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CPT/HCPCS Level I modifiers (-22 to -99)
Alters CPT or HCPCS code, Full list, CPT, appendix A ; Two separate lists : one for physician use and one for hospital use
Modifier functions
Altered (ex: increased or reduced svc) , bilateral, multiple, only portions of svc (ex: professional svc only), more than one surgeon
Increased procedural svc, indicates svcs significantly greater than usual, accompanied by written report and supportive documentation
unusual anesthesia, use of general anesthesia where local or regional is norm, used only with anesthesia codes, written report with submission of modifier
unrelated E/M svcs by same physician during a postoperative period, svc not related to surgery, if E/M provided during postoperative global period, no pymnt considered w/out -24
significant, separately identifiable E/M svc, same physician/and day of procedure/svc; documentation must support svc
professional component, professional component (physician,-26), technical component (technician + equipment, -TC)
mandated svc, mandated by payer, worker's comp, or official body or court of law, not request of pt, pts family, or another physician
anesthesia by surgeon, surgeon administers regional or general anesthesia, physician acts as both surgeon and anesthesiologist, used only with surgery codes
bilateral procedure, body is bilateral (ex: procedure on hands), caution: some codes describe bilateral procedures, typically not used integumentary system codes
multiple procedure - three types, same procedure, different sites, multiple operation(s), same operative session, procedure performed multiple times: list most resource-intense procedure first, then descending order of resource intensity ; next, other procedure(s) + -51 (unless code is -51 exempt or add-on code) : usual procedure pymnt : 1st 100%, 2nd 50%, 3rd 25-50%, depending on payer
reduced svcs, svc reduced or not performed to the extent described in code description, there is no other code that accurately reflects the svc actually provided, physician directed reduction, documentation substantiates reduction, not to be used for pt unable to pay, submit regular charge amnt, payer will adjust.
discontinued procedure, surgical/diagnostic procedures, procedure started then stopped due to pts condition, does not apply to presurgical discontinuance, submit regular charge, payer will adjust, DO NOT USE -53: when pt cancels scheduled procedure, with E/M codes, with time-based code
surgical care only, physician provides only procedure(intraoperative); other physician does preoperative and postoperative svc, documented pt transfer must be in record, some payers require copy of transfer order
postoperative mgmnt only, physician provides only the care after hospital discharge; report surgical code + modifier -55 , if transferred while pt hospitalized, report postoperative mgmnt with subsequent hospital codes
preoperative mgmnt only, physician provided only preoperative care; report surgical code + modifier -56, not acceptable for medicare, usual reimbursement for portions, surgical package: 10% preoperative, 70% intraoperative, 20% postoperative; each payer determines reimbursement for portions
decision for surgery used with, E/M, 99201-99499,92002,92004 ; Medicine, 92012 & 92014 ophthalmologic svcs; Medicare: Only for preoperative period of major surgery (day before or day of)
staged/related by same physician during postoperative period, subsequent procedure planned at time of initial surgery: during postoperative period of previous surgery in series (ex: multiple skin grafts completed in several session), don not use when code describes total session (ex: 67208 destruction of lesion of retina, one or more sessions), more extensive than original procedure or, for therapy following diagnostic procedure (ex: breast biopsy and subsequent mastectomy)
distinct procedural svc, used toreport svcs not normally reported together, different session or encounter, different procedure, different site, separate incision, excision, lesion, injury (ex: physician removes several lesions from pts leg; also notes a suspicious lesion on torso and biopsies it) , excision code for lesion removal + biopsy code for torso with -59, indicates biopsy as distinct procedure, not part of lesion removal
Two surgeons, both function as cosurgeons (equals), usually of different specialties, each reports same code + -62, each dictates operative/procedure note for their portion, total reimbursement = 125%; each physician = 62 1/2%
procedure performed on infants less than 4kg, kilogram = 2.2lbs (4kg = 8.8lbs.), small size increases complexity, use with all surgery section codes except integumentary system or directed otherwise
surgical team, team - several physicians with various specialties plus technicians and other support personnel, very complex procedures, payers may increase pymnt up to 50%: each physician's svc must be documented in the medical record
repeat procedure/svc by same physician, note: same physician, used to indicate necessary svc
repeat procedure/svc by another physician, note: another physician, performed by one physician, repeated by another physician, submitted with written report to establish medical necessity and identity of performing physician
unplanned return to operating room for a related procedure during postoperative period, for complication of first procedure (ex: pt had outpt procedure in morning; was returned to operating room in afternoon with severe hemorrhage), indicates not typographical error, medical record must specifically document need for svce provided
unrelated procedure or svc by same physician during postoperative period, (ex: several days after discharge for procedure, pt returns for unrelated problem), diagnosis code would also be different
assistant surgeon, reimbursed at 15-30%, payers identify procedures for which they would reimburse assistant at surgery
minimum assistant surgery, svcs at level less than that described in -80, reimbursed at 10% if svcs reported with the modifier are recognized by payer
assistant surgeon, teaching hospitals: have residents who assist as part of education, must demonstrate no qualified resident available to use -82, unavailibility must be documented in written report
reference (outside) library, physician has business relationship with outside lab, physician pays lab, physician bills payer for lab svcs
repeat clkinical diagnostic laboratory test, repeat same laboratory tests on same day for multiple test results (ex: serial troponin levels acute MI confirmation), not tests rerun to confirm or negate original test results, not assigned for malfunction or equipment, loss of specimen, or technician error
multiple modifiers, used when svc needs more than one modifier but payer allows for only one modifier with each code, the new CMS-1500 allows for multiple modifiers
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