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Use and abuse of modifiers

By Alice Anne Andress

Modifiers are two character designators that identify a change in the code for the procedure or service. They are an essential part of coding and can not only cause delays and denials in reimbursement, but can also be considered abused by some carriers. It is imperative that these modifiers are understood and correctly appended to the service and procedure codes.

Modifier -22

Modifier -22 is used when necessary to report a procedure that is greater than that normally required. This modifier is appended to procedures only, and not Evaluation and Management services. It is used only when additional work factors requiring the physician’s technical skill significantly increase the work, time and complexity of the procedure that is normally performed. It is appropriate to use in such instances as extra work that may be involved due to morbid obesity, significant scarring and some extensive trauma cases. When using this modifier, the physician must send documentation that supports the unusual procedural service by sending a statement regarding the unusual aspect of the service and a copy of the operative report. This modifier does have an effect on payment and in supported cases, will result in additional reimbursement. As such, it is under the watchful eye of the carriers.

Modifier -25

Modifier -25 is used to report that a significant, separately identifiable Evaluation and Management service was performed by the same physician on the same day of the procedure or other service. Significant, separately identifiable is when the medical record documentation is clearly evident that the Evaluation and Management code was above and beyond the usual preoperative and postoperative care that is associated with the procedure. The need to bill for an Evaluation and Management service may be prompted by a symptom, complaint, condition or problem that may or may not be related to the procedure or other service. This modifier has become the most used and abused modifier. Many carriers may request supporting documentation when this modifier is used on a claim.

Modifier -25 is appended to an Evaluation and Management code. There is not a requirement that there must be two different diagnosis codes, but both services should be distinct. Most procedural codes include time for evaluation of the patient, so the billing of an additional Evaluation and Management code must be supported. The addition of such wording as “the patient’s condition required” provides the carrier with confirmation that it was medically necessary for the patient to have the service on the same day that another procedure or service was performed. When billing a preventive medicine service and a problem oriented service on the same day, it is important to be sure that the patient’s condition requires additional work (ordering of diagnostic studies, writing prescriptions, etc.). When using modifier -25, it is not necessary to submit documentation prior to the claim reimbursement. This modifier has been targeted by the Office of Inspector General for over-utilization under a special fraud alert.

Modifiers -54, -55 and -56

Modifiers -54, -55, and -56 are modifiers that are surgical in nature. Modifier -54 is used to report surgical care only. Modifier -55 is used to report post-operative care only, and modifier -56 is used to report pre-operative care only. To be sure that the correct modifier is used, it is imperative to understand what is included in a surgery in addition to the operation itself. These modifiers cannot be used when the surgical procedure has no global days (0).

Modifier -54 is used when a physician performs a surgical procedure and another physician provides the pre-operative and post-operative management of the patient. Modifier -54 is added to the surgical procedure. For billing purposes, a major surgery is considered to be a global package. This means that several services are “bundled” into the surgery service, which results in one fee. Each surgery is assigned a post-operative period or global fee period. The average global fee period is 90days; however, some procedures have other post-operative days associated with them that range from zero to 270 days.

Examples of post-operative services that are considered part of the global fee period and are not separately billable are: related Evaluation and Management encounter on the date immediately before or on the date of the procedure, local filtration, digital, blocks (metacarpal/metatarsal), topical anesthesia, written orders, evaluation of patient in recover, standard post-operative care.

Post-operative services that are included in the global package are: lines and tubes to include intravenous lines, nasogastric tubes, insertion, maintenance and removal of foley catheters, maintenance and removal of tracheostomy tubes, removal of drains, casts, splints, wires, sutures, and staples, care of the incision to include dressings.

For example, if a patient has a mastectomy and then begins chemotherapy, modifier -54 would be added to the mastectomy code. Modifier -54 can have an effect on payment of the service and may be used on Medicare claims.

Modifier -55 is used when one physician does the surgery and another physician provides post-operative care. To bill for post-operative care without performance of the surgery, attach a modifier -55 to the procedure code. Post-operative care begins the day after the surgery. If it becomes necessary for the surgeon to address a problem during the post-operative period, it can be billed separately if the service contains a diagnosis which is separate from the original procedure.

Management of patient-controlled medications are included in the surgeon’s payment for the surgery. Pain management by a continuous epidural is considered billable and would be billed using CPT code 62319 on the first day. This includes the catheter and injection of the medication. Subsequent daily management of the epidural can be billed using CPT code 01996. Both codes cannot be billed on the same day.

Any visit performed by the surgeon, which occurs one day prior to the surgery, is considered to be included. For example, when a patient undergoes a cardiac procedure performed by a cardiothoracic surgeon and then the follow-up care is rendered by the patient’s cardiologist, Modifier -55 would be added to the codes submitted by the patient’s cardiologist. Modifier -55 can have an effect on payment of the service and may be used on Medicare claims.

Modifier -56 is used when one physician performs the pre-operative care and another physician performs the surgery. To bill for pre-operative care without the performance of the surgery, attach a modifier -56 to the procedure code. Some insurance companies will not recognize modifier -56 and in fact, many billed services with modifier -56 will come under review. Modifier -56 can have an effect on payment of the service and may be used on Medicare claims. For an example, a patient presents to his cardiologist for his pre-operative examination and testing. The patient then travels to a cardiothoracic surgeon to have the surgery performed. The patient’s cardiologist will bill for services using modifier -56.

Alice Anne Andress, CCS-P, CCP is the Director of Physician Services at Parente Randolph, LLC.

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