by the same provider on the same day, the service may be reportable, in addition to the other procedures or services, with modifier 59 (Distinct procedural service). Under certain circumstances, you apply modifier 59 to indicate that the services, although not normally reportable together, were done together for a reason. You use modifier 59 when there is NO other appropriate modifier. If there is another modifier that more accurately describes the service(s), use it instead. Modifier 59 tells the insurance company that the procedure or service that is normally bundled under one code was done separately. There are many situations that indicate use of the separate procedure modifier.
Example: A patient receives a total abdominal hysterectomy (TAH) and at the same time the provider repairs an enterocele. The enterocele repair is distinct and not related to the TAH. You report the primary procedure, the TAH, with the appropriate abdominal hysterectomy code first and then the separate distinct procedure, the enterocele repair, with modifier 59.
Look to the Descriptor for Help
Some codes clearly indicate the use of modifier 59 by their description. The descriptor states they are separate from other procedures by including the statement “separate procedure.” This designation identifies procedures that the physician normally performs as an integral part of a total service or procedure but which the provider may, on occasion, perform separately.
Per CPT® guidelines, you should not report these codes in addition to the code for the total procedure or service. However, if the “separate procedure” is done independently or is unrelated or distinct from other procedures and services done at the same time, you can report the “separate procedure” code. When you append modifier 59 to the “separate procedure” code, you tell the payer that the procedure is not a component of the other procedure but a distinct, independent service.
Does the primary procedure include the separate procedure? The term, “separate procedure” should prompt you to review the documentation to see why the provider did the separate procedure. The records must justify the reason(s) that the procedure is not a component of another procedure but is distinct and independent.
CMS guidelines state that you should not report a “separate procedure” carried out with another procedure in an anatomically related region through the same skin incision, orifice, or surgical approach. The patient record needs to indicate one of the following situations:
By appending modifier 59, you tell the insurer that the provider performs a separate procedure from the procedure normally bundled under one code.
Identifying Codes not Typically Reported Together
CMS provides National Correct Coding Initiative (NCCI) edits that tell you which procedures or code pairs are typically bundled together for Medicare. Use of modifier 59 advises the payer that there is justification for two separate procedures.
Column 1 of the NCCI edits lists the comprehensive code (or the one that includes the services of the code listed in column 2). Column 2 is the component code (or the one that is included as part of the procedure or service in column 1). You will see in the edits that each code pair has a numeric marker indicating whether CMS allows the use of modifier 59:
Application of the modifier tells Medicare to pay for both even though the two procedures are normally done together, as they are separate and distinct in this situation. Always append modifier 59 to the column 2 code.
|Column1/Column 2 Edits|
|Col1||Col2||In existence prior to 1996||Effective Date||Deletion
|PTP Edit Rationale|
|29823||29805||20020101||*||1||CPT® Manual or CMS manual coding instructions|
|1. Column 1 indicates the payable code.
2. Column 2 contains the code that is not payable with this particular Column 1 code, unless a modifier is permitted and submitted.
3. The third column indicates if the edit was in existence prior to 1996.
4. The fourth column indicates the effective date of the edit (year, month, date).
5. The fifth column indicates the deletion date of the edit (year, month, date).
6. The sixth column indicates if use of a modifier is permitted. This number is the modifier indicator for the edit.
7. The seventh column provides the underlying basis for each NCCI Procedure-to-Procedure (PTP) edit.
The column two code 29805 (Arthroscopy, shoulder, diagnostic, with or without synovial biopsy [separate procedure]) is designated as a “separate procedure”. Therefore, if the provider performs it with the column one code 29823 (Arthroscopy, shoulder, surgical; debridement, extensive), the column two code 29805 is bundled into the column one code 29823. This code pair allows a modifier as the 1 in column 6 indicates. You would append modifier 59 to 29805 to unbundle these services and report them as separate and distinct procedures.
You can visit the CMS website at cms.gov to find more details for appending modifier 59.
When a physician or other qualified health care professional needs to take the patient back to the operating room within the global period of an initial surgery for a procedure unrelated to the initial surgery, you use modifier 79. Appending modifier 79 (Unrelated procedure or service by the same physician or other qualified health care professional during the post-operative period) to the second procedure indicates the surgery is completely unrelated to the initial procedure and that a new global period applies for the second procedure. You use this modifier when the second unrelated procedure is done by the same surgeon as the initial surgery and/or another physician in the same practice and specialty.
Be aware! The modifier does not necessarily require a return to an actual operating or procedure room. Services that qualify for modifier 79 may be done anywhere. The modifier may also apply if a less extensive procedure fails and the provider performs a more extensive procedure. In that situation, the second procedure is often separately reportable with modifier 79. Know the individual insurer’s regulations before you code.
Example: A physician performs an open reduction for a patient who fell and broke his tibia. A week later, his crutch catches carpeting and he falls again — this time breaking his ulna. The same surgeon performs an open reduction of the ulnar
fracture within the global period of the first procedure. These two procedures are obviously completely unrelated.
You would use 27758 (Open treatment of tibial shaft fracture [with or without fibular fracture], with plate/screws, with or without cerclage) for the first procedure. For the second procedure report 25545 (Open treatment of ulnar shaft fracture, includes internal fixation, when performed) for the repair of the ulna fracture with modifier 79, which shows the payer that the two procedures were unrelated surgeries and each has their own global reporting time frames.
When the provider plans to perform a service that he suspects or knows Medicare will not cover as reasonable and necessary, the patient must be provided an advance beneficiary notice (ABN) before the service is performed. The ABN lets patients know that they are financially responsible for the charge for the service. Modifier GA (Waiver of liability statement issued as required by payer policy, individual case) applies to a code when the payer requires the provider to present ABN notice before the patient receives an item or service the provider expects Medicare not to cover as reasonable and necessary. Use modifier GA to tell Medicare that the patient received the ABN, or waiver of liability as it is also known, and accepts responsibility for payment if Medicare denies the claim.
Medicare’s decision not to cover the item or service may be due to a National Coverage Determination (NCD) or, in the absence of a national coverage policy, a Local Coverage Determination (LCD) may exist, which defines the reasonable and necessary use of the item or service. The ABN is notification to the patient that Medicare certainly or most probably will not pay for the item or service and that the patient will be financially responsible for the charge. This form signifies that the patient was made aware and accepts the liability for the cost of the item or service if Medicare ends up not paying for it and allows you to collect from the patient upon Medicare’s denial.
Be aware! Medicare prohibits the routine use of ABNs. However, it does allow for certain exceptions, such as for those services that have a frequency limit on coverage. In these instances, all patients receiving these services can be given an ABN.
TIP: If the patient refuses to sign the ABN, you should notate the patient’s refusal to sign in the patient’s record and still append the GA modifier to advise Medicare that the patient was made aware of the probable noncoverage of the items or services. Upon their denial, Medicare will automatically assign liability to the beneficiary.
Example: A patient receives a screening colonoscopy and you know Medicare will deny the procedure because payment has already been made for a similar procedure within a set time frame. You report the appropriate HCPCS G0105 (Colorectal cancer screening; colonoscopy on individual at high risk) or G0121 (Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk) with the GA modifier, G0105-GA or G0121-GA.
Know When to Use Modifier TC
When a service is provided in a hospital or other facility, the hospital does not always bill for the entire service — both the professional and technical components. The hospital bills only for the technical component of the service when the physician who performs the service does not work for the hospital, that is, the physician may own her own solo practice, be a part owner in a group practice, or be employed by a group practice.
Typically, when a procedure or service is done in a hospital or outpatient facility by an outside physician, the physician’s staff code and bill for his time and expertise (the professional component) on a CMS-1500 claim form, and the hospital bills for all other costs associated with the service or procedure (the technical component) on the UB-04 form.
The technical component, or hospital component in this instance, includes all the resources included in the procedure, such as the cost of the hospital personnel, the space, as medical and surgical instruments and supplies, radiological or other equipment, and disposables used for the service, as well as the overhead costs like utilities and operating expenses.
Caveat: Recall that you do not need to append a TC modifier on the hospital claim as it is implicit that when you bill for hospital services that you are billing for the technical portion. The insurance company will pay the hospital one amount and the physician a separate amount for each of their involvement in the service or procedure.
Hold off Applying Modifiers for Global Services
As we explained previously, if you want to report a service as a global service, you do not append a modifier. A situation where you would want to bill the service as global is when there is no division of the costs for a service or procedure because the same entity provides all components of the service or procedure. In this instance, the charge includes both the professional and technical components. When you code for both the professional and technical component of a service, you report the CPT® code without a modifier, which shows the insurance company that the service (typically done at one location) is a global service that includes both components. The insurance company then makes one payment covering both components.
Example: A patient has a consultation with a physician. The coder codes the consultation with 99243 (Office consultation for a new or established patient, which requires these 3 components: a detailed history, a detailed examination, and medical decision-making of low complexity…), with no modifier.
No PC/TC Split Also Signals No Modifier
Just as there are services and procedures that have a technical and professional portion, such as radiology, surgery and medicine services, and some laboratory services, there are many CPT® codes that do not have separate technical and professional components. You do not report these codes separately as there is no separate PC (modifier 26) and TC payment amounts.
Example: An example of a service that is a global test or service that cannot be split into technical and professional components is radiation treatment delivery (codes 77401-77412).
Are you grappling with which modifier to select and when? Do you need help interpreting modifier assignments?
Designed for beginning coders, coding instructors, and as a refresher for experienced coders, Modifiers Explained 2018 jumpstarts learning with an in-depth and easy-to-follow primer on modifiers, including how and when to use them.