Modifiers for Physician Svcs

8/9/2019 Modifiers for Physician Svcs

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Copyright 2006 American Health Information Management Association. All rights reserved.

Modifiers forPhysician Services

Practical Tools for Seminar Learning


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Disclaimer

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The American Health Information Management Association makes norepresentation or guarantee with respect to the contents herein and specificallydisclaims any implied guarantee of suitability for any specific purpose. AHIMA hasno liability or responsibility to any person or entity with respect to any loss ordamage caused by the use of this audio seminar, including but not limited to any

loss of revenue, interruption of service, loss of business, or indirect damagesresulting from the use of this program. AHIMA makes no guarantee that the useof this program will prevent differences of opinion or disputes with Medicare orother third party payers as to the amount that will be paid to providers of service.

How to earn one (1) CEU for participationTo earn one (1) continuing education unit, each participant must do the following:

Step 1: Listen to the seminar, via Webcast link, audio CD, or MP3.

Step 2: Complete the assessment quiz contained in this resource book.Use the included answer key. Do not returnthe quiz to AHIMA.Save it for your records.

Step 3: Fax or mail us the completed sign-in form from this resource book.The fax number and address are located at the bottom of the form.

Step 4: Print the certificate of attendance for each listener. The certificate must be

retained by each participant as a record of their participation, along with a copyof their completed quiz.

After listening to the seminar, please let us know what you think, by completing our online

evaluation survey at http://campus.ahima.org/audio/fastfactsresources.htm


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Faculty

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Susan M. Hull, MPH, RHIA, CCS, CCS-P

Susan M. Hull, MPH, RHIA, CCS, CCS-P is a professional practice resources managerfor the American Health Information Management Association (AHIMA). In her role asmanager, Susan provides professional expertise to AHIMA members, the media, and

outside organizations on coding practice issues, and develops written products aimedat furthering the art and science of coding.

Susan has over 20 years experience in the HIM field. Before joining AHIMA in 2002,she served as Senior Executive Director for HMI Corporation where she oversawcoding reviews; chargemaster maintenance and development; and presented seminarsin outpatient, inpatient, and physician documentation and coding. Prior to this, sheworked in numerous HIM roles, including consultant, HIM department director, andHIM software developer and manager.

In addition to AHIMA, Susan is actively involved as a volunteer in the HIM profession.She has presented on timely HIM topics to the Health Information Management

Associations of California, Tennessee, and Southern Illinois, as well as the SouthernIllinois Healthcare Financial Management Association.

Susan received a bachelor of arts degree and a master of public health in HealthServices and Hospital Administration from the University of California, Los Angeles.


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Table of Contents

Disclaimer ..................................................................................................................... i

How to earn one (1) CEU for participation......................................................................... i

Faculty .........................................................................................................................ii

Why to use modifiers...................................................................................................... 1

When to use modifiers.................................................................................................... 1Modifiers to use with E&M codes ..................................................................................... 2

Modifier 25 .................................................................................................................... 2

Modifier 25 CMS guidelines .......................................................................................... 3

Modifier 22 Unusual procedural service ......................................................................... 3

Modifier 50 Bilateral service.......................................................................................... 4

Modifier 52 Reduced services ....................................................................................... 4

Modifier 53 Discontinued procedure .............................................................................. 5

Modifier 58 Staged or related procedure during postoperative period............................... 5

Modifier 59 Distinct procedural service .......................................................................... 6

Abuse of modifiers 25 and 59 .......................................................................................... 7

AHIMA Audio Seminars................................................................................................... 7

About assessment quiz ................................................................................................... 8

Thank you for attending (with link for evaluation survey) .................................................. 8

Appendix ................................................................................................................... 9

Assessment Quiz

Continuing Education Credit and Compliance Sign-in Form

Certificate of Attendance and Quiz Completion

Quiz Answer Key


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Modifiers for Physician Services

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Notes Comments

Why to use modifiers

To reduce the likelihoodthat appropriate servicesw ill be denied

To communicate additionalinformat ion to the payer

1

When to use modifiers

Only part of a service was performed

A bilateral procedure was performed

A procedure was more than usual

A procedure was less than usual

An unusual event occurred

A service has both a technical and a

professional component

2


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2

Notes Comments

Modifiers to use with E&M codes

Modifier 24Unrelated evaluation and managementby the same physician during thepostoperative global period

Modifier 25Medical visit and procedure onthe same date of service

Modifier 57Visit resulted in the init ial decision for surgery(use with major procedures only)

3

Modifier 25

Significant separately identifiableevaluation and management service by thesame physician on the same day of theprocedure or other service

CPT guidelines do not require differentICD-9 -CM diagnosis codes

May be used w ith preventative medicine

codes if a problem is identified and requiresadditional evaluation

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Notes Comments

Modifier 25 CMS guidelines

Use only w ith minorprocedures and endoscopiesif decision for surgery madeon same day as procedure

Global days of 0-10 ordiagnostic procedure

May be used if preoperative and/orpostoperative services are above andbeyond the usual for the procedure

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Modifier 22 - Unusual procedural service

Reflects that the procedure took longerand/ or was more difficult for some reason

Do not assign every time

Documentation required

Operative report

Letter explaining the situation,including med ical necessity for

the more complex procedure Enough to support the amount of

additional reimbursement you are requesting

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Notes Comments

Modifier 50 Bilateral service

Bilateral service on paired organs

The skin is not a paired organ

Do not use w ith CPT codesthat are inherently bilateralor including bi lateral intheir description

Reimbursement is usually 150%

Modifier 50 takes precedence over LT and RTbut check carrier policies especially regardingradiological procedures

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Modifier 52 Reduced services

Service partially reduced at thephysicians discretion

May or may not affect reimbursement,depending upon the payer

Do not report with E&M services

If a codeable service was performed,report the appropriate CPT code for

that service

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5

Notes Comments

Modifier 53 Discontinued procedure

Report when a procedure is terminateddue to extenuating circumstances or thosethat threaten the w ell being of the patient

Do not use when an endoscopic procedureis converted to open

Usually assigned due to anadverse reaction on the partof the patient. Be sure toassign the appropriate ICD-9-CMdiagnosis code.

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Modifier 58 Staged or related procedureduring postoperative period

Report when second procedure was:

Planned prospectively at the time ofthe original procedure (staged)

Is more extensive than the original procedure

Is performed for therapy following a diagnosticsurgical procedure

Do not assign this modifier to theoriginal procedure

Important when second procedure occurs within

the postoperative period of the first

Not for unexpected return to the OR

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Notes Comments

Modifier 59 Distinct procedural service

A most controversial modifier

Use to report

A different session or patient encounter

A different procedure or surgery

A different site or organ

A separate incision or excision

A separate le sion

A separate inju ry

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Modifier 59 Distinct procedural service

The modifier of last resort

Use only when there is documentationto support appropriateness ofreimbursement for both procedures

When in doubt, leave it out.

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This modifier is very highon the OIG watch list,w ith a 40% error rateidentified for modifier 59


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Notes Comments

Assessment

To access the assessment quiz that follows thisseminar, download the seminars resource book at

http://campus.ahima.org/audio/fastfactsresources.html

Your sign-in form and certificate of completion are also foundin the resource book.

Thank you for attending!

Please visit the AHIMA Audio SeminarsWeb site to complete your evaluationform online at:

http:/ / campus.ahima.org/ audio/fastfactsresources.html


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Appendix

Assessment Quiz

Continuing Education Credit and Compliance Sign-in Form

Certificate of Attendance and Quiz Completion

Quiz Answer Key


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Assessment Quiz Modifiers for Physician Services

ANSWERS to this quiz are found on the last page of the

seminar resource book, Practical Tools for Seminar Learning.

To earn continuing education credit of one (1) AHIMA CEU, Fast Facts Audio Seminar listeners must also completethis 10-question quiz. This CE credit is for attending the audio seminar AND completing this quiz. Please keep acopy of the completed quiz with your certificate of attendance. Do not send a copy to AHIMA .

1. True or false? If an identical procedure is

performed on the skin of the left and rightankles, modifier 50 should be appended to thecode.

a. True b. False

2. A patient underwent appendectomy on01/01/06. This procedure has a 90 daypostoperative global period. He experiencesright upper quadrant abdominal pain on the 45thday and visits his surgeon (the same one whoperformed the appendectomy). A diagnosis ofcholelithiasis is made and workup initiated.What modifier, if any, should the attendingphysician report with his evaluation and

management code for that days service.a. No modifier. The ICD-9-CM diagnosis code

for cholelithiasis will indicate to the payer thatthis is an unrelated service.

b. Modifier 24

c. Modifier 25

d. Modifier 59

3. The patient undergoes an abdominalhysterectomy. She weighs 340 pounds and hasan abdominal panniculus (fat pad) over sixinches thick. The surgeon documents extensivetedious incision to reach the pelvic organs andextensive closing time to close the fat pad.What modifier, if any is appropriate, to assignwith this surgery code.

a. Modifier 59

b. Modifier 22

c. No modifier. There is no way to express extratime needed to perform a surgery because ofpatients physiology.

d. Modifier 24

4. The Department of Health and Human ServicesOffice of the Inspector General, following anaudit of use of modifier 59, estimated thatoverpayments resulting from abuse of thismodifier were approximately ____________ inFY 2003.

a. $59 million b. $2 million

c. $135 million d. $1.50

5. In the office, the patient is undergoing an

evaluation and management service and thephysician discontinues the evaluation becausethe patient is verbally abusive and raucous. Howshould this service be reported?

a. Evaluation and management code for theintended evaluation plus modifier 52

b. Evaluation and management code for whatwas actually done

c. No code since the service was not completed

d. A level 5 evaluation and management codebecause the patient caused upheaval in theoffice

6. According to the HHS OIG audit, whatpercentage of claims submitted with modifier 25were found to be inappropriate?

a. 10% b. 25%

c. 35% d. 50%

7. The main reason that claims were found to beinappropriately reported with modifier 25 was:

a. Failure to document either the evaluation andmanagement service and/or the procedure

b. Missing identifying information

c. Failure to respond to request for medicalrecords

d. Failure to meet requirements for use ofmodifier 25

8. True or false? Claims that inappropriatelyreported modifier 59 were generally in violationof the Correct Coding Initiative.

a. True b. False

9. A modifier may be appropriate with all but one othe following types of codes. Which type of codeis never reported with a modifier?

a. Evaluation and management codes

b. CPT unlisted procedure codes

c. CPT procedure codes

d. HCPCS Level II codes

10. True or false? Unless specific payer guidelinesstate otherwise, modifier 50 takes precedenceover modifiers LT and RT.

a. True b. False

Do not send a copy of completed quizzes to AHIMA. Please keep them with your certificate of attendance, for yourrecords. Be sure to complete and send the seminar sign-in sheet found on the next page of this resource book.


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Return this form to: Distance Education, AHIM A, 233 N. Michigan, Ste 2150, Chicago, IL 60601 Fax 312/ 233-109

Do not send completed Fast Facts Audio Seminar quizzes keep them for your records

Continuing Education Credit and Compliance Sign-in FormFast Facts Audio Seminar Modifiers for Physician Services

Please duplicate this form so that everyone in attendance may sign-in. Those wishing to receive AHIMAcontinuing education credit must supply their AHIMA ID number. Those individuals will receive a total of 1 continuingeducation (CE) clock hour, for attending the seminar AND completing the assessment quiz. The CE certificate is locateon the last page of the seminar resource book, Practical Tools for Seminar Learning. Each participant should keep acopy of the CE certificate AND the completed quiz on file as proof of training.

Sign below to certify that you have listened to this audio seminar and completed

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Please visit the AHIMA Audio Seminars Web site to complete the evaluation form online athttp://campus.ahima.org/audio/fastfactsresources.html


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Certificate of Attendance

Fast Facts Audio Seminar


_____________________________________Name

_____________________________________AHIMA ID Number

_____________________________________Date Attended

_____________________________________

Anne M. WillmoreProject Manager

Distance Education

The American Health In formation Management Associationhas approved this program for one (1) continuing education unit.

Participant certifies that he or she has attended this audio seminarand completed the accompanying quiz.

Retain this certificate as evidence of participation.No record will be kept at AHIMA of your participation.


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Quiz Answer KeyFast Facts Audio Seminar: Modifiers for Physician Services

1: false; 2: b; 3: b; 4: a; 5: c; 6: c; 7: a; 8: true; 9: b; 10: true

Do not send a copy of your completed Fast Facts Audio Seminar quiz to AHIMA.Please keep it with your certificate of attendance, for your records.

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Modifiers for Physician Svcs