Tackling Modifiers in the Day of Increased · Tackling Modifiers in the Day of Increased Scrutiny...
Transcript of Tackling Modifiers in the Day of Increased · Tackling Modifiers in the Day of Increased Scrutiny...
Tackling Modifiers in the Day of Increased
Scrutiny Jean C. Russell, MS, RHIT, AHIMA-Approved ICD-10 Train the Trainer
Partner, Epoch Health Solutions, LLC
[email protected] (518) 369-4986
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Agenda
• Recent Changes to the CMS Outpatient Code Editor (OCE), the Medically Unlikely Edits (MUE) and the National Correct Coding Initiative (NCCI) Edits
• Latest Twist to Modifier – 59 Reporting
• Modifier – 25 Reporting Hints
• Other Modifiers, and When to Use Them
• Hospital-Based Clinic Billing, Upcoming Changes
• Recent Changes to Inpatient-Only Reporting
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The CMS Outpatient Code Editor (OCE) and Recent
Changes to MUEs and NCCIs
Medically Unlikely Edits
(MUEs) • Developed in 2007
• Included in the NCCI program which are part of the
Medicare Outpatient Code Editor (OCE)
• Goal is to reduce the error rate for Medicare claims
• Designed to reduce errors that result from the following:
• Clerical entries
• Incorrect coding on the basis of anatomic considerations
• HCPCS/CPT® code descriptors
• Information about MUE is in Chapter 1, Section V, of the
NCCI Policy Manual
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Medically Unlikely Edits
• A MUE is the maximum number of units that a provider
should report under most circumstances for a single
claim on a single date of service
• All CPT® and HCPCS codes do not have an MUE
• Medicare - All Medicare MUE’s are not published
• Unpublished MUE’s are considered “confidential” and are
for CMS and the CMS contractors’ use only
• Medicaid - There are NO confidential or non-published
MUE edits for the Medicaid NCCI Program at this time,
they are all published
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Revisions to CMS MUEs
• April 1, 2013
• Moved some edits to Date of Service edits
• Added a new data field to the MUE table
“MUE Adjudication Indicator” or MAI
• August 2014
• Made additional changes effective January
2015
Source: Transmittal 1421, CR 8853, Released August 15, 2014
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MAI – Adjudication Indicator
• MAI of “1” – Adjudicated as a claim line edit (the standard (i.e., original) MUE) • UOS (units of service ) of each line is compared to the
MUE value
• MAI of “2” – Absolute date of service edit • UOS are summed for a DOS (date of service) • These are “per day edits based on policy” • Considered impossible because contrary of
statute, regulation or sub-regulatory guidance • E.g., 94002, vent management initial day • Cannot report more than once per day
• Essentially cannot be over-ridden – FIRM LIMITS
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MAI – Adjudication Indicator
• MAI of “3” – Date of service edits
• Sum all UOS for the code for the same DOS without any modifier
• “Per day edits based on benchmarks”
• If appealed, contractors may pay UOS in excess of MUE if there is adequate documentation of medical necessity and correct reporting of units
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Modifier - 50
• Claim lines w/ a modifier – 50 have a single
unit
• As part of the MUE processing the units are
doubled before testing against the MUE
value
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Medically Unlikely Edits
• The table below is an excerpt of the MUE edits
• For each CPT® and HCPCS code there is a MUE listing the maximum expected units, the MAI and the Rationale
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MAI 1 – Claim Line Edit
• 1,787 of 10,847 – 16% of the edits
• The original MUE that can be bypassed with a modifier (e.g., 59, 76, 77, 91) when appropriate
• Rationale varies
• E.g., Nature of Service/Procedure
• CMS Policy
• Anatomic Consideration
• Examples
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MAI 2 – Date of Service
Edit: Policy • 4,417 of 10,847 – 41% of the edits
• Firm edits, can not be bypassed
• Rationale varies
• E.g., Code Description/CPT Instruction
• Nature of the procedure
• Anatomic Consideration
• Examples
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MAI 3 – Date of Service Edit:
Clinical • 4,641 of 10,847 – 43% of the edits
• Firm edits, can be appealed
• Rationale varies
• E.g., Code Description/CPT Instruction
• Nature of the procedure
• Clinical Data
• Examples
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MUE Policy
• MUE MAI 1 – Auto-denied if UOS > Maximum value
• Not summed on DOS
• Summed on the claim level
• MUE MAI 2, 3 – Denied if UOS > Maximum value
for DOS
• Summed regardless of the modifier
• Also sums other claims processed for that date of service
• MUE MAI 2 are almost un-appealable
• MUE MAI 3 can be appealed
• Coding denial, not medical necessity denial
• Cannot be billed to patient with an ABN
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The NCCI Edits – National Correct Coding Initiative • Developed to “promote correct coding and to
prevent improper payment” when incorrect code combinations are reported.
• Included in the I/OCE for Medicare
• The OCE edits associated with the NCCI edits are edit numbers 20 and 40
• NCCI edits generate a line item rejection
http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html?redirect=/NationalCorrectCodInitEd/
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NCCI / PTP Edits
• A complete list of the current NCCI edits is available on the CMS web site – Now known as PTP (Procedure to Procedure) Edits
• The list is updated quarterly
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http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/NCCI-Coding-Edits.html
NCCI Edits • NCCI/PTP Edits are coding pair edits
• CMS has just added a new column with the rationale for the edit
• Identifies the sub-set of edits that are “Mutually Exclusive Procedures”
• Unlike the other edits, for MEPs the first column is actually the lesser paid procedure
• Reporting both procedures w/o a modifier would actually reimburse less than correctly reporting the most significant procedure
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OCE Software/Data File
• CMS has recently released a free OCE editor that can be downloaded
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Latest Twist to Modifier – 59 (Distinct Procedure)
Reporting
What are Modifiers
• Two Characters appended to a CPT® or HCPCS code
that modify the meaning of the service
• Required when a combination of codes generates an edit
– usually a:
• Outpatient Code Edit (OCE) such as a significant procedure
with a separately identifiable medical visit
• Correct Coding Initiative Edit (CCI) such as a combination of
two primary/initial infusion codes
• Medically Unlikely Edit (MUE) such as more than seven
units of a secondary infusion code
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Modifier – 59 “Picked Apart”
• "Distinct Procedural Service: Under certain circumstances it
may be necessary to indicate that a procedure or service was
distinct or independent from other non-E/M services
performed on the same day. Modifier 59 is used to identify
procedures / services, other than E/M, that are not normally
reported together, but are appropriate under the
circumstances. Documentation must support a different site
or organ system, separate incision/excision, separate
lesion, or separate injury (or area of injury in extensive
injuries) not ordinarily encountered or performed on the same
day by the same individual…“
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Modifier – 59 “Picked Apart”
• “…However, when another already established
modifier is appropriate it should be used rather than
modifier 59. Only if no more descriptive modifier is
available, and the use of modifier 59 best explains the
circumstances, should modifier 59 be used…See also
page 684, Level II HCPCS/National Modifier Listing“
In other words, modifier – 59 is the
modifier of last resort
24 Source: CPT Professional Edition, 2015, Page 680
Modifier - 59
• Distinct Procedural Service – Indicates a procedure or
service was distinct or independent from others
performed on the same day
• Documentation must support:
• Different session Separate lesion
• Different procedure/surgery Separate injury
• Different site or organ system
• Separate incision/excision
[CPT® book]
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Modifier – 59 Changes
Effective January 2015 • Modifier – 59 is the most widely used modifier
• And, according to CMS, frequently reported
inappropriately
• Will over-ride an NCCI and/or MUE edit
• Modifier – 59 “often over-rides the edit in the exact
circumstances for which CMS created it in the first
place. CMS believes that more precise coding options
coupled with increased education and selective editing
is needed to reduce the errors associated with this
overpayment.”
Source: MLN Matters Number: MM8863, CR R1422OTN, 8863, Release Date August 15, 2014
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Modifier – 59 Changes
Effective January 2015 • CMS has created four new modifiers that are much more
specific
• These should be used in place of modifier – 59
• Modifier – 59 is still available but will be closely watched
and should not be used when a new modifier will apply
• Also, modifier – 59 may not be sufficient to bypass certain
edits
• Some edits may be by-passable only with a specific modifier
(e.g., XE) but not others
Source: MLN Matters Number: MM8863, CR R1422OTN, 8863, Release Date August 15, 2014
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New Modifiers
• XE Separate Encounter, A Service That Is Distinct
Because It Occurred During A Separate Encounter
• XS Separate Structure, A Service That Is Distinct
Because It Was Performed On A Separate
Organ/Structure,
• XP Separate Practitioner, A Service That Is Distinct
Because It Was Performed By A Different Practitioner,
and
• XU Unusual Non-Overlapping Service, The Use Of A
Service That Is Distinct Because It Does Not Overlap
Usual Components Of The Main Service.
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Further Information
• NGS released a policy education topic in January “clarifying” the reporting of these new modifiers
• Modifier – 59 – Use When:
• There is no other appropriate modifier
• Documentation indicates two separate procedures performed on the same day by the same physician
• Documentation for the services represents a distinct procedural service and no other descriptive modifier is available, and the use of modifier 59 best explains the circumstances
Source: http://www.ngsmedicare.com/ngs/portal/ngsmedicare/newngs/home-lob/pages/policy-
education/modifiers/subsets%20of%20modifier%2059/!ut/p/a1/1VTbcpswEP0VXvLIaAER40eBXez4QtLGE8SLRwjhyBMEATm3r6_IrWlSJ82005lqGMGulrO3s0IZSlGm2JXcMC1rxS56OTtcYzIdO04EsySYAJDZi
GCyjL0Ye-
gMZSibJxGiUa2U4Fryne51210ru0LyHgjRoxeSNevP1aabJyGix6zVVviseQvElW70OaLmuBIGgrWC10oLpZW4PoAX6nu5qS8kv316W6LY8ftkLF03kncHUNWFLKVozWe3yzuhO6surSet5Q97pw2XBaKlU5TgD3O
7ZGbDDOf28BByO8cuwIAPPbf0H_L_kUiKqKkY7FkEfqugP5l4SQAEfwlHo5NjLw7dR4N3XFATw2CvkwjQt0_m-AGg-wB4Fi3WJ6vxV2P9ppH0XT7QV2ygv-
ICfcWXvxe_85_FD75jKBHh6QBPJm5yOvjThsar6dgUJJyt5itwpzH-NODRR7w2c-G2i2ixMbBMn9tSlTVKn4cRpXuG0fwnt5eXGTE3QT_2Nxql_-4qaKoq8B4fO4Wt31zdnRJCRB7ANSGTar1c2iwPbm98-
h2UR4yQ/dl5/d5/L2dBISEvZ0FBIS9nQSEh/?LOB=Part%20B&LOC=Connecticut&ngsLOB=Part%20B&ngsLOC=Connecticut&jurisdiction=Jurisdiction%20K
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Modifier - 59
• Modifier – 59 – Use When:
• Modifier 59 is with the secondary, additional or lesser procedure of combinations listed in NCCI edits
• The second initial injection procedure code when the IV protocol requires two separate IV sites or when the patient has to come back for a second encounter
• Modifier – 59 – Do Not Use When:
• Code pairs are not part of the NCCI procedure to procedure edits
• Another valid modifier exists to identify and describe the separate services
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Modifier - 59
• Modifier – 59 – Do Not Use When:
• Submission of E&M codes
• Submission of weekly radiation therapy management codes (CPT code 77427)
• Documentation does not support the services were a distinct procedural service
• Multiple administration of injections of the same drug
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Modifier – XE, XS, XP and XU
• Use When and Do Not Use When:
• The same for all codes except for the following
• Use XE When - Documentation supports separate patient/provider encounter
• Use XS When - Documentation supports separate organ/structure
• Use XP When – Documentation supports performed by a different practitioner
• Use XU When - Documentation indicates that the service is distinct because it does not overlap usual components of the main service
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CMS Scenarios
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CMS Scenarios
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CMS Scenarios
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CMS Scenarios
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Additional Information
• Per CMS: • Modifiers are appended to HCPCS and CPT codes
when clinical circumstances justify the use of the modifier.
• Ensure that you have clinical circumstances to justify the modifiers and please do not append to HCPCS and CPT codes to simply bypass the NCCI edits.
• Medicare considers two physicians in the same group with the same specialty performing services on the same day as the same physician.
• Providers should evaluate other anatomic modifiers: E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, LM and RI.
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February, 2015 Hospital Open Door Forum
• During the forum they explained that modifier – 59 is still active and can continue to be reported
• Apparently none of the rules surrounding modifier – 59 have changed
• Providers “may” report one of the replacement modifiers (X{EPSU}
However, the use of the new modifiers is not required at this time
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February, 2015 Hospital Open Door Forum
• The new modifiers will be phased in over the next year(s) as additional instruction is provided
• CMS will be reviewing specific circumstances where there is a significant use of modifier – 59 and determine whether a more specific modifier is recommended
• CMS (Dr. Duvall) acknowledged that there has been limited instruction on the reporting of the new modifiers and therefore no benefit to them yet 39
Modifier – 59 and the
replacement Modifiers • Separate diagnosis is not necessary and not
sufficient to support these modifiers
• “Use of modifier -59 to indicate different
procedures/surgeries does not require a different
diagnosis for each HCPCS/CPT coded
procedure/surgery. Additionally, different
diagnoses are not adequate criteria for use of
modifier -59. The HCPCS/CPT codes remain
bundled unless the procedures/surgeries are
performed at different anatomic sites or
separate patient encounters. “
NCCI Policy on Modifier – 59
http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/downloads/modifier59.pdf
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Modifier 59 Replacement
Modifier Guidance • The 2015 NCCI policy manual does present
the new modifiers, the examples in the
manual continue to utilize modifier – 59
• The Modifier – 59 guidance document on the
CMS website mentions the new modifiers,
but the examples continue to refer to
modifier - 59
Source:
http://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Downloads/modifier59.pdf
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CMS Definition of
“Encounter” 90.6 - Definition of Encounter (Rev. 1, 10-01-03)
The term “encounter” means a direct personal contact in the
hospital between a patient and a physician, or other person who is
authorized by State law and, if applicable, by hospital staff bylaws
to order or furnish services for diagnosis or treatment of the
patient. Direct personal contact does not include telephone
contacts between a patient and physician…Patients will be
treated as hospital outpatients for purposes of billing for certain
diagnostic services that are ordered during or as a result of an
encounter that occurred while such patients are in an outpatient
status at the hospital…When a patient has follow-up visits with a
physician in the hospital following an initial encounter, each
subsequent visit to the physician will be treated as a separate
encounter for billing.
Chapter 2, Medicare Claims Processing Manual, Section 90.6
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Modifier – 25 (Significant, Separately Identifiable
E/M Service)
Modifier - 25
• Separately Identifiable Medical Visit
• Needed when an E/M is reported in
conjunction with an APC status S (significant
procedure) or T (surgical procedure)
• E.g.,
• Drug injection/infusion codes are APC
status S
• EKGs are also status S
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Modifier – 25 “Picked Apart”
• “Significant, Separately Identifiable Evaluation and Management Services by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service:
• It may be necessary to indicate on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable E/M service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure that was performed...
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Modifier – 25 “Picked Apart”
• …A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines for instructions on determining level of E/M service). The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. The circumstances may be reported by adding modifier – 25 to the appropriate level of E/M service...”
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E/M Medical Visit
• Clinic or ED E/M (e.g., 99214, 99285)
• Requires a modifier 25 when reported in
addition to infusion services (status S or T)
• Report an E/M service only if a separately
identifiable medical visit has been provided
• Do not report for standard nursing care
provided as part of the infusion services
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New Issue for 2015
• CMS eliminated APC status indicator X (ancillary service) in 2015
• Moved most of these codes to an APC status indicator Q1 – Q1 are STV-packaged codes
• Each of these Q1 codes is APC status S (Addendum A)
• A modifier – 25 is required when billing a status V with either an APC status S or T
• Therefore, it is now required when billing with codes that used to be an APC status X (ancillary service)
• E.g., 99283 and a 71020 (chest x-ray)
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Example 1 Scenario
• A patient visits the cardiologist for an appointment complaining of occasional chest discomfort during exercise. The patient has a history of htn and high cholesterol. After the physician completes an office visit it is determined that the patient needs a cardiovascular stress test that is performed that day by the same physician at the hospital.
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Example 1 Coding
• The physician codes an E/M visit (99201 – 99215) and he also codes for the cardiovascular stress test (93015). The modifier 25 is added to the E/M visit to indicate that there was a separately identifiable E/M on the same day of a procedure.
• Coding: Professional: 99214 – 25, 93016, 93018
• Technical: 99213 – 25, 93017
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Example 2 Scenario/Coding
• Scenario: The patient is scheduled to come in for a cardiovascular stress test and the physician also completes a history and performs a limited exam related to the stress test
• Coding: Only report the stress test code(s)
• Professional: 93016, 93018
• Technical: 93017
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When NOT to Report – 25 Modifier • When there is only an E/M service performed during the
office visit (no procedure done)
• When the procedure is so minimal that it is incorporated in the E/M service and does not qualify for a separate CPT®/HCPCS code (e.g., pelvic exam)
• When the patient came in for a scheduled procedure only
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Modifier – 25 Reporting Hints
• Only applied to E/M codes
• Does not require different diagnoses, but, it certainly doesn’t hurt
• The modifier is “asking” for payment on both the E/M code and the procedure code
• This is a closely monitored modifier, claims are audited
• 2005 OIG report found that more than 33% were reported incorrectly, $538 million in improper payments (http://oig.hhs.gov/oei/reports/oei-07-03-00470.pdf)
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Reporting Hints
• Make sure the documentation supports the application of the modifier
• Professionally the E/M requires a History, Exam and level of Medical Decision Making
• Technically the E/M requires technical guidelines (Medicare) and a significant and separately identifiable medical visit, generally with a physician or mid-level
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OIG Identified Areas of Concern 1. E/M services with modifier 25 must be significant, separately identifiable and above and beyond the usual care associated with the procedure
• They note that all services include a certain amount of inherent E/M services
• It is not enough that there is “limited pertinent historical inquiry about reasons for the examination, the presence of allergies, acquisition of informed consent, discussion of follow-up, and the review of the medical record”
Source: http://www.radiologytoday.net/archive/rt_110308p8.shtml
http://oig.hhs.gov/oei/reports/oei-07-03-00470.pdf
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OIG Identified Areas of Concern
• Correct Coding Initiative rules further specify that if the patient evaluation during a medical visit “is limited to whether or not the procedure should be performed, whether comorbidity may impact the procedure, or involves discussion and education with the patient, [then] an evaluation/management code is not reported separately.”
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Source: Chapter 9, NCCI Policy Manual
OIG Identified Areas of Concern 2. Appropriate documentation of both the E/M and the procedure must be maintained. The E/M must clearly describe the E/M elements (History, Exam, MDM). The documentation must be unambiguous!
• It may help to physically present the documentation as separate notes. This would help to demonstrate that they are separate.
• The E/M should be documented in a similar manner to the way they would document an E/M that was performed without a procedure on the same day.
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Other Modifiers
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Modifiers – 76 and - 77
• Modifier – 76: Repeat procedure or service
by same clinician
• Modifier – 77: Repeat procedure or service
by different clinician
• Applicable for repeat procedures on the
same date of service
• May by-pass an MUE edit when applicable
and appropriate
• Guidelines tell us to utilize these modifiers
before we utilize modifier - 59 59
Modifier - 76
• Repeat EKG in a single day (93005)
• Repeat 94640, non-pressurized inhalation treatment for acute airway obstruction
• Per CPT, report modifier – 76 when performed more than once per day
• Two injections of the same drug in a single day
• E.g., 96401, chemotherapy (or MAB) SQ/IM injection, non-hormonal, - 76 60
Modifier – 91
• Modifier – 91: Repeat clinical
diagnostic laboratory test
• Applicable for repeat lab test on the
same date of service to obtain
subsequent test results, for instance to
see whether a patient is getting better
or worse due to treatment
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Modifier – 91 Example
• Repeat troponin (84484)
• Physician refers a patient to observation for chest pain, he orders four repeat troponins during the stay (84484) and EKG’s (93005) [MUE of 3] to R/O MI
• 93005 84484
• 93005 x 3 – 76 84484 x 3 -91
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Modifier – 91 Example
• Basic metabolic panel (80048) and electrolyte panel (80051)
• Physician orders a basic metabolic panel (80048). After reviewing the results and treating the patient, he orders a follow-up electrolyte panel (80051)
• 80048
• 80051-91
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Modifier Reporting Summary
Correct Reporting of Modifiers
• Modifiers in general are used to bypass a billing edit and allow a particular line-item to be paid
• Should only be applied when the medical record documentation and medical necessity warrant the application of the modifier
• Frequently require a review of the medical record before they can be applied
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Correct Reporting of Modifiers
• The requirement for a modifier,
especially if frequent, often indicates a
miss-reporting of the service
• That is, a bundled service is being
incorrectly “exploded” or miss-charged
• The root cause should be identified
and corrected in these cases
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Hospital-Based Clinic Billing, Recent Changes
and What it Foretells
Report to Congress
• March 2012 and June 2013 “Report to
Congress” by MedPAC
• Questioned the appropriateness of
increased Medicare payment and beneficiary
cost when private physician practices
become hospital outpatient departments
• Recommended Medicare pay these services
at the MPFS rates
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CMS Proposal
• CMS has proposed to gather data on
these services
• Opted to create a modifier and a new
POS
• Seeking more information on the
frequency and type of services
provided in a PBD to improve the
accuracy of the MPFS practice
expenses for these services 69
Hospital Modifier (Technical)
• Data collection requirement that will impact
both physician and hospital reporting
• Facility / Technical Reporting: • New modifier created to report (on each code) a service that
is provided in a hospital’s off-campus provider-based
departments
• PO - Services, procedures and/or surgeries provided at off-
campus provider-based outpatient departments
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Hospital Technical Modifier
• Reporting this new modifier will be voluntary in CY
2015
• And mandatory after January 1, 2016
• CMS will be using this modifier to gather and
analyze the impact of hospitals increasingly
acquiring physician practices
• Not required for remote locations, satellite facilities
or emergency departments
• Only for off-campus provider based departments
• CMS is updating Medicare Claims Processing
Manual, Chapter 4, sections 20.6.11 for the use of the “PO” HCPCS modifier
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Place of Service (Professional) • Physicians will be required to report a new
place-of-service (POS) code on the CMS-1500 claim
• CMS requesting 2 new POS codes to replace POS 22 (hospital OP)
• Will not be available until July 1, 2015
• Will be required as soon as it is defined and released
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Place of Service (Professional) • Will be reported to distinguish between
1. On-campus outpatient hospital outpatient services (including remote or satellite locations)
2. Off-campus outpatient hospital services – Same areas where PO modifier will be reported
• Emergency services will continue to be reported with POS 23
• Further information should be forthcoming
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Impact on Reimbursement
• Data collection process was finalized in
the 2015 final rule
• No changes have been made yet to
payments furnished in a off-campus
PBD setting
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Off-campus
• Commenters have asked for a better definition of “off-
campus”
• CMS responded that a “campus” is defined as the
physical area immediately adjacent to the provider’s
main buildings
• Within 250 yards of the main buildings
• “Remote location” includes hospital campus other than
the main campus
• Remote locations are not required to report the off
campus POS
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CMS definitions
• 42 CFR 413.65(a)(2) defines campus to mean, “the physical area immediately adjacent to the provider’s main buildings, other areas and structures that are not strictly contiguous to the main buildings but are located within 250 yards of the main buildings, and any other areas determined on an individual case basis, by the CMS regional office, to be part of the provider’s campus.”
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CMS definitions
• 42 CFR 413.65 defines a remote location of a hospital as “a facility or an organization that is either created by, or acquired by, a hospital that is a main provider for the purpose of furnishing inpatient hospital services under the name… control of the main provider, in accordance with the provisions of this section. A remote location of a hospital comprises both the specific physical facility that serves as the site of services for which separate payment could be claimed under the Medicare or Medicaid program, and the personnel and equipment needed to deliver the services at that facility. The Medicare conditions of participation do not apply to a remote location of a hospital as an independent entity.” 77
CMS definitions
• 42 CFR 412.22(h) defines a satellite facility to mean “a part of a hospital that provides inpatient services in a building also used by another hospital, or in one or more entire buildings located on the same campus as buildings used by another hospital.”
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OIG and Provider-Based
• The 2015 OIG work plan includes a comparison of provider-based and free-standing clinic payments for similar procedures
• They note that payments for provider-based are often higher
• The requirements to be met for a facility to be defined as provider base were published in the 2000 APG final rule and are located at 42 CFR § 413.65(d)
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False Claims Act and Provider Based • One downstate NY hospital had a voluntary self disclosure
resulting from billing services as provider based that did not meet the requirements (hyperbaric oxygen therapy)
• Providers should self-audit their provider based reported services to verify that they meet the requirements
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Will Provider-Based Status Disappear • Not immediately, if at all
• OIG has recommended eliminating it, but so far CMS has not concurred
• CMS apparently encourages the integration of hospitals and physician services
• However, changes to how the services are reimbursed is likely in the future
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Recent Changes to Reporting Inpatient-Only Procedures to Medicare
April 2015 Update of OPPS
• CMS is revising billing instructions
• Pertains to inpatient-only procedures provided in the outpatient setting on the date of the inpatient admission or during the 3 days preceding the inpatient admission
• If related to the inpatient admission (which is likely) then these will be bundled into the inpatient billing
• Prior to this change these were NOT PAID, now they are included in the inpatient visit
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Source: CMS Transmittal 3217, Date March 13,
2015
April 2015 Update of OPPS
• What this means (my interpretation):
• We will no longer have to “eat” the cost of the inpatient-only procedure that is performed as an outpatient
• It will be incorporated into the inpatient (MS-DRG) claim
• It can be coded as a procedure on the claim
• And will likely impact the assigned DRG (move from a medical to a surgical DRG)
• Physicians still have to be aware
• Must get the inpatient order within three calendar days of the surgery
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Information and opinions included in this presentation are
provided based on our interpretation of current available
regulatory resources. No representation is made as to
the completeness or accuracy of the information. Please
refer to your payer or specific regulatory guidelines as
necessary.