Medicare 101:
“Basics of Modifier Billing”
Part B Provider Outreach and Education
February 26, 2014
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DISCLAIMER
This resource is not a legal document. This presentation was prepared
as a tool to assist our providers. This presentation was current at the
time it was created. Although every reasonable effort has been made
to assure accurate information, responsibility for correct claims
submission lies with the provider of services. Reproduction of this
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CPT Disclaimer American Medical Association (AMA)
Notice and Disclaimer
Current Procedural Terminology (CPT) only copyright ©2013 American
Medical Association. All rights reserved. CPT® is a registered
trademark of the American Medical Association (AMA). Applicable
FARS/DFARS Restrictions Apply to Government Use. Fee schedules,
relative value units, conversion factors, and/or related components are
not assigned by the AMA, are not part of CPT, and the AMA is not
recommending their use. The AMA does not directly or indirectly
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Agenda
• What is a Modifier?
• Types of Modifiers
• Understand the Medicare Physician Fee
Schedule Database
• Resources
Back to
the
Basics
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Modifiers
• Two digit HCPCS Level I and II codes
– referred to as CPT modifiers and HCPCS modifiers
• Indicates that a service or procedure has been
altered
• Should always be appended to a procedure code
• Can be pricing or informational
Alpha
Numeric
Alpha-Numeric
GA
78
E1
5
Modifiers
• Pricing modifiers will
– Effect payment of service
– Will determine allowance of service billed
– Should always be placed in the first modifier field
• Informational modifiers will
– Provides additional information
– May state whether a service is reasonable and necessary
– Should be used in the second, third or fourth field if pricing
modifier being used
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Modifier Categories
• There are several types of modifiers that are specific
to billing categories and specialties
• The most widespread used for Medicare Part B are
–
–
–
–
–
–
Evaluation and Management (E&M)
Global Surgery
Diagnostic services (i.e., radiology procedures)
Clinical laboratory
National Correct Coding Initiative (NCCI)
Surgical billing
• You may view a comprehensive list on the Cahaba
GBA website at the link shown below
http://www.cahabagba.com/news/modifiers-for-medicare-billing/
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Medicare Physician Fee Schedule
Database (MPFSDB)
• Referred to as the Physician Fee Schedule
(PFS) Relative Value File
• Payment indicator list
• Provides information about specific codes
• Updated quarterly by the Centers for
Medicare and Medicaid Services (CMS)
• Changes listed in the Medicare B Newsline
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MPFSDB
• You can access the file by either the Cahaba GBA or
CMS websites
– For Cahaba GBA
• Go to www.cahabagba.com
• Click on “Fee Schedules” under the quick links
– For CMS
• Go to www.cms.gov
• Click on Medicare
• Under Medicare Fee-for-Service Payment select
“Physician Fee Schedule Look-up Tool”
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MPFSDB
Cahaba GBA
https://apps.cahabagba.com/fees/getFilesByYea
r.do?year=2014
CMS
http://www.cms.gov/apps/physician-feeschedule/overview.aspx
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Global Surgery
• Global surgical package, also called global surgery,
includes all necessary services normally furnished by
a surgeon before, during, and after a procedure.
Medicare payment for the surgical procedure
includes the pre-operative, intra-operative and post –
operative services.
• Physicians in the same group practice who are in the
same specialty must bill and be paid as though they
were a single physician.
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Global Surgery
• There are three types of global surgical packages:
– 0 day: Endoscopies and some minor procedures
• No pre-operative period and no post-operative days
• Visit on day of procedure is generally not payable as a separate
service
– 10 day: Other minor procedures
• No pre-operative period
• Visit on day of the procedure is generally not payable as a separate
service
• Total global period is 11 days
– 90 day: Major procedures
• One day pre-operative included
• Day of the procedure is generally not payable as a separate service
• Total global period is 92 days
http://cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf
Modifier 24, 25, and 57
Evaluation & Management
(E&M)
• 24 – Unrelated E&M service during a postoperative period of a major or minor surgical
procedure
• For codes with 10 or 90 day global period
• Used with E&M codes only
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Modifier 24, 25, and 57
Modifier 24 Example
Date of
Service
Treatment
CPT/Modifier
02/03/2014
Destruction of
premalignant
lesion
E&M for upper
respiratory
infection (URI)
17000
02/06/2014
99213-24
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Modifier 24, 25, and 57
Evaluation & Management
(E&M)
• 25 – Significant, separately identifiable
evaluation and management service by same
physician on same day of procedure
• For codes with 0 or 10 day global period
• Different diagnoses are not required
• Used with E&M codes only
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Modifier 24, 25, and 57
Claim Submission Errors
Modifier 25
• Modifier 25 billed on claim line item with no
other service submitted
• Modifier 25 appended to a surgical or
radiological procedure code
• Modifier 25 billed on same claim with service
that does not have global days
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Modifier 24, 25, and 57
Modifier 25 Example
Date of
Service
Treatment
CPT/Modifier
01/06/2014
Trigger point
injections
E&M visit
Neck pain and
elevated blood
pressure
20553
01/06/2014
99213-25
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Modifier 24, 25, and 57
Evaluation & Management
(E&M)
• 57– Decision for surgery-E&M
service resulting in the initial
decision to perform major
surgery
• Use only when surgical code
has a 90 day global period
– E&M day before surgery
– E&M day of surgery
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Modifier 24, 25, and 57
Modifier 57 Example
Date of Service
Treatment
CPT/Modifier
02/25/2014
Total hip
replacement
27130
02/25/2014
History and
physical
99221-57
• Use modifier 57 if decision for surgery was done at
that time
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Modifier 54, 55, 58, 78, and 79
Transfer of Care (aka Split Care)
• 54 -Surgical care only; Surgeon is performing only
the preoperative and intra-operative care
• 55 - Postoperative management only; Physician,
other than surgeon, assumes all or part of
postoperative care
• Modifiers should be placed on the surgical code
• Used on 10 day and 90 day surgical procedures
20
Modifier 54, 55, 58, 78, and 79
Transfer of Care (aka Split Care)
Both the surgeon and the physician providing the
postoperative care must keep a copy of the written
transfer agreement in the beneficiary’s medical
record.
When a transfer of postoperative care occurs, the
receiving physician cannot bill for any part of the
global services until he has provided at least one
service. Once the physician has seen the patient, that
physician may bill for the period beginning with the
date on which he assumes care of the patient.
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Transfer of Care
• Doctor A billing pre-operative and major surgery
01 17
14
21
66984
54
• Doctor B billing post-operative portion
01 17
14
11
66984
55
22
Modifier 54, 55, 58, 78, and 79
Staged Procedure
• 58 - Staged or related procedure during the
post-op period by the same physician
– Must be planned at time of original procedure
– Must be more extensive than original procedure
– A therapeutic surgical procedure following a
diagnostic surgical procedure
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Modifier 54, 55, 58, 78, and 79
Return Trip and Unrelated Procedure
• 78 –Return to the operating room for a related
procedure during a post-operative period
– Bill CPT code describing procedure performed during return
trip
– Payment limited to intra-operative services only
• 79 –unrelated procedure by the same physician
during a post-operative period
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Modifier 26, TC
Diagnostic Services
• 26 – Professional Component only
• TC – Technical component only
• Both modifiers affect payment
• Verify your code before submitting on claim
• PC/TC indicators located on the MPFS
database
25
Modifier 26, TC
Claim Submission Errors
Modifier 26 and TC
• Modifier 26/TC used on same
claim line for global procedure
• Modifier 26 and TC appended
to office visit and injection
procedure codes
• Misuse of modifier 26 on clinical
lab codes
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Modifier QW, 91 and 90
Laboratory
• QW – CLIA waived test
• Submit with clinical lab tests that are waived
• Food and Drug Administration (FDA) determine
which lab tests are waived
• Certain codes do not require HCPCS modifier QW
• Use the first modifier field when submitting claim
– Don’t forget to submit the CLIA certificate number
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Modifier QW, 91 and 90
Laboratory
• List of approved test is posted on a
quarterly basis in the Medicare B
Newsline
• Providers should refer to the CLIA
brochure at
http://cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNProducts/Downloads/CLIABroch
ure.pdf
http://www.cms.gov/Regulations-and-Guidance/Legislation/CLIA/downloads//waivetbl.pdf
Modifier QW, 90, 91
Laboratory
• 90 – Reference lab
– Specimen referred to
another lab for testing
– Reference lab receives
the specimen
– Labs bill contractor in
their jurisdiction for tests
performed by reference
lab
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Modifier QW, 90, 91
Laboratory
• 91– Repeat clinical diagnostic laboratory test
• Identifies a medically necessary lab test on the same
day of the same previous laboratory test
• Should not be used for
– Rerun of a lab test to confirm results
– Testing problems for the specimen or of the equipment
– A procedure code that describe a series of test
• Do not bill modifier 91 on all claim line services
– You will not append modifier to your initial lab procedure
code
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Modifier 59
Correct Coding Initiative
• 59 - Distinct procedural service (on the same
date of service by same physician)
–
–
–
–
Different session or patient encounter
Different procedure or surgery
Separate incision/excision
Separate injury
• Should only be used if no other modifier is
available
• Use of the modifier should be supported in
the medical record
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Modifier 59
Correct Coding Initiative
• Column 1/Column 2 list
• Column 1 is the primary code
• Column 2 is the code that bundles into column 1
code
• Last column provides the CCI Modifier Indicator
– 1 = Modifier can be used
– 0 = No modifier is allowed
– 9 = Concept not applicable
• Refer to the NCCI Coding Edits at
http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/
NCCI-Coding-Edits.html
32
Modifier 59
Correct Coding Initiative
Date of
Service
Treatment
Procedure
02/17/2014
Biopsy of
right hand
11000-59
02/17/2014
Destruction
of lesion
17000
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Modifier 59
Claim Submission Errors
Modifier 59
• Improper usage for Modifier 59
– appended to the procedure code with no other
services billed on claim
– submitted with an evaluation & management
procedure code
– used with the weekly radiation therapy
management code (CPT 77427)
– billed on same claim with service that does not
have global days (e.g, J-codes)
34
Modifier 50, 51, 62, 66, 80, AS
Bilateral Service
• 50 – Bilateral procedure
• Surgery performed on both sides of the body at the
same operative session or on the same day
– Fee Schedule indicator 1
– Number of service is 1
– Bill code once with modifier
• Modifier 50 allowable is 150% of MPFS
• Modifier does not apply to Ambulatory Surgery
Center claims
35
Modifier 50, 51, 62, 66, 80, AS
Multiple Procedure
• 51 – Multiple procedures other than Evaluation &
Management performed at same session, by same
physician on the same patient on the same day
–
–
–
–
Do not use with add-on codes
Not required on claims submitted to Medicare contractor
Reduction determined by the MPFS approved amount
M/S pricing indicators effect surgical procedures, endoscopy
rules, technical components, therapy services,
cardiovascular and ophthalmology services
36
Modifier 50, 51, 62, 66, 80, AS
Co-surgery/Surgical Team
• 62 – Two surgeons work together as primary surgeons
performing distinct parts of procedure
– Both surgeons must agree to use modifier 62
– Fee Schedule indicator must be 1 or 2
– Both reimbursed each at 62.5% of allowance
• 66 – Team surgery, highly complex procedure
requiring skills of different specialties
– Highly complex procedure
– Often of different specialties
– Documentation required and subject to medical review
37
Modifier 50, 51, 62, 66, 80, AS
Assistant-at-Surgery
• 80 - An assistant surgeon’s services for
physician
– Allowed amount equals16% of the amount
• AS – Used by Physician Assistants, Clinical
Nurse Specialist and Nurse Practitioners
assisting in surgery
– Payment is 85% of 16% of surgical fee
38
Modifier GA, 76, 77, GV, GW
Advance Beneficiary Notice of
Noncoverage
• GA – Advance Beneficiary Notice (ABN) on file
• GY – Item or service statutorily excluded or does not
meet definition of any Medicare Benefit
• GZ – Item or service expected to be denied as not
reasonable and necessary; no ABN on file
39
Modifier GA, 76, 77, GV, GW
Modifier 76 & 77
• 76 –Repeat procedure by same physician
• 77 –Repeat procedure by another physician
• Procedure was repeated subsequent to
original service
• Repeat procedures on same day
• Add modifier to repeated service
40
Modifier GA, 76, 77, GV, GW
Hospice Modifiers
• GV – Attending physician not employed or paid under
agreement by patient’s hospice provider
– Services related to hospice condition
– Patients can be seen by both the attending
physician and hospice employed physician
• GW – Services not related to a hospice patient’s
terminal condition
• Use hospice modifiers after each procedure code
billed
41
Specialty Modifiers
Anesthesia
• AA - Anesthesia Services performed personally by the
anesthesiologist
• AD - Medical Supervision by a physician; more than 4
concurrent anesthesia procedures
• QK - Medical direction of two, three or four concurrent
anesthesia procedures involving qualified individuals
• QX - CRNA service; with medical direction by a physician
• QY - Medical direction of one certified registered nurse
anesthetist by an anesthesiologist
• QZ - CRNA service: without medical direction by a physician
42
Specialty Modifiers
Therapy
• GN - Services delivered under an outpatient speech
language pathology plan of care
• GO - Services delivered under an outpatient
occupational therapy plan of care
• GP - Services delivered under an outpatient physical
therapy plan of care
• KX - Requirements specified in the medical policy
have been met. May be used when a therapy
exception is appropriate
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Specialty Modifiers
Ambulance
Two of the following modifiers are required for each base line item to report
the origin and the destination
•
•
•
•
•
•
•
•
•
•
•
D Diagnostic or therapeutic site other than “P” or “H” when these are used as
origin codes
E Residential, domiciliary, custodial facility (other than an 1819 facility)
G Hospital based dialysis facility (hospital or hospital related)
H Hospital
I Site of transfer (e.g., airport or helicopter pad) between modes of ambulance
transport
J Non-hospital based dialysis facility
N Skilled nursing facility (SNF) (1819 facility)
P Physician’s office (includes HMO non-hospital facility, clinic, etc.)
R Residence
S Scene of accident or acute event
X (Destination code only) Intermediate stop at physician’s office in route to the
hospital (includes HMO non-hospital facility, clinic, etc.)
44
New Modifiers
Modifiers
AO
JE
PM
Description
Alternate payment method
declined by provider of service
Administered via dialysate
Post mortem
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Tips to Remember
• Always use the appropriate modifier for the
procedure
• List pricing modifiers first and informational modifiers
second
• Denial of payment may result if
– An invalid modifier is used
– The modifier is not used and is required
• Refer to resource tools such as
– Your CPT or HCPCS manual
– Modifier chart on the Cahaba GBA website
46
Common Pricing Modifiers
Modifier
Description
AA
Anesthesia Services performed personally by the anesthesiologist
AS
Assist at Surgery Non physician practitioner (PA,NP,CNS)
QK
Medical direction of two, three or four concurrent anesthesia procedures involving
qualified individuals
QX
CRNA service; with medical direction by a physician
QY
Medical direction of one certified registered nurse anesthetist by an anesthesiologist
QZ
CRNA service: without medical direction by a physician
TC
Technical component
26
Professional fee
50
Bilateral service
54
Surgical care only
55
Post-operative care
62
Co-surgery
78
Return to the operating room
80
Assist at surgery physician
47
Medicare Updates
• Comprehensive Error Rate Testing
Program
– New name, logo for Educational Task
Force
• Foresee Survey
– We want your opinion!
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Acronyms
Participants can view a list of acronyms used
during today’s webinar by accessing the
glossary section on the Cahaba GBA website,
www.cahabagba.com
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Resources
Cahaba GBA
www.cahabagba.com
Centers for Medicare and Medicaid Services
www.cms.gov
Resource Center for New Providers
https://www.cahabagba.com/part-b/education/welcome-to-theresource-center-for-new-providers/
Global Surgery Fact Sheet
http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetwork-MLN/MLNProducts/downloads/GloballSurgery-ICN907166.pdf
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Questions?
Provider Contact Center: 1-877-567-7271
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