Webinar
1/26/06
Topic: Bundling Modifiers
Questions & Answers
Question 1:
Which website can I visit to view the modifier listing in the September
2005 Medicare Part B Resource?
Answer 1:
Medicare Part B Resource’s are located at http://www.medicarenhic.com/news/prov_ca_resource.shtml
Question 2: If the report states it is a
bilateral service, can we bill without the 50 modifier?
Answer 2: Please refer to the CPT / HCPCS
coding books. IF the definition of the
code says bilateral, THEN the 50 modifier is not needed, nor would you bill the
procedure code more than once. If the
definition of the code does not mention bilateral, then modifier 50 is needed
for billing. You must also check the
Medicare Physician Fee Schedule Data Base (MFSDB) to determine if the code
allows for billing as a bilateral procedure.
If not, bill the services on separate lines without the modifier. Your documentation should always support the
codes and modifiers you use.
Question 3: Which modifier should be used for a
bilateral procedure if not the 50 modifier?
Answer 3:
None. Only the 50 modifier should
be used for bilateral services.
Question 4:
When should the 50 modifier not be used for
bilateral services?
Answer 4: You do not need the 50 modifier if
the CPT code description states it is a bilateral service, or if the code is
not subject to bilateral rules on the MFSDB.
Question 5: What is the correct way to bill
modifier 50? 1 unit or
2 units?
Answer 5: Always bill the procedure code on
one line with modifier 50, and use 1 unit for a bilateral service.. Your allowance
will be 150% of the allowance for the service for a unilateral service.
Question 6:
If I add modifier 51 to my claims, should I reduce the procedure by
50%?
Answer 6: If a service is subject to the
multiple surgery guidelines, our system is set up to automatically reduce the
payment for the lesser fee schedule allowance procedure by 50%.
Question 7: How should a discontinued 45378 be reported?
Answer 7: Bill the procedure with modifier
53. You do not need to submit a report with it.
All other codes submitted with the 53 modifier must have documentation
submitted with them.
Question 8: What modifier should be used if
follow-up care is provided by another physician?
Answer 8: The provider performing the surgery
should use modifier 54. The provider who
is performing the follow-up care would use modifier 55. Both bill with the procedure code of the
global surgery and use the date the surgery took place.
Question 9: What should we do if the patient is
treated for a fracture in another part of the state and then is seen in our
office for part of the follow-up care?
Answer 9: If possible, you need to coordinate
with the physician’s office in that area.
The other provider would bill the surgery with modifier 54 for the
intra-operative services, then bill with a 55 modifier for the number of post
operative care services that he / she performed. Your office then may bill the same service
with a 55 modifier for the number of post-operative care days that you
furnished. Remember to state the date
you assumed care of the patient in item 19.
If coordination is not possible, you should bill for the services
rendered. If a post payment audit is
conducted, it would identify any potential overpayments to the surgeon if the
services were not billed correctly.
Question 10:
How should we bill the following example? The doctor performs the surgery and begins
the post-op during the 90 days global period.
For 2 days, the provider leaves the patient in the care of another
provider before coming back to take over care again.
Answer 10:
The surgeon bills the surgery CPT code on one line with modifier
54. The surgeon also bills the surgery
CPT again on another line with the 55 modifier.
Item 19 would contain the dates the provider relinquished care and then
assumed care again. The second provider
will bill one detail line with the surgery CPT code, the surgery date of
service, and in Item 19 indicate date care was assumed and then
relinquished. The date of service used
for all of these detail lines will be the date of the surgery.
Question 11: Would a 55 modifier be used on
office visits?
Answer 11:
No. Modifier 55, for post
operative care, is used with the CPT code of the global service performed.
Question 12: Can modifier 58 be used for staged debridement
of a gangrene wound?
Answer 12: If the modifier accurately
represents what is done, it can be used.
Question 13: On the CCI edits, which number (0,
1 or 9) in the far right column will allow the edit to be bypassed with a
modifier?
Answer 13: The number 1 will allow the edit to
be bypassed.
Question 14:
If the service cannot be unbundled, can it be billed for modifier 51 for
payment?
Answer 14: If the procedure cannot be
unbundled, it cannot be paid separately.
Question 15:
What is the difference between the 51 and 59 modifiers?
Answer 15:
The 51 modifier simply states it is a multiple surgery or procedure (the
2nd, 3rd, 4th…). The 59 modifier identifies a service as a
separately identifiable service which should not be part of another
service. It is generally used with
bundled codes identified on the National Correct Coding Initiative which were
performed at separate times, on different body areas, or that can otherwise be
considered separately identifiable.
These services must be clearly documented in the medical record..
Question 16:
What is the difference between the 53 and 74 modifiers?
Answer 16:
The 53 modifier is used by the surgeon to identify a procedure that has
begun but must be terminated for some reason.
The 74 modifier is used by the surgical center to identify a procedure
terminated procedure after anesthesia has begun.
Question 17: Can modifier 76 be used with X-ray
codes?
Answer 17: Yes.
Question 18:
What is the difference between modifiers 76 and 78?
Answer 18:
The 76 modifier is used for a repeat of the same procedure by the same
physician on the same day, while the 78 modifier is for the return to the
operating room for
related surgery during the post-operative period.
Question 19: Would you use the modifier 78 when
a patient had cataracts on the left eye and returns within 10 days to do the
right?
Answer 19: You would use modifier 79 because
it is an unrelated service.
Question 20: If the patient has a new problem
during the post-operative period, is it appropriate to use the 79 modifier for
patients that return to the surgery room?
Answer 20:
Yes, it is.
Question 21: Could you go over the percentage of
payment for a surgeon, assistant to surgeon and physicians assistant assisting
at surgery?
Answer 21:
The surgeon will be allowed at 100% of the physician’s fee
schedule. Physicians assisting at
surgery will be allowed 16% of the physician’s fee schedule. Physician assistants assisting at surgery are
allowed 65% of the 16% of the physician’s fee schedule.
Question 22:
What is the SG modifier?
Answer 22:
The SG modifier is a facility modifier that indicates that the service
was performed in an Ambulatory Surgical Center (ASC).
Question 23:
Is the SG modifier used on all procedures to indicate it was performed
in an
Answer 23:
Yes, but only by the ASC.
Physicians would not use the SG.
Question 24:
What should we do if the patient refuses to sign the ABN? Can we charge the patient upfront?
Answer 24:
If the patient refuses to sign the ABN, you need to make a business
decision whether to perform the service.
If they do not sign the ABN, and you choose to perform the services, you
should document your efforts to have them sign, make sure you have a witness
sign, and use the GA for billing. If the services are denied and the patient
complains to Medicare about being held liable, you will be asked to provide
documentation of your use of the GA modifier.
More details of these provisions are available in the IOM 100-04,
chapter 30, Section 40.3
at http://new.cms.hhs.gov/manuals/downloads/clm104c30.pdf
Question 25: If a service is never covered by
Medicare (such as acupuncture), then the ABN is not necessary?
Answer 25: That is correct. The patient may be billed at the time of
service.
Question 26:
Why would you bill at all if you are using a modifier GY?
Answer 26:
A patient may have a secondary insurance that will cover the service.
Question 27: If the service is billed with the
GZ modifier, we cannot collect money upfront from the patient?
Answer 27:
That is correct.
Question 28:
What services can the liability modifiers be
used on?
Answer 28:
All services billed into Medicare for payment which may be considered to
be not reasonable or necessary for the diagnosis or treatment of the patient’s
illness or injury. Items considered to
be investigational are never considered reasonable and necessary and subject to
the waiver of liability provisions.
Links of Interest!!
Please see
the Medicare Fee Schedule Database Base for further information on payments
indicators, such as bilateral, if
assistants are allowed, if PAs are covered for the specific CPT code and other
information necessary to properly submit a claim: http://www.cms.hhs.gov/PhysicianFeeSched/PFSRVF/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=1&sortOrder=ascending&itemID=CMS044816
CCI edits
and information may be found at: http://new.cms.hhs.gov/NationalCorrectCodInitEd/01_overview.asp
3/02/2006