Table Of Content

11100 11101 11312 11313 11400 11446 11450 11471 11600 11601 11602 19357 20206 20664 20838 20900 20973 20974 20975 20979 22851 22852 22855 23000 28531 33476 33478 33496 33518 33519 33521 33522 33523 33530 33533 33534 33535 33536 33542 33647 33660 42802 42804 42806 42808 42809 42810 42815 50575 50600 50605 50610 50620 50630 50650 50660 50728 50740 50750 50760 50770 50780 50782 50783 50785 63056 63057 63076 63077 63251 63252 69960 69970 69979 69990 70010 70015 70030 70100 75791 11100 11101 11312 11313 11400 11446 11450 11471 11600 11601 11602 19357 20206 20664 20838 20900 20973 20974 20975 20979 22851 C 22852 22855 23000 28531 33476 33478 33496 33518 33519 33521 33522 33523 33530 33533 33534 33535 33536 33542 33647 33660 42802 42804 42806 42808 42809 42810 42815 50575 50600 50605 50610 50620 50630 50650 50660 50728 50740 50750 50760 50770 50780 50782 50783 50785 63056 63057 63076 63077 63251 O 63252 69960 69970 69979 69990 70010 70015 70030 70100 75791 75801 77776 82164 82172 82247 82248 84260 84270 85415 85420 86880 86885 86886 90970 90989 92606 92607 92974 92975 92977 92978 92979 92980 92981 92982 96413 96415 96416 99381 99382 99383 99386 99387 99391 99392 99393 3285F 3288F 3290F3291F 3292F 3293F 0217T 75801 77776 82164 82172 82247 82248 84260 84270 85415 85420 86880 86885 86886 90970 90989 92606 92607 92974 D 92975 92977 92978 92979 92980 92981 92982 96413 96415 96416 99381 99382 99383 99386 99387 99391 99392 99393 3285F 3288F 3290F 3291F 3292F 3293F0217T 11100 1110111312 11313 11400 11446 11450 11471 11600 11601 11602 19357 20206 20664 20838 20900 20973 20974 20975 20979 22851 22852 22855 23000 28531 I 33476 33478 33496 33518 33519 33521 33522 33523 33530 33533 33534 33535 33536 33542 33647 33660 42802 42804 42806 42808 42809 42810 42815 50575 50600 50605 50610 50620 50630 50650 50660 50728 50740 50750 50760 50770 50780 50782 50783 50785 63056 63057 63076 63077 63251 63252 69960 69970 69979 69990 N 70010 70015 70030 70100 75791 11100 11101 11312 11313 11400 11446 11450 11471 11600 11601 11602 19357 20206 20664 20838 20900 20973 20974 20975 20979 22851 22852 22855 23000 28531 33476 33478 33496 33518 33519 33521 33522 33523 33530 33533 33534 33535 33536 33542 33647 33660 42802 42804 42806 42808 G 42809 42810 42815 50575 50600 50605 50610 50620 50630 50650 50660 50728 50740 50750 50760 50770 50780 50782 50783 50785 63056 63057 63076 63077 63251 63252 69960 69970 69979 69990 70010 70015 70030 70100 75791 75801 77776 82164 82172 82247 82248 84260 84270 85415 85420 86880 86885 86886 90970 90989 92606 92607 92974 92975 92977 92978 92979 92980 92981 92982 96413 96415 96416 99381 99382 99383 99386 99387 99391 99392 99393 3285F 3288F w 3290F3291F 3292F 3293F 0217T 75801C 77776 8O2164 821D72 82247I 822N48 84260G 84270 8 5415 85420 86880 86885 86886 90970 90989 92606 92607 92974 with 92975 92977 92978 92979 92980 92981 92982 96413 96415 96416 99381 99382 99383 99386 99387 99391 99392 99393 3285F 3288F 3290F 3291F 3292F 3293F0217T i t 11100 11101 11312 11313 11400 11446 11450 11471 11600 11601 11602 19357 20206 20664 20838 20900 20973 20974 20975 20979 22851 22852 22855 23000 28531 h 33476 33478 33496 33518 33519 33521 33522 33523 33530 33533 33534 33535 33536 33542 33647 33660 42802 42804 42806 42808 42809 42810 42815 50575 50600 50605 50610 50620 50630 50650 50660M 50728 5074O0 50750 5D0760 507I70 5F0780 50I782 E50783 5R0785 630S56 63057 63076 63077 63251 63252 69960 69970 69979 69990 M 70010 70015 70030 70100 75791 11100 11101 11312 11313 11400 11446 11450 11471 11600 11601 11602 19357 20206 20664 20838 20900 20973 20974 20975 20979 22851 22852 22855 23000 28531 33476 33478 33496 33518 33519 33521 33522 33523 33530 33533 33534 33535 33536 33542 33647 33660 42802 42804 42806 42808 42809 42810 42815 50575 50600 50605 50610 50620 50630 50650 50660 50728 50740 50750 50760 50770 50780 50782 50783 50785 63056 63057 63076 63077 63251 O 63252 69960 69970 69979 69990 70010 70015 70030 70100 75791 75801 77776 82164 82172 82247 82248 84260 84270 85415 85420 86880 86885 86886 90970 90989 92606 92607 92974 92975 92977 92978 92979 92980 92981 92982 96413 96415 96416 99381 99382 99383 99386 99387 99391 99392 99393 3285F 3288F A Guide to Correct CPT® and 3290F3291F 3292F 3293F 0217T 75801 77776 82164 82172 82247 82248 84260 84270 85415 85420 86880 86885 86886 90970 90989 92606 92607 92974 D 92975 92977 92978 92979 92980 92981 92982 96413 96415 96416 99381 99382 99383 99386 99387 99391 99392 99393 3285F 3288F 3290F 3291F 3292F 3293F0217T HCPCS Level II Modifier Usage 11100 11101 11312 11313 11400 11446 11450 11471 11600 11601 11602 19357 20206 20664 20838 20900 20973 20974 20975 20979 22851 22852 22855 23000 28531 I 33476 33478 33496 33518 33519 33521 33522 33523 33530 33533 33534 33535 33536 33542 33647 33660 42802 42804 42806 42808 42809 42810 42815 50575 50600 50605 50610 50620 50630 50650 50660 50728 50740 50750 50760 50770 50780 50782 50783 50785 63056 63057 63076 63077 63251 63252 69960 69970 69979 69990 F 70010 70015 70030 70100 75791 11100 11101 11312 11313 11400 11446 11450 11471 11600 11601 11602 19357 20206 20664 20838 20900 20973 20974 20975 20979 22851 22852 22855 23000 28531 33476 33478 33496 33518 33519 33521 33522 33523 33530 33533 33534 33535 33536 33542 33647 33660 42802 42804 42806 42808 I 42809 42810 42815 50575 50600 50605 50610 50620 50630 50650 50660 50728 50740 50750 50760 50770 50780 50782 50783 50785 63056 63057 63076 63077 63251 E 63252 69960 69970 69979 69990 70010 70015 70030 70100 75791 75801 77776 82164 82172 82247 82248 84260 84270 85415 85420 86880 86885 86886 90970 90989 92606 92607 92974 92975 92977 92978 92979 92980 92981 92982 96413 96415 96416 99381 99382 99383 99386 99387 99391 99392 99393 3285F 3288F R 3290F3291F 3292F 3293F 0217T 75801 77776 82164 82172 82247 82248 84260 84270 85415 85420 86880 86885 86886 90970 90989 92606 92607 92974 92975 92977 92978 92979 92980 92981 92982 96413 96415 96416 99381 99382 99383 99386 99387 99391 99392 99393 3285F 3288F 3290F 3291F 3292F 3293F0217T S 11100 11101 11312 11313 11400 11446 11450 11471 Ph 11600 11601 11602 19357 20206 20664 20838 20900 20973 20974 20975 20979 22851 22852 22855 23000 28531 33476 33478 33496 33518 33519 33521 33522 33523 33530 33533 33534 33535 33536 33542 33647 33660 42802 42804 42806 42808 42809 42810 42815 50575 50600 50605 50610 50620 50630 50650 50660 50728 50740 50750 50760 50770 50780 50782 50783 50785 63056 63057 63076 63077 63251 63252 69960 69970 69979 F 69990 70010 70015 70030 70100 75791 11100 11101 11312 11313 11400 11446 11450 11471 11600 11601 11602 19357 20206 20664 20838 20900 20973 20974 20975 o 20979 22851 22852 22855 23000 28531 33476 33478 33496 33518 33519 33521 33522 33523 33530 33533 33534 33535 33536 33542 33647 33660 42802 42804 42806 u 42808 42809 42810 42815 50575 50600 50605 50610 50620 50630 50650 TA 50660 50728 50740 50750 50760 50770 50780 50782 50783 50785 63056 63057 63076 rt 63077 63251 63252 69960 69970 69979 69990 70010 70015 70030 70100 75791 75801 77776 82164 82172 82247 82248 84260 84270 85415 85420 86880 86885 86886 h 90970 90989 92606 92607 92974 92975 92977 92978 92979 92980 92981 92982 56 96413 96415 96416 99381 99382 99383 99386 99387 99391 99392 99393 3285F e 3288F 3290F3291F 3292F 3293F 0217T 75801 77776 82164 82172 82247 82248 84260 84270 85415 85420 86880 86885 86886 90970 90989 92606 92607 92974 d 92975 92977 92978 92979 92980 92981 92982 96413 96415 96416 99381 99382 99383 99386 99387 99391 99392 99393 3285F 3288F 3290F 3291F 3292F 3293F0217T it 11100 11101 11312 11313 11400 11446 11450 11471 11600 11601 11602 T9 19357 20206 20664 20838 20900 20973 20974 20975 20979 22851 22852 22855 23000 i o 28531 33476 33478 33496 33518 33519 33521 33522 33523 33530 33533 33534 33535 33536 33542 33647 33660 42802 42804 42806 42808 42809 42810 42815 50575 n 50600 50605 50610 50620 50630 50650 50660 50728 50740 50750 50760 50770 50780 50782 50783 50785 63056 63057 63076 63077 63251 63252 69960 69970 69979 69990 70010 70015 70030 70100 75791 F11o10u0 1r1t1h0 1e 11d31it2i 1o13n13 11400 11446 11450 66 11471 11600 TA 11601 11602 19357 20206 20664 20838 20900 20973 20974 20975 20979 22851 22852 22855 23000 28531 33476 33478 33496 33518 33519 33521 CP 33522 33523 33530 33533 33534 33535 33536 33542 33647 33660 42802 42804 42806 42808 42809 42810 42815 50575 50600 50605 50610 50620 50630 50650 50660 50728 50740 50750 50760 50770 T8 50780 50782 50783 50785 63056 63057 63076 63077 63251 63252 69960 69970 69979 69990 70010 70015 70030 70100 75791 75801 77776 82164 82172 82247 82248 84260 84270 85415 85420 86880 86885 86886 90970 90989 92606 92607 92974 92975 92977 92978 92979 92980 92981 92982 96413 96415 96416 99381 99382 99383 99386 99387 99391 99392 99393 3285F 3288F 3290F3291F 3292F 3293F 0217T 75801 77776 82164 82172 82247 82248 84260 84270 85415 85420 86880 86885 86886 90970 90989 92606 92607 92974 92975 92977 92978 92979 92980 92981 92982 96413 96415 96416 99381 99382 99383 99386 99387 99391 99392 99393 3285F 3288F 3290F 3291F 3292F 3293F0217T 11100 11101 11312 11313 11400 11446 11450 11471 11600 11601 11602 19357 20206 20664 20838 20900 20973 20974 20975 20979 22851 22852 22855 23000 28531 33476 33478 33496 33518 33519 33521 33522 33523 33530 33533 33534 33535 33536 33542 33647 33660 42802 42804 42806 42808 42809 42810 42815 50575 50600 50605 50610 50620 50630 50650 50660 50728 50740 50750 50760 50770 50780 50782 50783 50785 63056 63057 63076 63077 63251 63252 69960 69970 69979 69990 70010 70015 70030 70100 75791 11100 11101 11312 11313 11400 11446 11450 11471 11600 11601 11602 19357 20206 20664 20838 20900 20973 20974 20975 20979 22851 22852 22855 23000 28531 33476 33478 33496 33518 33519 33521 33522 33523 33530 33533 Un 33534 33535 33536 33542 33647 33660 42802 42804 42806 42808 42809 42810 42815 50575 50600 50605 50610 50620 50630 50650 50660 50728 50740 50750 50760 50770 50780 50782 50783 50785 63056 63057 63076 63077 63251 63252 69960 69970 69979 69990 70010 70015 70030 70100 75791 75801 77776 82164 82172 82247 82248 84260 84270 85415 85420 86880 86885 86886 90970 90989 92606 92607 92974 92975 92977 92978 92979 92980 92981 92982 96413 96415 96416 99381 99382 99383 99386 99387 99391 99392 99393 3285F 3288F 3290F3291F 3292F 3293F 0217T 75801 77776 82164 82172 82247 82248 84260 84270 85415 85420 86880 86885 86886 90970 90989 92606 92607 92974 Deborah J. Grider 92975 92977 92978 92979 92980 92981 92982 96413 96415 96416 99381 99382 99383 99386 99387 99391 99392 99393 3285F 3288F 3290F 3291F 3292F 3293F0217T 11100 11101 11312 11313 11400 11446 11450 11471 11600 11601 11602 19357 20206 20664 20838 20900 20973 20974 20975 20979 22851 22852 22855 23000 28531 33476 33478 33496 33518 33519 33521 33522 33523 33530 33533 33534 33535 33536 33542 33647 33660 42802 42804 42806 42808 42809 42810 42815 50575 50600 50605 50610 50620 50630 50650 50660 50728 50740 50750 50760 50770 50780 50782 50783 50785 63056 63057 63076 63077 63251 63252 69960 69970 69979 69990 70010 70015 70030 70100 75791 11100 11101 11312 11313 11400 11446 11450 11471 11600 11601 11602 19357 20206 20664 20838 20900 20973 20974 20975 20979 22851 22852 22855 23000 28531 33476 33478 33496 33518 33519 33521 33522 33523 33530 33533 33534 33535 33536 33542 33647 33660 42802 42804 42806 42808 42809 42810 42815 50575 50600 50605 50610 50620 50630 50650 50660 50728 50740 50750 50760 50770 50780 50782 50783 50785 63056 63057 63076 63077 63251 63252 69960 69970 69979 69990 70010 70015 70030 70100 75791 75801 77776 82164 82172 82247 82248 84260 84270 85415 85420 86880 86885 86886 90970 90989 92606 92607 92974 92975 92977 92978 92979 92980 92981 92982 96413 96415 96416 99381 99382 99383 99386 99387 99391 99392 99393 3285F 3288F Coding with Modifi ers A Guide to Correct CPT® and HCPCS Level II Modifi er Usage FOURTH EDITION DEBORAH J. GRIDER cpc,cpc-h, cpc-i, cpc-p, cpma, cemc, cpcd, cobgc, ccs-p CCPPTTMMooddiiffiieerrss44EE__PP44..iinnddbb ii 1111//77//1111 1111::1188 AAMM Executive Vice President, Chief Executive Offi cer: James L. Madara, MD Chief Operating Offi cer: Bernard L. Hengesbaugh Senior Vice President, Publishing and Business Services: Robert A. Musacchio, PhD Vice President, Business Operations: Vanessa Hayden Vice President, Publications and Clinical Solutions: Mary Lou White Senior Acquisitions Editor: Elise Schumacher Continuity Editor: Carol Brockman Manager, Book and Product Development and Production: Nancy Baker Senior Developmental Editor: Michael Ryder Production Specialist: Meghan Anderson Director, Sales, Marketing and Strategic Relationships: Joann Skiba Director, Sales and Business Products: Mark Daniels Manager, Marketing and Strategic Planning: Erin Kalitowski Marketing Manager: Lori Hollacher Content Reviewers: Grace Kotowicz, Elizabeth Lumakovska, Karen O’Hara Copyright 2011 by the American Medical Association. All rights reserved. Printed in the United States of America No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher. Internet address: www.ama-assn.org Current Procedural Terminology (CPT®) is copyright 1966, 1970, 1973, 1977, 1981, 1983-2011 by the American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association. Th e American Medical Association (“AMA”) and its authors and editors have consulted sources believed to be knowledgeable in their fi elds. However, neither the AMA nor its authors or editors warrant that the information is in every respect accurate and/or complete. Th e AMA, its authors, and editors assume no responsibility for use of the information contained in this publication. Neither the AMA, its authors or editors shall be responsible for, and expressly disclaims liability for, damages of any kind arising out of the use of, reference to, or reliance on, the content of this publication. Th is publication is for informational purposes only. Th e AMA does not provide medical, legal, fi nancial, or other professional advice, and readers are encouraged to consult a professional advisor for such advice. Th e contents of this publication represent the views of the author[s] and should not be construed to be the views or policy of the AMA, or of the institution with which the author[s] may be affi liated, unless this is clearly specifi ed. Please visit www.ama-assn.org/go/Modifi ers for potential updates. Additional copies of this book may be ordered by calling 800 621-8335 or from the secure AMA Web site at www.amabookstore.com. Refer to product number OP322011. ISBN 978-1-60359-616-9 Literature code: BP03:11-P-077:12/11 CCPPTTMMooddiiffiieerrss44EE__PP44..iinnddbb iiii 1111//77//1111 1111::1188 AAMM iii Contents Preface xi About the Author . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xv Chapter 1 Introduction to CPT Modifi ers 1 CPT Code Set Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 HIPAA and CPT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Who Maintains the CPT Code Set Nomenclature? . . . . . . . . . . . . . . . . 2 How Suggestions for Changes to the CPT Code Set Are Reviewed . . . . . . . 3 The CPT Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 The HCPCS Coding System . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Modifi ers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .10 Types of Modifi ers Used in the Reimbursement Process. . . . . . . . . . . . .12 Why Use Modifi ers?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 Surgical Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 Modifi ers and Reimbursement. . . . . . . . . . . . . . . . . . . . . . . . . . .17 RBRVS Payment Rules and Policies . . . . . . . . . . . . . . . . . . . . . . . .18 The Proper Use of Modifi ers: Step by Step . . . . . . . . . . . . . . . . . . . .19 Chapter 1 Review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20 Test Your Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21 Chapter 2 Modifi ers 22 to 24 and the Physical Status Modifi ers 23 Modifi er 22: Increased Procedural Services. . . . . . . . . . . . . . . . . . . .23 Modifi er 23: Unusual Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . .30 Reporting Anesthesia Services . . . . . . . . . . . . . . . . . . . . . . . . . .32 Physical Status Modifi ers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .35 Modifi er 24: Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period. . . . . . . . . . . . . . . . . .38 Test Your Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .44 CCPPTTMMooddiiffiieerrss44EE__PP44..iinnddbb iiiiii 1111//77//1111 1111::1188 AAMM iv CODING WITH MODIFIERS Chapter 3 Modifi ers 25 to 47 49 Modifi er 25: Signifi cant, Separately Identifi able Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service. . . . . . . . . . . . . . . . . . .49 The National Correct Coding Initiative and Modifi er 25. . . . . . . . . . . . . .52 Checkpoint Exercises 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .68 Modifi er 26: Professional Component. . . . . . . . . . . . . . . . . . . . . . .69 Checkpoint Exercises 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .76 Modifi er 27: Multiple Outpatient Hospital E/M Encounters on the Same Date. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .76 Modifi er 32: Mandated Services. . . . . . . . . . . . . . . . . . . . . . . . . .77 Modifi er 33 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .80 Modifi er 47: Anesthesia by Surgeon. . . . . . . . . . . . . . . . . . . . . . . .82 Test Your Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .87 Chapter 4 Modifi ers 50 to 56 91 Modifi er 50: Bilateral Procedure . . . . . . . . . . . . . . . . . . . . . . . . . .91 Modifi er 51: Multiple Procedures . . . . . . . . . . . . . . . . . . . . . . . . .97 Modifi er 52: Reduced Services. . . . . . . . . . . . . . . . . . . . . . . . . . 107 Modifi er 53: Discontinued Procedure . . . . . . . . . . . . . . . . . . . . . . 111 Checkpoint Exercises 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 Modifi ers 54, 55, and 56 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116 Modifi er 54: Surgical Care Only . . . . . . . . . . . . . . . . . . . . . . . . . 123 Modifi er 55: Postoperative Management Only . . . . . . . . . . . . . . . . . 125 Modifi er 56: Preoperative Management Only. . . . . . . . . . . . . . . . . . 128 Checkpoint Exercises 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131 Test Your Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132 Chapter 5 Modifi ers 57 to 63 135 Modifi er 57: Decision for Surgery . . . . . . . . . . . . . . . . . . . . . . . . 135 Modifi er 58: Staged or Related Procedure or Service by the Same Physician During the Postoperative Period. . . . . . . . . . . . . . . . 140 Checkpoint Exercises 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146 Modifi er 59: Distinct Procedural Service . . . . . . . . . . . . . . . . . . . . 147 The National Correct Coding Initiative. . . . . . . . . . . . . . . . . . . . . . 149 Modifi er 62: Two Surgeons. . . . . . . . . . . . . . . . . . . . . . . . . . . . 161 Modifi er 63: Procedure Performed on Infants Less than 4 kg . . . . . . . . . 169 Checkpoint Exercises 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 172 Test Your Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 174 CCPPTTMMooddiiffiieerrss44EE__PP44..iinnddbb iivv 1111//77//1111 1111::1188 AAMM CONTENTS v Chapter 6 Modifi ers 66 to 82 179 Modifi er 66: Surgical Team. . . . . . . . . . . . . . . . . . . . . . . . . . . . 179 Repeat Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 183 Modifi er 76: Repeat Procedure or Service by Same Physician or Other Qualifi ed Health Care Professional. . . . . . . . . . . . . . . . . . . 183 Modifi er 77: Repeat Procedure or Service by Another Physician or Other Qualifi ed Health Care Professional. . . . . . . . . . . . . . . . . . . 188 Checkpoint Exercises 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191 Modifi er 78: Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualifi ed Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 192 Modifi er 79: Unrelated Procedure or Service by the Same Physician During the Postoperative Period . . . . . . . . . . . . . . . . . . . . . . . . . 197 Modifi ers 80 to 82: Assistant Surgeons . . . . . . . . . . . . . . . . . . . . . 201 Modifi er 80: Assistant Surgeon . . . . . . . . . . . . . . . . . . . . . . . . . 201 Modifi er 81: Minimum Assistant Surgeon. . . . . . . . . . . . . . . . . . . . 207 Modifi er 82: Assistant Surgeon (when qualifi ed resident surgeon not available) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 209 Test Your Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 214 Chapter 7 Modifi ers 90 to 99 217 Modifi er 90: Reference (Outside) Laboratory . . . . . . . . . . . . . . . . . . 217 Modifi er 91: Repeat Clinical Diagnostic Laboratory Test . . . . . . . . . . . . 220 Modifi er 92: Alternative Laboratory Platform Testing . . . . . . . . . . . . . 225 Modifi er 99: Multiple Modifi ers . . . . . . . . . . . . . . . . . . . . . . . . . 227 Test Your Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 230 Chapter 8 HCPCS Level II Modifi ers 233 Reporting HCPCS Modifi ers According to HIPAA Rules . . . . . . . . . . . . 234 Modifi ers Used for Ambulance Services . . . . . . . . . . . . . . . . . . . . 235 Anesthesia HCPCS Level II Modifi ers . . . . . . . . . . . . . . . . . . . . . . 236 Dressings, Wounds, and Supplies . . . . . . . . . . . . . . . . . . . . . . . . 240 Drugs and Enteral/Parenteral Therapy, Supplies, and Infusion . . . . . . . . 241 Glucose Monitoring and Supplies . . . . . . . . . . . . . . . . . . . . . . . . 243 Durable Medical Equipment and Orthotic/Prosthetic Devices . . . . . . . . . 246 Ostomy Supplies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 248 Lower-Limb Prostheses. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249 Pathology and Laboratory Services . . . . . . . . . . . . . . . . . . . . . . . 251 CCPPTTMMooddiiffiieerrss44EE__PP44..iinnddbb vv 1111//77//1111 1111::1188 AAMM vi CODING WITH MODIFIERS Waived and Provider-Performed Microscopy (PPM) Tests . . . . . . . . . . . 253 Radiology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 254 Dialysis/Hemodialysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 259 Oxygen and Monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 261 Vision Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262 Professional Service Modifi ers. . . . . . . . . . . . . . . . . . . . . . . . . . 267 Modifi ers Used in Mental Health. . . . . . . . . . . . . . . . . . . . . . . . . 268 Miscellaneous Modifi ers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 273 Anatomic Modifi ers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282 Foot Care Modifi ers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 285 National Modifi ers Not Payable by Medicare . . . . . . . . . . . . . . . . . . 286 Test Your Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 289 Chapter 9 Ambulatory Surgery Center and Hospital Outpatient Modifi ers 293 Status Indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 293 Ambulatory Payment Classifi cations . . . . . . . . . . . . . . . . . . . . . . 297 CPT/HCPCS Level II Modifi ers Approved for Use in the Ambulatory Surgery Center . . . . . . . . . . . . . . . . . . . . . . . . . . . 300 When to Use HCPCS Level II Modifi ers Approved for Outpatient Hospital Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . 305 Modifi er 25: Signifi cant, Separately Identifi able Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service. . . . . . . . . . . . . . . . . . 307 Modifi er 27: Multiple Outpatient Hospital E/M Encounters on the Same Date. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 311 Modifi er 50: Bilateral Procedure . . . . . . . . . . . . . . . . . . . . . . . . . 315 Modifi er 52: Reduced Services. . . . . . . . . . . . . . . . . . . . . . . . . . 319 Checkpoint Exercises 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 323 Modifi er 58: Staged or Related Procedure or Service by the Same Physician During the Postoperative Period. . . . . . . . . . . . . . . . 323 Modifi er 59: Distinct Procedural Service . . . . . . . . . . . . . . . . . . . . 326 Modifi er 73: Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedure Prior to the Administration of Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 331 Modifi er 74: Discontinued Outpatient Hospital/Ambulatory Surgery Center (ASC) Procedure After Administration of Anesthesia . . . . . . . . . 334 Checkpoint Exercises 2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 336 Modifi ers 76, 77, 78, and 79 . . . . . . . . . . . . . . . . . . . . . . . . . . . 337 Modifi er 76: Repeat Procedure or Service by Same Physician or Other Qualifi ed Health Care Professional . . . . . . . . . . . . . . . . . . . . 337 CCPPTTMMooddiiffiieerrss44EE__PP44..iinnddbb vvii 1111//77//1111 1111::1188 AAMM CONTENTS vii Modifi er 77: Repeat Procedure or Service by Another Physician or Other Qualifi ed Health Care Professional . . . . . . . . . . . . . . . . . . . . 339 Modifi er 78: Unplanned Return to the Operating Room/Procedure Room by the Same Physician or Other Qualifi ed Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period . . . . . . . . . . . . . . . . . . . . . . . . . 340 Modifi er 79: Unrelated Procedure or Service by the Same Physician During the Postoperative Period . . . . . . . . . . . . . . . . . . . . . . . . . 341 Modifi er 91: Repeat Clinical Diagnostic Laboratory Test . . . . . . . . . . . . 343 Checkpoint Exercises 3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 345 HCPCS Level II (National) Modifi ers Approved for the ASC . . . . . . . . . . 345 Test Your Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 348 Chapter 10 Genetic Testing Modifi ers and Category II Modifi ers 353 Genetic Modifi ers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 353 Category II Modifi ers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 365 Modifi er 1P: Performance Measure Exclusion Modifi er due to Medical Reasons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 366 Modifi er 2P: Performance Measure Exclusion Modifi er due to Patient Reasons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 367 Modifi er 3P: Performance Measure Exclusion Modifi er due to System Reasons. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 368 Modifi er 8P: Performance Measure Reporting . . . . . . . . . . . . . . . . . 369 Test Your Knowledge . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 370 Appendix A HCPCS (Level I) CPT Modifi ers 371 CPT Modifi ers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 371 Anesthesia Physical Status Modifi ers . . . . . . . . . . . . . . . . . . . . . . 377 Modifi ers Approved for Ambulatory Surgery Center (ASC) Hospital Outpatient Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 377 Appendix B HCPCS (Level II) Modifi ers 383 HCPCS Modifi ers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 383 Appendix C Genetic Testing Modifi ers 397 CCPPTTMMooddiiffiieerrss44EE__PP44..iinnddbb vviiii 1111//77//1111 1111::1188 AAMM viii CODING WITH MODIFIERS Appendix D Logic Trees 403 Modifi er 22: Increased Procedural Services. . . . . . . . . . . . . . . . . . . 403 Modifi er 23: Unusual Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . 404 Modifi er 24: Unrelated Evaluation and Management Service by the Same Physician During a Postoperative Period . . . . . . . . . . . . . 405 Modifi er 25: Signifi cant, Separately Identifi able Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service. . . . . . . . . . . . . . . . . . . . . . . . 406 Modifi er 26: Professional Component. . . . . . . . . . . . . . . . . . . . . . 407 Modifi er 27: Multiple Outpatient Hospital E/M Encounters on the Same Date. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 408 Modifi er 32: Mandated Services. . . . . . . . . . . . . . . . . . . . . . . . . 409 Modifi er 47: Anesthesia by Surgeon. . . . . . . . . . . . . . . . . . . . . . . 410 Modifi er 50: Bilateral Procedure . . . . . . . . . . . . . . . . . . . . . . . . . 411 Modifi er 51: Multiple Procedures . . . . . . . . . . . . . . . . . . . . . . . . 412 Modifi er 52: Reduced Services. . . . . . . . . . . . . . . . . . . . . . . . . . 413 Modifi er 53: Discontinued Procedure . . . . . . . . . . . . . . . . . . . . . . 414 Modifi er 54: Surgical Care Only . . . . . . . . . . . . . . . . . . . . . . . . . 415 Modifi er 55: Postoperative Management Only . . . . . . . . . . . . . . . . . 416 Modifi er 56: Preoperative Management Only. . . . . . . . . . . . . . . . . . 417 Modifi er 57: Decision for Surgery . . . . . . . . . . . . . . . . . . . . . . . . 418 Modifi er 58: Staged or Related Procedure or Service by the Same Physician During the Postoperative Period. . . . . . . . . . . . . . . . 419 Modifi er 59: Distinct Procedural Service . . . . . . . . . . . . . . . . . . . . 420 Modifi er 62: Two Surgeons. . . . . . . . . . . . . . . . . . . . . . . . . . . . 421 Modifi er 63: Procedure Performed on Infants less than 4 kg. . . . . . . . . . 422 Modifi er 66: Surgical Team. . . . . . . . . . . . . . . . . . . . . . . . . . . . 423 Modifi er 73: Discontinued Out-patient Hospital/Ambulatory Surgery Center (ASC) Procedure Prior to the Administration of Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 424 Modifi er 74: Discontinued Out-patient Hospital/Ambulatory Surgery Center (ASC) Procedure After Administration of Anesthesia . . . . . . . . . 425 Modifi er 76: Repeat Procedure or Service by Same Physician or Other Qualifi ed Health Care Professional . . . . . . . . . . . . . . . . . . . . 426 Modifi er 77: Repeat Procedure by Another Physician or Other Qualifi ed Health Care Professional . . . . . . . . . . . . . . . . . . . . 427 Modifi er 78: Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualifi ed Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 428 Modifi er 79: Unrelated Procedure or Service by the Same Physician During the Postoperative Period . . . . . . . . . . . . . . . . . . . . . . . . . 429 Modifi er 80: Assistant Surgeon . . . . . . . . . . . . . . . . . . . . . . . . . 430 CCPPTTMMooddiiffiieerrss44EE__PP44..iinnddbb vviiiiii 1111//77//1111 1111::1188 AAMM CONTENTS ix Modifi er 81: Minimum Assistant Surgeon. . . . . . . . . . . . . . . . . . . . 431 Modifi er 82: Assistant Surgeon (when qualifi ed resident surgeon not available) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 432 Modifi er 90: Reference (Outside) Laboratory . . . . . . . . . . . . . . . . . . 433 Modifi er 91: Repeat Clinical Diagnostic Laboratory Test . . . . . . . . . . . . 434 Modifi er 92: Alternative Laboratory Platform Testing . . . . . . . . . . . . . 435 Modifi er 99: Multiple Modifi ers . . . . . . . . . . . . . . . . . . . . . . . . . 436 Subject Index 437 Code Index 453 CCPPTTMMooddiiffiieerrss44EE__PP44..iinnddbb iixx 1111//77//1111 1111::1188 AAMM

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Coding with Modifiers: A Guide to Correct CPT and HCPCS Level II Modifier Usage [With CDROM] PDF

732 Pages·2011·5.53 MB·English

by Deborah J. Grider

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