Webinar

March 7, 2006

Topic: Billing errors –Bundling

Questions & Answers

Question 1: Please clarify. Is Modifier 57 for major or minor surgeries?

Answer 1: Modifier 57 is for major surgeries only.

Question 2: What is the order of the descriptive and cap exceptions modifiers for physical, occupational and speech therapy?

Answer 2: The therapy modifier goes first, then the exception modifier.

Question 3: Do we submit the documentation report from the chart when using modifier 59?

Answer 3: Only if we specifically request the information. Do not send in with the initial claim.

Question 4: Would a removal of a port catheter be part of the global period?

Answer 4: Yes, if it is done during the global period by the operating physician.

Question 5: If the doctor removing the port catheter is not the surgeon and not assuming care, can he bill for the removal separately?

Answer 5: Yes, the other doctor could bill the services separately.

Question 6: Which modifier can I use to get paid on an additional EKG after the first EKG is paid? Sometimes my doctors do an EKG on a patient more then once and we do not get paid any after the first one.

Answer 6: You may use modifier 76, repeat procedure by same physician.

Question 7: How would we bill unlisted procedures? Is there a specific modifier?

Answer 7: You would use the unlisted procedure code from the correct section of the CPT book and list the description in item 19 of the CMS 1500 form or the electronic equivalent. There is no modifier for unlisted procedure. A report must be submitted in order for NHIC to determine appropriate coverage and payment.

Question 8: A physician is seeing a patient in the office for a follow up on a 90 day procedure and the patient has developed a seroma which he decides to treat in the office. This is not considered part of the surgical procedure recovery. What would we use for the modifier?

Answer 8: If the service is not related to the original surgical procedure then you would use a Modifier 24 for the E&M code if you perform significant and separately identifiable service over and above what you would do for post operative follow up. The medical record must support the level of care provided to identify and determine treatment for the seroma. If the seroma is incised and drained, then the correct procedure code and modifier 79 must be used to reflect it is unrelated to the original surgical procedures.

Question 9: Is the fee schedule that is on the web just for the physician or is it used by the facilities using the amount with the # in front?

Answer 9: The fee schedule on the website is just for the physicians services. Ambulatory Surgery Centers have their own fee schedule.

Question 10: When billing for three surgeons, one primary surgeon and two assistant surgeons, the second assistant surgeon is always denied as duplicate even with separate dollar amounts and claims.

Answer 10: If you are billing electronically, you may indicate in the comments field that this billing is for the second assistant surgeon. It billing on paper, you may submit a report reflecting two assistant surgeons were used. If it is medically necessary to have two assistant surgeons for the procedure, and the second service is denied, you need to go through the redetermination process. Please submit documentation to support the need for multiple assistant surgeons.

Question 11: Where does the descriptive modifier go for therapy under the exceptions? For example GP for Physical Therapy, KX for the exceptions and LT for the left knee and RT for the Right shoulder. What Order?

Answer 11: Try billing GP, KX, LT, RT. The general rule is that any pricing or coverage modifiers go first, descriptive modifiers go last.

Question 12: Can we bill separately for screws if the patient is having foot surgery?

Answer 12: Medicare only pays for implanted devices that replace the functioning of a malformed body member, such as a joint or hallux implant. Supplies such as screws are not paid separately.

Question 13: What modifier would be used if you had two different surgeons performing two different separate procedures at the same time? They are co-surgeons.

Answer 13: Modifier 62 may be the appropriate modifier if the services provided meet the definition. “When two surgeons work together as primary surgeons performing distinct part(s) of a procedure, each surgeon should report his/her distinct operative work by adding modifier 62 to the procedure codes and any associated add-on codes(s) for that procedure as long as both surgeons continue to work together as primary surgeons. Each surgeon should report the co-surgery using the same procedure code. If additional procedures(s) (including add-on procedure(s)) are performed during the same surgical session, separate code(s) may also be reported with modifier 62 added.”

If you are not sure the procedures being performed meet this definition, look at the definition of modifier 66, Surgical Team. For more definitive coding assistance, please check with your professional association.

Question 14: If you are doing a procedure that calls for an add-on code but the procedure is bilateral, do you use modifier 50 or the add-on code each time? Example 64483 and 64484.

Answer 14: The first thing you have to do is check the MFSDB to see if the bilateral modifier is allowed, or if this allows payment as a multiple procedure. If it allows use of the bilateral modifier, you would include it each time a bilateral procedure is performed. If it should be billed as separate, multiple procedures, use modifier 59, or LT / RT to identify the separate areas. Medical records must clearly identify the services provided, and support the medical necessity.

Question 15: If the office visit and a Chest X Ray are performed on the same day can we use a modifier 25 along with the office visit.

Answer 15: These are separate procedures and should pay without use of a modifier.

Question 16: Our provider is a southern CA provider in San Bernardino county but has a northern CA Medicare provider number, does this effect pay?

Answer 16: California is divided by population and even though San Bernardino is graphically located in the south by population we have San Bernardino county in Northern California and you are in area 99.

Question 17: For CPT 11750 can you bill 11750 TA, 11750-59 to indicate different borders of the same were removed but not the whole toenail?

Answer 17: The definition of the CPT code says partial or whole, so you would not bill twice for the same toe.

Question 18: Is there a limit on the number of claims we can bill modifier with Modifier 59? In pathology we often have several specimens with the same codes and date of service.

Answer 18: There is no limit as long as they are separate services.

3/30/2006