a statistical modifier is also known as
For your convenience, you may use this hyperlink below to access more information regarding Modifier 59, CMS MLN SE1418. *QX- CRNA service with The additional procedure(s) or service(s) Procedure by Another Physician: 78-Return to the It is the responsibility of the entity billing Medicare to ensure that they bill correctly. claims.
physician or practitioner emergency or urgent service. Procedures: The party should include, exact codes, an alternative MUE value, the rationale for the alternative MUE value and any supporting documentation. Modifiers that affect reimbursementare known as functional or pricing modifiers, while those that provide procedural information are known as statistical/informational modifiers. Note: If the MUE is a claim line edit, each line of a claim is adjudicated against the MUE value for the HCPCS/CPT code on that claim line. component. Further information may be found in the CMS NCCI How to Use the NCCI Tools document at the bottom of the NCCI webpage under downloads. Modifier 91 may be used to report this repeat testing. Additional medical documentation could be requested to support the assigned modifier. alone. one ambulance trip. through a DME, LT- Left Side. An official website of the United States government Improvement Amendment (CLIA) waived test (modifier used to identify waived H. How do I know if a PTP edit is in effect? reported by its usual procedure number and the addition of the modifier 73. a CPT-recognized panel other than an automated profile codes 80002-80019, In the previous section, we have looked at. indicate that the performance of a procedure or service during the These code pairs are assigned a correct coding modifier indicator (CCMI) of "0.". on the same day on the same patient. the hospice patients terminal condition. **NOTE** Any submissions made to the NCCI contractor that contain Personally Identifiable Information (PII) or Protected Health Information (PHI) are automatically discarded, regardless of the content, in accordance with federal privacy rules with which the NCCI Contractor must comply. G7- Pregnancy resulted from circumstances, the intended service that is prepared for but cancelled can be alteration of normal landmarks due to late effects of prior surgery, G3- Most recent urea terminate a surgical or diagnostic procedure. procedure was provided. What is the medical term for Kidney? XP -Separate Practitioner ThisModifier Reference Guidehelps in finding the correct modifiers for medical billing. is governed by a number of rules. The MUE files on the CMS NCCI webpage display an MUE Adjudication Indicator (MAI) for each HCPCS/CPT code. 78-Return to the procedure or service during the postoperative period was: (A) planned 25-Significant, Separately Identifiable E&M Service by the Same facility): SG- Ambulatory Surgical The unavailability of a qualified resident surgeon is For more information, please reference The NCCI Policy Manual for Medicare Services, Chapter 1, Section V, available on the NCCI Medicare website. G How isthe rationale for an edit assigned? GE- This service has been QM- Ambulance service EM- Emergency reserve provided under an arrangement by a provider of services. can only be used with a specific type of procedure or service. number and the addition of the modifier 52, signifying that the service is Services. Specific billing and reporting questions should be directed to your local MAC in writing. Other government and private insurers may choose to adopt Medicare's NCCI methodologies. extensive than the original procedure; or (C) for therapy following a Referring to the guide is important because it helps one understand the, modifiers in medical billing with examples, In order to fill this gap in information, the AMA created. Does the service or procedure have a technical component or professional component? GV- Attending physician not Only if there is not a substitute physician under a reciprocal billing arrangement. Outpatient Hospital/ASC Procedure after Administration of Anesthesia: A deleted edit is one where no edit exists for that particular code pair. B. Statistical modifiers that affect pricing are appended to a procedure code. Global surgery modifiers: 24, 25, 57, 58, 78, 79
a prerequisite for use of this modifier. In order to fill this gap in information, the AMA created CPT modifiers, which provides this detailed information in an efficient and standardized way. QD- Recording and storage What modifiers are allowed with the NCCI PTP edits? Surgeon: service code(s). ), Outpatient hospital services furnished in an Most edits involving paired organs or structures (e.g., eyes, ears, extremities, lungs, kidneys) have NCCI PTP modifier indicators of 1 because the 2 codes of the code pair edit may be reported if performed on the contralateral organs or structures.
In general, these circumstances relate to separate patient encounters, separate anatomic sites, or separate specimens. postoperative period was unrelated to the original procedure. - When entering a pricing modifier and a statistical modifier that If the UOS on the claim line exceeds the MUE value, all UOS for that claim line are denied. statutorily excluded or does not meet the definition of any Medicare benefit. Most of these code pairs should not be reported with NCCI PTP associated modifiers when performed on the ipsilateral organ or structure unless there is a specific coding rationale to bypass the edit. Diaper dermati 1. (For repeat
I. The article provides more information on the appropriate use of the 59 modifier and can be found in the downloads section at the bottom of the NCCI webpage. What was the location on the body where the procedure was performed? Physicians use of this modifier when laboratory "add-on" codes The appropriate use of HCPCS/CPT modifiers to report the same code on separate lines of a claim will enable a provider/supplier to report medically reasonable and necessary UOS in excess of an MUE value. Level II HCPCS Alphanumeric Modifiers B. ], EJ- Subsequent claims for a defined course of therapy (example: EPO, sodium hyaluronate). Under these be identified by adding the modifier 26 to the usual procedure number. (example: 93005). Based on the "Internet-only Manuals (IOM)," "Medicare Claims Processing Manual," Publication 100-04, Chapter 16, Section 100.5.1, the repeat testing cannot be performed to confirm initial results; due to testing problems with specimens and equipment or for any other reason when a normal, one-time, reportable result is all that is required.. more descriptive modifier available, and the use of modifier 59 best explains know how modifiers impact practice reimbursement and understand payer considerations. less than six dialysis sessions have been provided in a month. PO -Outpatient hospital services furnished in an As such, different diagnoses are not required for Outpatient Hospital/ASC Procedure Prior to the Administration of performed by a resident without the presence of a teaching physician under the furnished directly by a provider of services. This may also be true for certain edits with an MAI of 1. The CMS interprets the notice delivery requirements under Section1879 of the Social Security Act (the Act) as applying to situations in which a provider/supplier expects the initial claim determination to be a reasonable and necessary denial. field. The presence of an Advance Beneficiary Notice (ABN) shall not shift liability to the beneficiary for UOS denied based on an MUE. .gov Incorrect use of modifiers is considered fraud or non-compliance, and can result in further audits and revenue loss. field. It is the responsibility of the provider submitting claims to stay informed of these requirements. required a significant, separately identifiable E&M service above and was performed during a postoperative period for a reason(s) unrelated to the I (Or) CPT Modifiers The physician may need to indicate that on the day a procedure or Under these circumstances, the procedure started but terminated can be field and the statistical/informational modifier in the second field. The application of Medicares NCCI methodologies and thereby the application of Medicare payment policies and rules to claims other than Medicare Part B claims may result in denials by other plans. started. Although aPTP edit has been deleted, there is a Correct Coding Modifier Indicator (CCMI) present in the field, what does this mean? 55-Postoperative Most MUE values are visible to providers / suppliers on the NCCI webpage. The physician may need to indicate that the performance of a usually required for the listed procedure. The NCCI Policy Manual for Medicare Services may be obtained on theCMS NCCI webpage. The PTP edits and MUEs may be updated at least quarterly. only. An MAI of 1 indicates that the edit is a claim line edit. MUEs are designed to reduce errors due to clerical entries and incorrect coding based on criteria such as anatomic considerations, HCPCS/CPT code descriptors, CPT coding instructions, established CMS policies, nature of a service/procedure, nature of an analyte, nature of equipment, prescribing information, and claims data. Note: The TC modifier should Howlong are the PTP edits and MUEs in the NCCI program valid? The ideal MUE is the maximum unit(s) of service that would be reported for a HCPCS/CPT code on the vast majority of appropriately reported claims. statistical/informational modifier, enter the statistical modifier in the first The summed value is compared to the MUE value. The existence of the NCCI PTP edit indicates that the 2 codes generally cannot be reported together unless the 2 corresponding procedures are performed at 2 separate patient encounters or 2 separate anatomic locations. The CMS MUE program was developed to reduce the paid claims error rate for Medicare claims. Under certain circumstances more than four modifiers This document may be found at the bottom of the NCCI webpage under downloads. *SF- The second opinion ordered All available MUE tables for Medicare for the most recent quarter are published on the CMS website. A denial of services due to an MUE is a coding denial, not a medical necessity denial. of test results (e.g., glucose tolerance tests, evocative/suppression testing). performed on the same day. J. The CPT code range from 00100 019 M usculoskeletal System Surgery Coding Guidelines: The section is divided by the anatomical site (General, Head, Neck, Back, etc) ANESTHESIA CPC Sample questions: 1. that a procedure or service was distinct or independent from other services *TC-Technical Component. QU- Physician providing (Outside) Laboratory: single definitive procedure code. (For repeat Modifiers Position in If the units were actually provided but one of the other conditions is not met, a change in denial reason may be warranted (for example, a change from the MUE denial based on incorrect coding to a determination that the item / service is not reasonable and necessary under section 1862(a)(1)). appropriate, it should be used rather than modifier 59. Services: 53-Discontinued 62-Two Surgeons: technical component (TC) enter the 26 or the TC modifier in the first modifier The public/confidential status of MUEs may change. No, there are some Column 1 / Column 2 correct coding edits which the CMS does not think would ever warrant the use of any of the modifiers associated with the NCCI PTP edits. procedures are a combination of a physician component and a technical A. Nephr/o B. Ren/o C. Pyel/o D. Both A and B 2. Only: ABN issuance based on an MUE is NOT appropriate. to the donation. Under these circumstances, the laboratory It is important to know the restrictions, formats and guidelines in using the medical modifiers as miscoded claims can result in denials. An MAI of 2 or 3 indicates that the edit is a date of service MUE. Q6- Service furnished by a Other government and private insurers may voluntarily choose to adopt Medicare's NCCI methodologies.
When two surgeons work together as primary surgeons GB- Claim being It is important to know the restrictions, formats and guidelines in using the medical modifiers as miscoded claims can result in denials. The CMS posts the current and previous quarters PTP edit and MUE files, and change report files. 50-Bilateral service.]. reduction ratio (URR) of 65 to 69.9. Under these Procedure or Service by the Same Physician During the Postoperative Period: and another physician performs the surgical procedure. F. How doNCCI edits apply to Critical Access Hospitals (CAHs)? program. of care. AI -Principal physician, AJ- Clinical Social Worker
99-Multiple converted from screening mammogram on the same day. For outpatient hospital/ambulatory surgery tests). This document may be found at the bottom of the NCCI webpage under downloads. anesthesia and/or surgical preparation of the patient should not be reported. confirm initial results; due to testing problems with specimens or equipment; physician, 91-Repeat Clinical The edit for this PTP code pair was deleted. The NCCI program contractor provides general information to the public regarding the NCCI program and edits. Unless otherwise identified in the listings, bilateral on the same day, see modifier 76. the service provided by the physician to the patient. When one physician performs the postoperative management and The CMS publishes which codes have date of service and which codes have claim line MUEs. Modifiers that may be used under appropriate clinical circumstances to bypass an NCCI PTP edit include: Anatomic modifiers: E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, LD, RC, LM, RI 24-Unrelated E&M Service, Same Physician, During Postoperative However, if the 2 corresponding procedures are performed at the same patient encounter and incontiguous structures in the same organ or anatomic region, NCCI PTP-associated modifiers generally should not be used. Providers should continue to only report services that are medically reasonable and necessary. (See subsequent discussion of modifiers in this section.)
different procedure or surgery, different site or organ system, separate
26-Professional Component: Certain B. https:// Further information is available in MLN Matters MM8853.
GH- Diagnostic mammogram GZ- Item or service The physician may need to indicate that a procedure or Procedure Coding System II. postoperative period was unrelated to the original procedure. An MAI of 1 indicates that the edit is a claim line MUE. service in a rural Health Professional Shortage Area (HPSA). Your business needs to be operating at peak performance if its going to survive. surgeon. Procedure: Center (ASC) facility service. GO- Service delivered XS -Separate Structure that are not normally reported together but are appropriate under the
should report his/her distinct operative work by adding the modifier 62 to the the well-being of the patient prior to or after administration of anesthesia, off-campus provider-based department. LT- Left Side. GY- Item or service professional component (example: 93010). If the sum is greater than the MUE value, all UOS for the code on the current claim are denied. *QK- Medical direction of day. Appended to HCPCS and CPT codes, modifiers are always either two digits or alphanumerical characters. Due to extenuating circumstances or those that threaten the well-being of the patient, the physician may cancel a surgical or diagnostic
*QT- Recording and storage Note: If a co-surgeon acts as an assistant in the performance of additional Q4- Service for Placing a modifier after a CPT or HCPCS code does not guarantee reimbursement. (Note: * Denotes modifiers which are valid for the first affects pricing; enter the pricing modifier in the first modifier field and the of modifier 91. The exception is for the QT, QW and SF modifiers. In the course of treatment of the patient, it may be Surgeon (when a qualified resident surgeon is not available in a teaching What does "Column 1" or Column 2 mean in the Column 1 / Column 2 NCCI edits table? M. Howdo I make an inquiry about the MUE program other than about MUE values for specific HCPCS/CPT codes? Procedure by the Same Physician: 77-Repeat If you have questions or concerns regarding this process, please contact your payer directly. and repeated procedure by the same physician (modifier 76) enter 26 in the The NHO may be able to clarify the reporting of the code in question. first modifier field and the 76 in the second modifier field. surgery. procedure prior to the patients anesthesia induction and/or surgical circumstance may be reported by adding modifier 76 to the repeated procedure. (For repeat employed or paid under an arrangement by the patients hospice provider. 99-272 (100% therapy plan of care. indicate that the performance of a procedure or service during the two, three, or four concurrent anesthesia procedures involving. MUE values are not utilization guidelines and do not represent UOS that may be reported without concern about medical review. subsequent (multiple) test results. 90-Reference through a DME. Management Only: or trauma. performed in part by a resident under the direction of a teaching physician. If a provider/supplier, healthcare organization, or other interested party believes that a MUE value should be modified, they may email the CMS NCCI Mailbox at NCCIPTPMUE@cms.hhs.gov. C. Whereis the effective date of a PTP edit? performed during the postoperative period of the initial procedure. How do I obtain the NCCI Policy Manual? requires a return to the operating room. Howdo I know what changed in the NCCI PTP and MUE files from quarter to quarter? procedures that are performed in the same operative session should be Pricing modifiers are used to determine the reasonable charge or fee for a service and are considered part of the seven digit procedure code by the CMS. primary care exception. Services associated with postoperative medical complications directly related So its really important to be conversant with the, . G1- Most recent urea alphanumeric, used with CPT codes to describe or adding extra information about Note: This modifier is not used to report the treatment of a problem that
What can I do about other commercial payers who deny payment citing NCCI edits? KD -Any Drug or biological substance infused those that threaten the well-being of the patient prior to or after The physician may need to indicate that a basic procedure or Surgical assistant services may be identified by adding the reduction ratio (URR) reading of less Than 60. D. If I have a situation where I think a modifier associated with the NCCI program should be used, is there someone who can tell me if I am using the modifier properly? G6- ESRD patient for whom [This modifier is used when the submitted procedure code is changed either for There has to be a clear understanding and knowledge of the rules, restrictions and guidelines in order to be able to assign the correct modifier. medical direction by a physician. reduction ratio (URR) reading of 60 to 64.9. Office visit R adiology: Radiology is by using imaging technologies such as (X-ray radiography, MRI, CT, nuclear medicine, ultrasound and PE ICD Test 1 Conventions: 1. Procedure or Service by the Same Physician During the Postoperative Period: The physician may need to This may represent a different session or patient encounter, Copyright MedConverge 2021 All rights reserved. In the previous section, we have looked at CPT modifiers with examples. A. If any additional service or procedure was performed, If the service or procedure was discontinued, Any other information that is important for claiming reimbursement. Surgeon (when a qualified resident surgeon is not available in a teaching The physician may need to (Used to Period: E&M Service may be prompted by the symptom or condition for which the Operating Room for a Related Procedure During the Postoperative Period: 79-Unrelated NCCI PTP edits for HCPCS/CPT codes apply to services reported by the same provider/supplier for the same beneficiary on the same date of service. identify procedures performed on the left side of the body.) Procedure: identify procedures performed on the left side of the body. valid in the first modifier field only. How did that affect your work? Sign up to get the latest information about your choice of CMS topics. Statement on file. modifier field. QA- FDA investigational It lists Level I (CPT-4), Level II (non-CPT-4 alpha numeric), and Level III (local) modifiers. Other modifiers: 27, 59, 91, XE, XS, XP, XU. re-submitted for payment because it is no longer covered under a global payment C. Can these modifiers that are associated with the NCCI PTP edits be used with all the Column 1 / Column 2 correct coding edits? Hasthe CMS published the MUE values for HCPCS/CPT codes?
If an additional procedure(s) (including Under certain circumstances, a charge may be made for the technical component circumstances. provided as routine care in a Medicare qualifying clinical trial. NCCI PTP edits and MUEs for HCPCS/CPT codes apply to services reported by the same provider/supplier for the same beneficiary on the same DOS. If the same code is reported on more than one line of a claim by using CPT modifiers, each line of the claim is adjudicated separately against the MUE value of the code on that claim line. condition. Secure .gov websites use HTTPSA Note: This modifier is not used to report the elective cancellation of a General information about edit rationale may be found in the NCCI Policy Manual, Chapter 1, available on the CMS NCCI webpage. However, we do not provide specific billing or coding advice to providers / suppliers and we do not deal with payment issues. Care (MAC) for a patient who has a history of severe cardiopulmonary
telecommunications system. The MUE files on the CMS NCCI website display an MAI for each HCPCS/CPT code. 98940, 98941, and 98942. The 26 modifier should not be appended to procedure codes that represent a How do I report medically reasonable and necessary units of service (UOS) in excess of an MUE value? (Effective for dates of service on or after October 1, 1995, Although the CMS 1500 and UB-04 claim forms have space for four modifiers, CMS and other payers generally do not look beyond the first two. service performed by another physician had to be repeated. service identified by a CPT code was performed, the patients condition Procedure by the Same Physician: Anesthesia: 74-Discontinued By continuing to browse the site, you agree to our use of cookies and, How to Choose the Best Medical Billing Service, Understanding Billing Telehealth Services & How We Can Help Your Practice, Managing Accounts Receivable: Help Your Business Stay on Top, AMA announces 2 new CPT Codes for COVID-19 Antibody Tests. irradiation, infection, very low weight (Neonates and infants less than 10 kg.) However, we do not provide specific billing or coding advice to providers/suppliers. rape or incest or pregnancy certified by a physician as life-threatening. The circumstance maybe Serving as either informational or a billing clarification, the application of modifiers removes the necessity of separate service or procedure listing. The Category II CPT codes do not always provide complete information about the specifics of a procedure. reported by adding modifier 25 to the appropriate level of E&M service. performed), but prior to the administration of anesthesia. SL - VACCINE FOR CHILDREN. Further information is available in MLN Matters MM8853. Plans that voluntarily choose to adopt Medicare's NCCI methodologies should review their edits and consider deactivating individual edits that conflict with their own benefit and coverage determinations. GA- Waiver of Liability 56-Preoperative 51-Multiple of the patient should not be reported. - When entering a pricing modifier, enter it in the first modifier field A modifier is essentially a code that denotes an alteration to a procedure or service already performed, without any change in the original code or definition. 74-Discontinued LD- Left anterior Contact your local A/B MAC about other edits that may be in place on a national or local level which are not NCCI edits. or cancelled as a result of extenuating circumstances or those that threaten 22- Unusual Procedural Services: that resulted in the initial decision to perform the surgery, 58-Staged or
