Modifiers

Question 1

-22

Answer 1

increased procedural services, Indicates services significantly greater than usual
Accompanied by written report with supportive documentation
Describes increased physician work

Question 2

-23

Answer 2

Unusual Anesthesia, Use of anesthesia where no anesthesia or local would be the norm
Example: Highly agitated senile patient
Only used with anesthesia codes
Written report with submission of modifier may be required

Question 3

-24

Answer 3

Unrelated E/M Services by Same Physician or Other Qualified Health Care Professional During a Postoperative Global Period, E/M Service not related to surgery is separately billable
Use -24 on E/M code only
If E/M provided during postop global period, no separate payment for E/M related to surgical procedure
Example: Patient is in global period for hip surgery and is now seen for a fractured collarbone

Question 4

-25

Answer 4

Significant, Separately Identifiable E/M Service, by the Same Physician or Other Qualified Health Care Professional and Same Day of Procedure or Other Service,
Documentation must support service
Example: Patient seen for sinus congestion, provider performs H&P, prescribes decongestant, notes lesion on back, and removes
Code: Procedure + E/M-25
Example: A patient seen on consultation by pain management and subsequent to rendering an opinion was given a nerve injection. Modifier -25 is placed on E/M code

Question 5

-26

Answer 5

Professional Component, Professional component (physician, -26)
Technical component (technician + equipment, -TC)
Example: Radiologist reviews x-rays (-26) taken by supervised technician (-TC)

Question 6

-32

Answer 6

Mandated Service, Mandated by payer, workers’ comp, or official body
Not request of patient, patient’s family, or another physician
Example: Workers’ Comp requests examination of person currently receiving disability benefits

Question 7

-33

Answer 7

Preventive Services,Patient Protection and Affordable Care Act of 2010 requires coverage without cost
United States Preventive Services Task Force grades preventive services
Grade A: substantial
Grade B: moderate

Question 8

-47

Answer 8

Anesthesia by Surgeon, Physician administers regional or general anesthesia
Acts as surgeon and anesthesiologist
Only used with Surgery codes
No separate payment when used on Medicare patients

Question 9

-50

Answer 9

Bilateral Procedure, Bilateral
Example: Procedure on hands
Caution: Some codes describe bilateral procedures; in these cases do not apply modifier -50

Question 10

-51

Answer 10

Multiple Procedure—Three Types
Same Procedure, Different Sites
Example: Multiple lacerations repaired
Multiple Operation(s), Same Operative Session
Procedure Performed Multiple Times
Example: Trigger point injections (20552)

Question 11

-51 cont.

Answer 11

Multiple Procedure
List most resource intense first (highest RVU value)
Next other procedure(s) + -51 (unless code is -51 exempt or an add-on code)
Usual payment: 1st procedure 100%, 2nd 50%, 3rd 25%
Medicare: 1st procedure paid 100%, 2nd–5th paid 50%, more than 5, priced manually

Question 12

-52

Answer 12

Reduced Services
Service reduced from code description
Physician directed reduction
Documentation substantiates reduction
Not for patients unable to pay fee
Submit full charge, payer will adjust 
Example: Lip shave (40500) but advancement flap not performed = 40500-52

Question 13

-53

Answer 13

Discontinued Procedure
Surgical/diagnostic procedures
Started then stopped due to patient’s condition
Does not apply to presurgical discontinuance

Question 14

-53 cont.

Answer 14

Discontinued Procedure
DO NOT USE -53 WHEN:
Patient cancels scheduled procedure
With E/M codes
With time-based code

Question 15

-54

Answer 15

Surgical Care Only
Physician provides only procedure (intraoperative)
Documented patient transfer must be in record
Some payers require copy of transfer

Question 16

-55

Answer 16

Postoperative Management Only
Physician provides care only after hospital discharge
If transferred while patient hospitalized, report postop management with subsequent hospital codes 99231-99233
Documentation of transfer in medical record
Surgery code billed with -55 modifier and surgery date of service
Bill after first postoperative visit

Question 17

-56

Answer 17

Preoperative Management Only
Physician provided only preoperative care
Not acceptable for Medicare
Requires surgical code with modifier -56

Question 18

Usual Reimbursement for Portions, Surgical Package

Answer 18

10% preoperative
70% intraoperative
20% postoperative
Each payer determines portions

Question 19

-57

Answer 19

Decision for Surgery Used with
E/M, 99201-99499
Medicine, 92012-92014 ophthalmologic services
Medicare: Only for preop period of major surgery (day before or day of)
90 day global

Question 20

-58

Answer 20

Staged/Related Procedure/Service by Same Physician or Other Qualified Health Care Professional During Postoperative Period (1 of 2)
Subsequent procedure planned or related to the first surgery
During postop of previous surgery in series
Example: Multiple skin grafts completed in several sessions
Global period starts over

Question 21

-58 cont.

Answer 21

Do not use when code describes a session

Example: 67208: lesion destruction of retina, one or more sessions

Question 22

-59

Answer 22

Distinct Procedural Service
Different session or encounter
Different procedure
Different site
Separate incision, excision, lesion, injury
Do not use when another HCPCS modifier is appropriate

Question 23

-59 cont.

Answer 23

Example: Physician removes several lesions from patient’s leg, also notes and biopsies a mole of torso
Biopsy code for mole + -59
Indicates biopsy distinct procedure, not part of lesion removal
CMS established four HCPCS subset modifiers that are:
Referred to as–X{EPSU} modifiers
More descriptively define modifier -59
Payer specific
For more information see page 271 of the text.

Question 24

-62

Answer 24

Two Surgeons
Both function as co-surgeons (equals)
Usually different specialties
Each surgeon reports same surgery code appending -62
Each surgeon dictates his/her portion of procedure

Question 25

-63

Answer 25

Procedure Performed on Infants Less Than 4 kg Kilogram: 2.2 lb (4 kg = 8.8 lb) Small size increases complexity Use with all Surgery section codes except Integumentary and those exempt by parenthetical notes

Question 26

-66

Answer 26

Surgical Team Team: Several physicians (3 or more) with various specialties plus technicians and other support personnel Very complex procedures Payers may increase payment

Question 27

-76

Answer 27

Repeat Procedure/Service by Same Physician or Other Qualified Health Care Professional Note: “Same Physician or Other Qualified Health Care Professional” Used to indicate necessary repeated service, not typographical error Example: X-rays before and after fracture repair Aerosol treatment for an asthma attack repeated in 90 minutes (94640-76)

Question 28

-77

Answer 28

Repeat Procedure/Service by Another Physician or Other Qualified Health Care Professional Note: “Another Physician or Other Qualified Health Care Professional” Performed by one individual, repeated by another individual Submitted with a written report to establish medical necessity may be requested

Question 29

-78

Answer 29

Unplanned Return to Operating/Procedure Room Same Physician Following Initial Procedure for a Related Procedure During Postoperative Period For complication of first procedure Example: Patient has outpatient procedure in morning, was returned to operating room in afternoon with severe hemorrhage Indicates not typographical error Does not change global period time

Question 30

-79

Answer 30

Unrelated Procedure or Service by Same Physician or Other Qualified Health Care Professional During Postoperative Period Example: Several days after discharge for procedure, patient returns for an unrelated procedure/service Diagnosis would be different Remember the E/M code would have -24 If surgery is unrelated to original procedure, a new global period starts

Question 31

-80, -81

Answer 31

-80 Assistant and -81 Minimum Assistant Surgeons -80 Assistant Reimbursed at 15–30% Payers identify procedures for which they reimburse assistant -81 Minimum Assistant Surgeon Services at a level less than that described in -80 (Assistant Surgeon) Reimbursed at 10%, if at all

Question 32

-82

Answer 32

Assistant Surgeon Teaching hospitals: Have residents who assist as part of education—no fee, no modifier -82 Must demonstrate no qualified resident available Unavailability documented in written report

Question 33

-90

Answer 33

``` Reference (Outside) Laboratory Physician has business relationship with outside lab Physician pays lab Physician bills payer for lab services Cannot use for Medicare ```

Question 34

-91

Answer 34

Repeat Clinical Diagnostic Laboratory Test Repeat same laboratory tests on same day for multiple test results Not tests rerun to confirm original test results Not malfunction of equipment or technician error

Question 35

-92

Answer 35

Alternative Laboratory Platform Testing Indicates kit or transportable instrument Usually single use, disposable Example: 86701, HIV test kit

Question 36

-95

Answer 36

Synchronous Telemedicine Services Used when provider and patient interact from separate locations Identified by (★) star symbol Complete code list found in Appendix P

Question 37

-96, -97

Answer 37

-96 Habilitative Services and -97 Rehabilitative Services -96 Habilitative Services Help with learning daily living skills/functions not yet developed -97 Rehabilitative Services Help with regaining daily living skills/functions that have been lost or impaired due to injury or illness Intent with both services is individuals will retain and improve their skills/functions

Question 38

-99

Answer 38

Multiple Modifiers | Used when service needs more than one modifier but payer only allows for one modifier with each code

Question 39

CPT modifiers

Answer 39

Used to describe alterations to CPT code | Full list, CPT, Appendix A

Question 40

modifier functions

Answer 40

``` Altered (i.e., more or less) Bilateral Multiple Only portions of service (i.e., professional service only) More than one surgeon Unusual service ```