Modifier 22 - Unusual increased procedural services - tips and reimbursement guidelines

 MODIFIER 22-UNUSUAL PROCEDURAL SERVICES

This modifier indicates that a procedure was complicated, complex, difficult, or took significantly more time than usually required by the provider to complete the procedure. Documentation should be in simple “layman terminology” and contained in the operative report. The operative report should be attached to the claim.

Payment is usually 20-30% higher. Often, reimbursement will not be increased when the EOMB is returned. Often, this means that the documentation was insufficient to support increased time and effort.

Submit this claim electronically initially unless otherwise informed by your carrier so that it is filed in a timely fashion.

Increased Procedural Services (Modifier 22)

This Clinical Payment and Coding Policy is intended to serve as a general reference guide for increased procedural services. Health care providers (i.e. facilities, physicians and other qualified health care professionals) are expected to exercise independent medical judgement in providing care to patients. This policy is not intended to impact care decisions or medical practice.

Modifications to this policy may be made at any time. Any updates will result in an updated publication of this policy.

Description:

Modifier 22 is described by the American Medical Association’s (AMA) Current Procedural Technology (CPT) as identifying an increased procedural service. The CPT codebook states that “When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier 22 to the usual procedure code.” In addition, CPT states that modifier 22 should not be reported with evaluation and management (E/M) services. 

Reimbursement Information:

Additional payment for services may be considered in very unusual circumstances when the work effort is “substantially greater” than typically required. Use modifier 22 in such an instance. Use of modifier 22 is a representation by the provider that the treatment rendered on the date of services was substantially greater than typically required. The use of modifier 22 does not guarantee additional reimbursement. Thorough documentation indicating the substantial amount of additional work and reason for this work will be required for review. Reasons for additional work may include:

* Increased intensity

* Increased time

* Technical difficulty

* Severity of the patient’s condition

* Physical and mental effort

Documentation should provide the plan’s claim reviewers with a clinical picture of the patient; the procedures/services performed and support the use of modifier 22. A brief letter or statement is not a part of the medical record and is not sufficient to justify the use of modifier 22. Modifier 22 is not justified by generalized or conclusory statements including but not limited to the following:

* Surgery took additional two hours

* This was a difficult procedure

* Surgery for an obese patient

Additional Information:

* The additional difficulty of the procedure should be detailed in the body of the operative report.

* Modifier 22 should not be appended to a procedure/service if the additional work performed has a specific procedure code.

* Modifier 22 should only be reported with procedure codes that have a global period of 0, 10, or 90 days

Codes and Definitions

Modifier 22

Increased Procedural Services: When the work required to provide a service is substantially greater than typically required, it may be identified by adding modifier

22 to the usual procedure code. Documentation must support the substantial additional work and the reason for the additional work (ie, increased intensity, time,

technical difficulty of procedure, severity of patient’s condition, physical and mental effort required).

Note: This modifier should not be appended to an E/M service.

Coding Guidelines

Modifier -22 identifies a service that required substantially greater effort than usually required and well outside of the range typically needed. Per the AMA, any time the modifier -22 is used, when filing an insurance claim, the operative report should be sent along with the claim to indicate and justify the unusual service. The medical record documentation must support both the substantial additional work and the reason for the additional work (e.g. increased intensity, time, technical difficulty of procedure, severity of the patient’s condition, physical and mental effort required).

Inappropriate Use of Modifier -22

• Do not use when a listed procedure code is available to describe the service performed.

• Do not use modifier 22 in combination with an E/M service.

• Do not use modifier 22 in combination with an unlisted procedure code.

• Do not use modifier 22 in combination with anesthesia codes. Additional time units are

used to report the duration of the procedure. Additional effort and complexity are otherwise reported using anesthesia physical status modifiers.

 

UNUSUAL PROCEDURAL SERVICES

When the service(s) provided is greater than that usually required for the listed procedure, it may be identified by adding modifier 22 to the usual procedure number.

A report may also be appropriate. Using the Modifier Correctly

• The 22 modifier is appended to the basic CPT procedure code when the service(s) provided is greater than usually required for the listed procedure. Use of

modifier 22 allows the claim to undergo individual consideration.

• Modifier 22 is used to identify an increment of work that is infrequently encountered with a particular procedure and is not described by another code.

• The frequent reporting of modifier 22 has prompted many carriers to simply ignore it. When using modifier 22, the claim must be accompanied by documentation and a cover letter explaining the unusual circumstances. Documentation includes, but is not limited to, descriptive statements identifying the unusual circumstances, operative reports (state the usual time for performing the procedure and the prolonged time due to complication, if appropriate), pathology reports, progress notes, office notes, etc. Language that indicates unusual circumstances would be difficulty, increased risk, extended, hemorrhage, blood loss over 600cc, unusual findings, etc. If slight extension of the procedure was necessary (a procedure extended by 15–20 minutes) or, for example, routine lysis of adhesions was performed, these scenarios do not validate the use of the modifier 22.

• Surgical procedures that require additional physician work due to complications or medical emergencies may warrant the use of modifier 22 after the surgical

procedure code.

• Modifier 22 is applied to any code of a multiple procedure claim, regardless of whether that code is the primary or secondary procedure. In these instances, the

Medicare carrier first applies the multiple surgery reduction rules (e.g., 100 percent, 50 percent, 50 percent, 50 percent, 50 percent). Then, a decision is made

as to whether or not payment consideration for modifier 22 (unusual circumstances) is in order. For example, if the fee schedule amounts for procedures A,

B, and C are $1000, $500, and $250 respectively, and a modifier 22 is submitted with procedure B, the carrier would apply the multiple surgery payment

reduction rule first (major procedure 100 percent of the Medicare fee schedule) and reduce the procedure B (second surgical procedure) fee schedule amount

from $500 to $250. The carrier would then decide whether or not to pay an additional amount above the $250 based on the documentation submitted with

the claim for unusual procedural services, as designated by modifier 22.

Radiology UNUSUAL PROCEDURAL SERVICES

When the service(s) provided is greater than that usually required for the listed procedure, it may be identified by adding modifier 22 to the usual procedure number.

A report may also be appropriate. Note: This modifier is not to be used to report procedure(s) complicated by adhesion formation, scarring, and/or alteration of

normal landmarks due to late effects of prior surgery, irradiation, infection, very low weight (i.e., neonates and infants less than 4kg), or trauma. Using the Modifier Correctly

• Modifier 22 is appended to the basic CPT procedure code when the service(s) provided is greater than usually required for the listed procedure. Use of modifier 22 allows the claim to undergo individual consideration.

• Modifier 22 is used to identify an increment of work that is infrequently encountered with a particular procedure and is not described by another code.

• Modifier 22 is generally not appended to a radiology code. If a rare circumstance does occur, submit detailed documentation with a cover letter from the

radiologist or other provider.

• The frequent reporting of modifier 22 has prompted many carriers to simply ignore it.

• Modifier 22 is used with computerized tomography (CT) numbers when additional slices are required or a more detailed examination is necessary. However,

this is subject to payer discretion. Many payers will not allow additional reimbursement for additional CT slices.

Incorrect Use of the Modifier

• Appending this modifier to a radiology code without justification in the medical record documenting an unusual occurrence. Because of its overuse, many

payers do not acknowledge this modifier.

• Using this modifier on a routine basis; to do so would most certainly cause scrutiny of submitted claims and may result in an audit.

• Using modifier 22 to indicate that the radiology procedure was performed by a specialist; specialty designation does not warrant use of the 22 modifier.

• Using modifier 22 when more x-rays views are taken than actually specified by the CPT code description. This is incorrect, especially when the code descriptor

reads “complete” (e.g., 70130, 70321, 73110, etc.). Complete means any number of views taken of the body site.

Coding Tips

• Using modifier 22 identifies the service as one that requires individual consideration and manual review.

• Overuse of modifier 22 could trigger a carrier audit. Carriers monitor the use of this modifier very carefully. The 22 modifier should be used only when sufficient documentation is present in the medical record.

• A Medicare claim submitted with modifier 22 is forwarded to the carrier medical review staff for review and pricing. With sufficient documentation of medical necessity, increased payment may result.

Pathology and Laboratory UNUSUAL PROCEDURAL SERVICES

When the service(s) provided is greater than that usually required for the listed procedure, it may be identified by adding modifier 22 to the usual procedure number.

A report may also be appropriate. Note: This modifier is not to be used to report procedure(s) complicated by adhesion formation, scarring, and/or alteration of

normal landmarks due to late effects of prior surgery, irradiation, infection, very low weight (i.e., neonates and infants less than 4 kg), or trauma.

Using the Modifier Correctly

• Modifier 22 is used to the basic CPT code book procedure code when the service(s) provided is greater than usually required for the listed procedure. Use of

modifier 22 on services requires individual consideration of the claim(s).

• Modifier 22 is used to identify an increment of work that is infrequently encountered with a particular procedure and is not described by another code.

• The frequent use of modifier 22 has prompted many carriers to ignore it. When using modifier 22, the claim must be accompanied by documentation and a

cover letter explaining the unusual circumstances. Documentation includes, but is not limited to, descriptive statements identifying the unusual circumstances,

operative reports (state the usual time for performing the procedure and the prolonged time due to any complications), pathology reports, progress notes,

office notes, etc.

Incorrect Use of the Modifier

• Appending this modifier to a code without justification in the medical record of an unusual occurrence. Because of its overuse, many payers do not acknowledge

this modifier.

• Using this modifier on a routine basis. To do so would most certainly flag the claim and may result in an audit.

• Using modifier 22 to indicate a procedure was performed by a specialist. Specialty designation does not warrant use of modifier 22. 

Coding Tips

• Using modifier 22 identifies the service as one requiring individual consideration and manual review.

• Overuse of modifier 22 could trigger a carrier audit. Carriers monitor the use of this modifier very carefully. Make sure that modifier 22 is used only when sufficient documentation is present in the medical record.

• A Medicare claim submitted with modifier 22 is forwarded to the carrier medical review staff for review and pricing. With sufficient documentation of medical necessity increased payment may result.

Medicine UNUSUAL SERVICES

When the service(s) provided is greater than that usually required for the listed procedure, it may be identified by adding modifier 22 to the usual procedure number.

A report may also be appropriate. Note: This modifier is not to be used to report procedure(s) complicated by adhesion formation, scarring, and/or alteration of

normal landmarks due to late effects of prior surgery, irradiation, infection, very low weight (i.e., neonates and infants less than 4 kg), or trauma.

Using the Modifier Correctly 

• Modifier 22 is appended to the basic CPT procedure code when the service(s) provided is greater than usually required for the listed procedure. Use of modifier 22 on services requires individual claim consideration.

• Modifier 22 is used to identify an increment of work that is infrequently encountered with a particular procedure and is not described by another code.

• The frequent reporting of modifier 22 has prompted many carriers to ignore it.

When using modifier 22, the claim must be accompanied by documentation and a cover letter explaining the unusual circumstances. Documentation includes, but is not limited to, descriptive statements identifying the unusual circumstances, operative reports (state the usual time for performing the procedure and the prolonged time due to complication), pathology reports, progress notes, office notes, etc. Some words that indicate unusual circumstances would be difficult, increased risk, extended, etc. If a slight extension of the procedure was necessary (e.g., a procedure is extended by 15–20 minutes), this minimal prolonged time does not validate the use of modifier 22.

• Surgical or medical procedures that require additional physician “work” due to complications or medical emergencies may warrant the use of modifier 22.

• Modifier 22 is used with the following codes in the medicine section of the CPT manual, when an unusual circumstance is well-documented. 

Reimbursement Guidelines

A. General

1. Moda Health does allow additional reimbursement for increased procedural services for:

a. Certain specific chemical dependency services at specific reimbursement rates only when specified in the Moda Health provider contract and requirements specified in the contract are met.

b. Surgical procedure codes, and only after manual review to determine if an additional allowance is warranted. If the review determines that an additional allowance is warranted, the procedure will be reimbursed at 125% of the normal allowance (contracted fee or maximum plan allowable).

2. Moda Health does not allow additional reimbursement for increased procedural services for the following:

a. When the contracted fee allowance is based on a percentage of billed charges.

b. For anesthesia codes.

c. For non-surgical procedure codes (with limited chemical dependency exceptions noted above). Non-surgical procedures (e.g. laboratory, radiology, medical codes, etc.) submitted with modifier 22 for increased procedural services are reimbursed at the normal allowance (contracted fee or maximum plan allowance).

B. Billing Office & Claims Submission Responsibilities

1. When modifier -22 is used to indicate increased procedural services, the documentation must be submitted for manual review before any adjustment to increase the fee allowance can be considered.

a. The billing office should supply both of the following items:

i. A concise statement about how the service differs from the usual and indicating the factors contributing to the increased difficulty of the procedure.

ii. The operative report for the service.

b. The concise statement or brief cover letter is not a part of the medical record. This statement alone is not sufficient to support the need for an increased allowance, but assists in the review process by summarizing and directing our attention to what will be found in the operative report. The operative report must also be supplied and the increased difficulty and the reasons for it must be documented in the operative report.

c. It is the responsibility of the surgeon’s billing office to submit all necessary documentation.

d. The billing office may choose to submit claims with modifier 22 manually with the required supporting documentation attached, or submit the claims electronically and submit the required documentation for review upon request.

e. A prompt response to requests for medical records or additional information required for review will help to avoid unnecessary delays in adjudication of the claim.

2. If the nature, extent, and reasons for the increased work of the procedural service are not clearly documented in the record or if the documentation submitted is incomplete, the service will be reimbursed at the normal allowance (contracted fee or maximum planallowance).

C. Criteria for Surgical Codes

1. An increased allowance for surgical codes is considered warranted when two or more of the following factors are present:

a. Unusually lengthy procedure.

(Duration/time of procedure as compared with usual must be documented in the operative report, not merely on a cover letter.)

b. Excessive blood loss during the procedure.

c. Presence of an excessively large body habitus, e.g. BMI >40 (especially in abdominal surgery).

d. The delivery of twins, triplets, or other multiple gestations via cesarean delivery only of all gestations, and only if significant additional difficulty is encountered.

e. Trauma extensive enough to complicate the procedure and not billed as separate procedure codes. 

f. Other pathologies, tumors, malformations (genetic, traumatic, surgical) that directly interfere with the procedure but are not billed as separate procedure codes.

g. The services rendered are significantly more complex than described for the submitted CPT or HCPCS code, and there is not another, more appropriate code that describes the additional work or complexity involved.

2. An increased allowance for surgical codes is NOT considered warranted for:

a. The use of a robotic assisted surgery device.

b. Use of computer assisted navigation device.

c. Lysis of adhesions in the absence of any other factors. Lysis or division of an average amount of adhesions is included in the RVU for surgical procedures. Thus, the allowance for the primary surgical procedure(s) includes the work involved in lysis of adhesions.

d. The vaginal delivery of twins, triplets, or other multiple gestations, or a combination of vaginal delivery of at least one fetus followed by cesarean delivery of one or more additional gestations. Appropriate maternity procedure codes are available for use to properly report this situation.

e. Solely for a complication.

f. Solely for a lengthy procedure due to the surgeon’s choice of approach.

i. If the original approach fails and must be converted to another approach, then only the successful approach is reportable12, and the increased work and time due to the first attempted approach does not warrant an increased allowance.

Example:

The surgeon elects a laparoscopic cholecystectomy, but is unable to complete the procedure laparoscopically and must convert to an open cholecystecomy. The

increased time spent on the attempted laparoscopic approach does not warrant an increased allowance.

ii. If the original approach does not fail, but proves more difficult and requires additional time and effort to complete without converting to another approach, or

otherwise results in an intraoperative complication, then the increased work due to the surgeon’s choice of approach does not warrant an increased allowance.

Example:

If the surgeon elects a vaginal approach for a hysterectomy which results in additional work that would not have been considered increased procedural work substantially greater than typically required for an abdominal hysterectomy, then the increased work due to the vaginal approach does not warrant an increased

allowance.

g. A “reoperation” when the patient has had a prior surgery which does not significantly increase the difficulty of the current surgery.

h. A “reoperation” when a specific procedure code is available to specify that the procedure is a reoperation.

i. Modifier 63 and modifier 22 may not be reported on the same code.

D. Criteria for Maternity/Delivery Codes

1. An increased allowance for maternity/delivery codes is sometimes, but not always, considered warranted for a cesarean delivery (not VBAC attempt) of multiple gestations (e.g. twins, triplets, etc.).

a. Modifier 22 is not automatically warranted when multiple gestations are delivered by cesearean. CPT code 59510 (Routine obstetric care including antepartum care,

cesarean delivery, and postpartum care) includes delivery of all babies in multiple gestations, according to instructions from the AMA. (AMA14, Moda B)

b. If there is significant extra difficulty involved with delivering the additional baby/babies, then append modifier -22 and submit an explanation of the significant

extra difficulty involved and send a copy of the op report with claim. (AMA14, Moda B) The operative report must also support and document the significant extra

difficulty involved.

2. An increased allowance is not considered warranted for delivery of multiple gestations (e.g. twins, triplets, etc.) with a failed VBAC and delivery of all babies by cesarean.

a. Delivery of the first baby is coded with 59618 (Routine obstetric care including antepartum care, cesarean delivery, and postpartum care, following attempted

vaginal delivery after previous cesarean delivery).

b. Delivery of the subsequent newborns are separately coded. See RPM020, section K. (Moda B)

3. An increased allowance for maternity/delivery codes is not considered warranted for the following items or procedures. (This list is not exhaustive; see RPM020. (Moda B)) 

These are considered part of the global maternity package, and payment is included in the RVU allowance for the delivery/global maternity procedure codes:

a. An episiotomy and repair with a vaginal delivery.

b. Repair of cervical, vaginal or perineal lacerations. (AMA14, 15, 16)

c. Exploration of the uterus.

d. Artificial rupture of membranes (AROM) before delivery.

e. Induction of labor with pitocin or oxytocin.

f. A rapid or precipitous delivery.

g. A high-risk pregnancy. (High-risk pregnancies generate additional antepartum visits above the standard antepartum schedule which are separately reportable, and

additional diagnostic procedures which are separately reported.)

Finger Modifier Guidelines and usage examples

A. Policy

Aetna Better Health of Louisiana implements comprehensive and robust policies to ensure alignment with Louisiana Department of Health (LDH) and to warrant that regulatory standards are met. According to the AMA CPT Manual, the HCPCS Level II Manual and our policy, the anatomic specific modifiers, such as fingers, toes and coronary artery designate the area or part of the body on which the procedure is performed. It is correct coding to append modifiers to the greatest specificity at all times.

B. Overview

CPT and HCPCS Level II guidelines support the use of anatomic specific modifiers to develop policies which validate the area or part of the body on which a procedure is performed.

Procedure codes that do not specify right or left require an anatomical modifier. If an anatomical modifier is necessary to differentiate right or left and is not appended, the claim will be denied. Likewise, if a modifier is appended to a procedure code that does not match the appropriate anatomical site, the claim will be denied.

C. Definitions

Modifier is a code that provides the means by which the reporting physician can indicate that a service or procedure that has been performed has been altered by some specific circumstance but has not changed in its definition or code. Anatomical modifiers designate the area or part of the body on which the procedure is performed and assist in prompt, accurate adjudication of claims.

Including Coronary Artery, Eye Lid, Finger, Side of Body, and Toe.

D. Reimbursement Guidelines

When submitting claims, always append an anatomical modifier, when applicable. Louisiana Department of Health Medicaid policy for both the commercial and Medicaid Advantage lines of business is that a claim is incomplete without an anatomical modifier, when applicable

E. Codes/Condition of Coverage

These codes are not all inclusive and for more please refer AMA CPT Manual, the HCPCS Level II Manual. These modifiers can be used with diagnostic, as well as therapeutic services.

Anatomical Modifiers:

Including Coronary Artery, Eye Lid, Finger, Side of Body, and Toe.




LT, RT Modifiers LT and RT are only considered valid for procedure codes specific to body parts that exist only twice in the body, once on the left and once on the right (paired body parts). For example, eye procedures (e.g. cataract surgery) and knee procedures (e.g. total knee replacement).

Modifiers LT and RT should be used when a procedure was performed on only one side of the body, to identify which one of the paired organs was operated upon. LT and RT are not considered valid for toe procedures, excision of lesions, tendon/ligament injections (20550), or needle placements, etc. (Use finger and toe modifiers for finger and toe procedure codes; use eyelid modifiers for eyelid procedures.)

If the code description is for a structure that occurs multiple times on one side ofthe body (e.g. fingers, tendons, nerves, etc.) and is not specific enough for you to be able to mark on a body diagram where the left or right procedure is performed without looking at the medical record (e.g. place an “x” on the left shoulder for  73030-LT), then LT and RT are not valid modifiers. (Modifier -59 may be needed to indicate a separate lesion, separate nerve, separate tendon, etc. for nonpaired procedure codes.)



** To report an unplanned, unrelated procedure performed during postoperative period that is unrelated and not a result of the first surgery.
** To explain surgery/procedure.

Note
** Carrier may deny if modifier 79 is not included on the submitted claim.
** Claim should be submitted with a different diagnosis and documentation should support the medical necessity.
** The unrelated procedure starts a new global period.
** For repeat procedures on the same day, see modifier 76.
** Do not report modifier 79 with modifiers 58 or 78.
** Modifier 79 is an information modifier (not subject to payment reduction). Example
** January 22 – Patient is seen for an injury to the right index finger. The patient’s finger is amputated at the DIP joint.
** 26951 Amputation, finger or thumb, primary or secondary, any joint or phalanx, single, including neurectomies; with direct closure.
** March 15 – Same patient has an amputation of the right leg at femur.
** 27590 – 79 Amputation, thigh, through femur, any level.


Blue Cross Requires use of Anatomical Modifiers

Effective February 1, 2019, Blue Cross and Blue Shield of Minnesota (Blue Cross) will change the Reimbursement Policy titled “General Coding-Modifier Policy”. Submission of anatomical modifiers to specify locations will be required when submitting claims.

Anatomical Modifiers

The following modifiers indicate a specific anatomic site. Because these modifiers affect edits and payment, effective February 1, 2019 Blue Cross requires the anatomical modifier(s) be submitted in the first modifier position, if applicable.

E1 Upper left, eyelid
E2 Lower left, eyelid
E3 Upper right, eyelid
E4 Lower right, eyelid
FA Left hand, thumb
F1 Left hand, second digit
F2 Left hand, third digit
F3 Left hand, fourth digit
F4 Left hand, fifth digit
F5 Right hand, thumb
F6 Right hand, second digit
F7 Right hand, third digit
F8 Right hand, fourth digit
F9 Right hand, fifth digit
LC Left circumflex coronary artery
LD Left anterior descending coronary artery
LT Left side (used to identify procedures performed on the left side of the body)
RC Right coronary artery
RT Right side (used to identify procedures performed on the right side of the body)
TA Left foot, great toe
T1 Left foot, second digit
T2 Left foot, third digit
T3 Left foot, fourth digit
T4 Left foot, fifth digit
T5 Right foot, great toe
T6 Right foot, second digit
T7 Right foot, third digit
T8 Right foot, fourth digit
T9 Right foot, fifth digit





Modifier Guidelines

procedures have been inappropriately billed by a surgical assistant. If guidelines are not met, the claim will suspend.

• Modifier 95 is used to designate when a service is a real-time interaction between a physician or other qualified health care professional and a patient who is located at a distant site from the physician or other qualified health care professional.

• Modifier AS designates that services were provided by a physician assistant, nurse practitioner or nurse midwife for an assistant at surgery. Blue Cross and Blue Shield of North Carolina uses ClaimCheck® as its primary source for determining those procedures available for assistant surgeon billing by physician assistants, nurse practitioner or nurse midwife. Automatic edits are performed to determine if any procedures have been inappropriately billed by the physician assistant, nurse practitioner or nurse midwife.

• Modifier AX – item furnished in conjunction with dialysis services. J0604 and J0606 are drugs used for bone and mineral metabolism for the treatment of End Stage Renal Disease.

They are eligible for Transitional Drug Add-On Payment Adjustment when billed with AX modifier.

• HCPCS Level II anatomic specific modifiers E1-E4 (eyelids), FA-F9 (fingers), TA-T9 (toes), RC, LC, LD, RI, LM (coronary arteries), and RT / LT (right / left) designate the area or part of the body on which the procedure is performed. Codes for site-specific procedures submitted without appropriate modifiers are assumed to be on the same side or site. Services provided on separate anatomic sites should be identified with the use of appropriate sitespecific modifiers to allow automated, accurate payment of claims. (See also reimbursement policy titled “Maximum Units of Service”). Modifier 50 is used when bilateral procedures are performed on both sides at the same operative session. (See also reimbursement policy titled “Multiple Surgical Procedure Guidelines for Professional Providers”).
• Modifier GQ designates services performed via asynchronous telecommunications system and will not be allowed.
• Modifier GT designates services performed via interactive audio and video telecommunication systems and will be allowed with codes specified in the Corporate Reimbursement Policy titled, “Telehealth.”
• Modifier MS - six month maintenance and servicing fee for reasonable and necessary parts and labor which are not covered under any manufacturer or supplier warranty
• For Modifiers PA (surgical or other invasive procedure on wrong body part), PB (surgical or other invasive procedure on wrong patient), and PC (wrong surgery or other invasive procedure on patient), refer to Corporate Reimbursement Policy titled “Nonpayment for Serious Adverse Events”
• Modifier RA – Replacement of a DME item
• Modifier SZ – Effective 1/1/2017 in order to support Control/Home Plans’ compliance with the Federal requirement to separate visit limits for habilitative and rehabilitative services, Par/Host Plans may need to require that their providers are using the HCPCS modifier “SZ” when billing for habilitative services. (See policy titled “Rehabilitative Therapies”)
• Modifier RB – Replacement of a part of DME furnished as part of a repair


7 HCPCS Level II anatomic specific modifiers E1-E4 (eyelids), FA-F9 (fingers), TA-T9 (toes), RC, LC, LD, RI, LM (coronary arteries), and RT / LT (right / left) designate the area or part of the body on which the procedure is performed. Codes for site-specific procedures submitted without appropriate modifiers are assumed to be on the same side or site. Services provided on separate anatomic sites should be identified with the use of appropriate site-specific modifiers to allow automated, accurate payment of claims. (See also reimbursement policy titled “Maximum Units of Service”). Modifier 50 is used when bilateral procedures are performed on both sides at the same operative session. (See also reimbursement policy titled “Multiple Surgical Procedure Guidelines for Professional Providers”). Notification given 11/28/17 for effective date of 1/27/18.

AT modifier - Description - Use of the modifier in chiropractic billing

Modifier and Description

AT - Active Treatment

Provider Action Needed

The Active Treatment (AT) modifier was developed to clearly define the difference between active treatment and maintenance treatment. Medicare pays only for active/corrective treatment to correct acute or chronic subluxation. Medicare does not pay for maintenance therapy. Claims should include a primary diagnosis of subluxation and a secondary diagnosis that reflects the patient's neuromusculoskeletal condition. The patient's medical record should support the services you are billing. Related MLN Matters Article SE1601 discusses those medical record documentation requirements. 

Background

In 2014, the comprehensive error testing program (CERT) that measures improper payments in the Medicare feefor- service program reported a 54 percent error rate for chiropractic services. The majority of those errors were due to insufficient documentation/documentation errors. Year after year these error rates appear. CMS is providing an explanation of the AT modifier to assist providers with correctly documenting claims for chiropractic services provided to Medicare beneficiaries. The active treatment (AT) modifier defines the difference between active treatment and maintenance treatment. Effective October 1, 2004, the AT modifier is required under Medicare billing to receive reimbursement for Procedure codes 98940- 98941 , 98942. For Medicare purposes, the AT modifier is used only when chiropractors bill for active/ corrective treatment (acute and chronic care). The policy requires the following:

1. Every chiropractic claim for CPT 98940/98941/98942, with a date of service on or after October

1, 2004, should include the AT modifier if active/corrective treatment is being performed; and

2. The AT modifier should not be used if maintenance therapy is being performed. MACs deny chiropractic claims for CPT® 98940/98941/98942, with a date of service on or after October 1, 2004, that does not contain the AT modifier. The following categories help determine coverage of treatment. (See the Necessity for Treatment, Chapter 15, Section 240.1.3, of the Medicare Benefit Policy Manual (pages 226-227)).

1. Acute subluxation: A patient’s condition is considered acute when the patient is being treated for a new injury (identified by X-ray or physical examination).

the result of chiropractic manipulation is expected to be an improvement in, or arrest of progression of, the patient’s condition.

2. Chronic subluxation: A patient’s condition is considered chronic when it is not expected to significantly improve or be resolved with further treatment (as is the case with an acute condition); however, the continued therapy can be expected to result in some functional improvement. Once the clinical status has remained stable for a given condition, without expectation of additional objective clinical improvements, further manipulative treatment is considered maintenance therapy and is not covered. Both of the above scenarios are covered by CMS as long as there is active treatment which is well documented and improvement is expected.


Maintenance: Maintenance therapy includes services that seek to prevent disease, promote health and prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy. The AT modifier must not be placed on the claim when maintenance therapy has been provided.

 Be aware that once the provider cannot determine there is any improvement, treatment becomes maintenance and is no longer covered by Medicare.


Key points

For Medicare purposes, a chiropractor must place an AT modifier on a claim when providing active/corrective treatment to treat acute or chronic subluxation. However,  the presence of the AT modifier may not in all instances indicate that the service is reasonable and necessary. As always, MACs may deny if appropriate after medical review determines that the medical record does not support active/corrective treatment.

You must place the AT modifier on a claim when providing active/corrective treatment to treat acute or chronic subluxation. However, the presence of the AT modifier may not in all instances indicate that the service is reasonable and necessary.

Maintenance Therapy Maintenance therapy includes services that seek to prevent disease, promote health and prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy.

The AT modifier must not be placed on the claim when maintenance therapy has been provided. Claims without the AT modifier will be considered as maintenance therapy and denied.

You should consider providing the Advance Beneficiary Notice of Noncoverage (ABN) to the beneficiary. Chiropractors who give beneficiaries an ABN will place the modifier GA (or in rare instances modifier GZ) on the claim. The decision to deliver an ABN must be based on a genuine reason to expect that Medicare will not pay for a particular service on a specific occasion for that beneficiary due to lack of medical necessity for that service. The beneficiary can then make a reasonable and informed decision about receiving and paying for the service. If the beneficiary decides to receive the service, you must submit a claim to Medicare even though you expect that Medicare will deny the claim and that the beneficiary will pay.

"Since March 3, 2008 CMS has issued one form with the official title "Advance Beneficiary Notice of NonCoverage (ABN)" (form CMS-R-131). A properly executed ABN must use this form for each date an ABN is issued and all the required fields on the form must be completed including a mandatory field for cost estimates of the items/services at issue and a valid specific reason why the chiropractor believes Medicare payment for CMT will be denied on this date for this beneficiary. ABNs should not be issued routinely citing the same reason for each occurrence. One ABN cannot be used with added lines for future dates of services. For additional instructions on the proper completion of the ABN, see http://www.cms.gov/Medicare/Medicare-General-Information/BNI/index.html on the CMS website.

WHAT ARE HCPCS MODIFIERS?

A modifier comprises two alpha, numeric, or alphanumeric characters reported with a HCPCS code, when appropriate. Modifiers are designed to give Medicare and commercial payers additional information needed to process a claim. This includes HCPCS Level I (Physicians’ Current Procedural Terminology [CPT®]) and HCPCS Level II codes. The reporting physician appends a modifier to indicate special circumstances that affect the service provided without affecting the service or procedure description itself. When applicable, the appropriate two-character modifier code should be used to identify the modifying circumstance. The modifier should be placed after the usual procedure code number.

The CPT code book, CPT 2018, lists the following examples of when a modifier may be appropriate, including, but not limited to:

• Service/procedure is a global service comprising both a professional and technical component and only a single component is being reported

• Service/procedure involves more than a single provider and/or multiple locations

• Service /procedure was either more involved or did not require the degree of work specified in the code descriptor

• Service/procedure entailed completion of only a segment of the total service/procedure

• An extra or additional service was provided

• Service/procedure was performed on a mirror image body part (eyes, extremities, kidneys, lungs) and not unilaterally

• Service/procedure was repeated

Modifiers 24, 25, 57, and AI may be appended to evaluation and management services only. Each modifier is listed below with its official definition and an example of appropriate use.

Unrelated Evaluation and Management Service by the Same Physician Or Other Qualified Health Care Professional During a Postoperative Period The physician or other qualified health care professional may need to indicate that an evaluation and management service was performed during a postoperative period for a reason(s) unrelated to the original procedure. This circumstance may be reported by adding modifier 24 to the appropriate level of E/M service.

Modifier 24 is added to the selected E/M service code to identify the E/M service rendered by the same provider as unconnected and distinct from other services in the patient’s postoperative period.

AMBULANCE MODIFIERS

For ambulance services modifiers, single alpha characters with distinct definitions are paired to form a two-character modifier. The first character indicates the origination of the patient (e.g., patient’s home, physician office, etc.), and the second character indicates the destination of the patient (e.g., hospital, skilled nursing facility, etc.). When ambulance services are reported, the name of the hospital or facility should be included on the claim. If reporting the scene of an accident or acute event (character S) as the origin of the patient, a written description of the actual location of the scene or event must be included

with the claim(s).

D Diagnostic or therapeutic site other than “P” or “H” when these are used as origin codes

E Residential, domiciliary, custodial facility (other than 1819 facility)

G Hospital-based ESRD facility

H Hospital

INTRODUCTION

Almost every segment of the health care industry has been affected by the federal government’s antifraud and abuse campaigns over the last several years. Investigations of hospital billing practices, especially teaching hospitals, flooded the news media with reports of indictments, sanctions, and out-of-court settlements for millions of dollars. With trepidation seeping into all areas of health care, more of the federal government’s charges of fraud and abuse committed by clinical laboratories have been heard nationwide, with tens of millions of dollars being paid back to the government. Home health agencies (HHAs), skilled nursing facilities, and durable medical equipment (DME) companies were then targeted. Finally, physician practices and ambulatory surgery centers (ASCs), in state after state, have been undergoing investigations by the FBI, the Office of Inspector General, and officials from the Centers for Medicare and Medicaid Services (CMS). In June 2000, the OIG released a draft version of a physician compliance guidance document aimed at solo practitioners and small physician groups. The Federal Register of October 5, 2000, disclosed the final version of this compliance guidance. Given that the federal government claims it has recouped inappropriate payments and overpayments and has collected fines totaling, up to this point, several billion dollars, there are no signs that fraud and abuse activities will wane.

This chapter of Optum360 Learning: Understanding Modifiers explains the term “compliance” and provides an overview of the federal government’s current efforts to eradicate fraud, waste, and abuse in health care programs. This chapter also provides the reader with logic trees for each modifier. Logic trees should be used by physicians and facilities as self-auditing tools to help ensure correct modifier usage. 

Audiology billing Guide - CPT code list - payment guidelines

Policy Definition

Audiology is the study of hearing and hearing disorders and includes habilitation and rehabilitation for individuals who have hearing loss

Provider Billing Guidelines and Documentation Coding

Code Description Comments

92550–92588 Audiometric tests Bill once with a count of one

92597 Evaluation for use and/or fitting of voice prosthetic device to supplement oral speech

92601–92604 Diagnostic analysis of cochlear implant; with programming; subsequent reprogramming

92605 Evaluation for prescription of non speech generating augmentative and alternative communication device Reimbursed for facility only

92606 Therapeutic service(s) for the use of non speech generating device, including programming and modification

92607–92609 Speech generating and non-speech generating augmentativeand alternative communication device-related services
To bill professional component of service use CPT; to bill DME component, refer to Durable Medical Equipment (DME).

92620, 92621 Evaluation of central auditory function, with report

92625 Assessment of tinnitus

92626 Evaluation of auditory rehabilitation status; first hour

92627 Evaluation of auditory rehab status; ea add’l 15 minutes Bill in conjunction with 92626

92630 Auditory rehabilitation; pre-lingual hearing loss

92633 Auditory rehabilitation; post-lingual hearing loss

 92700 Unlisted otorhinolaryngological service or procedure Submit documentation of services rendered


Modifiers

• When billing for monaural hearing aids, a RT or LT modifier in the second modifier field is required for payment. Claims submitted without the RT or LT modifier may be denied.

• When billing for a binaural hearing aid the RT or LT modifier is not required. Claims submitted with a RT or LT modifier will be denied as inappropriately billed.


AUDIOLOGY SERVICES  Payable Codes to Audiologists

SERVICE DESCRIPTION CODE

Spontaneous Nystagmus; w/record 92541

Positional Nystagmus; w/record 92542

Caloric Vestibular Test; w/record 92543

Optokinetic Nystagmus; w/record 92544

Oscillating Tracking; w/record 92545

Use of Vertical Electrodes 92547

Screening Test, Pure Tone, Air Only 92551

Pure Tone Audiometry; Air Only 92552

Pure Tone Audiometry; Air and Bone 92553

Speech Audiometry Threshold 92555

Speech Audiometry Threshold; with speech recognition 92556

Comprehensive Audiometry 92557

Tone Decay Test 92563

Short Increment Sensitivity Index 92564

Stenger Test, Pure Tone 92565

Tympanometry 92567

Acoustic Reflex Testing; Threshold 92568

Acoustic Reflex Testing; Decay 92569

Filtered Speech Test 92571

Staggered Spondaic Word Test 92572

Sensorineural Acuity Level Test 92575

Synthetic Sentence ID Test 92576

Stenger Test, Speech 92577

Visual Reinforcement Audiometry (VRA) 92579

Conditioning Play Audiometry 92582

Select Picture Audiometry 92583

Electrocochleography 92584

Auditory Evoked Potentials; Comprehensive 92585

Auditory Evoked Potentials; Limited 92586

Evoked Otoacoustic Emissions; Limited 92587

Evoked Otoacoustic Emissions; Comprehensive 92588

Hearing Aid Exam/Selection; Monaural 92590

Hearing Aid Exam/Selection; Binaural 92591

Hearing Aid Check; Monaural 92592

Hearing Aid Check; Binaural 92593

Electroacoustic Evaluation Hearing Aid; Monaural 92594

Electroacoustic Evaluation Hearing Aid; Binaural 92595

Evaluation of Central Auditory Function w/report; init 60 Min 92620

Evaluation of Central Auditory Function; ea additional 15 Min 92621

Assessment of Tinnitus Assessment 92625



Restrictions

• Payment for the following codes is restricted to one each per recipient per 180 days

92552 92553 92555 92556 92557 92563 92564 92565 92567 92568 92569 92571 92572 92575 92576 92577 92579 92582 92583 92584 92585

• Audiologist are reminded that for recipients in the CommunityCARE program, there must be a written authorization from the recipient’s PCP for the audiologist’s services. This includes recipients that are referred to them by the Head Start program.



Audiologists Employed by Hospitals 

Audiologists who are salaried employees of hospitals cannot bill Medicaid for their professional services rendered at that hospital because their services are included in the hospital’s per diem rate. Audiologists can enroll and bill Medicaid if they are providing services at a hospital at which there is no audiologist on staff.




B. Billing for Audiology Services

See the CMS Web site at http://www.cms.gov/PhysicianFeeSched/50_Audiology.asp for a listing of all CPT codes for audiology services. For information concerning codes that are not on the list, and which codes may be billed when furnished by technicians, contractors shall provide guidance. The Physician Fee Schedule at

http://www.cms.gov/PFSlookup/01_Overview.asp#TopOfPage allows you to search pricing amounts, various payment policy indicators, RVUs, and GPCIs.

Audiology services may not be billed when the place of service is a comprehensive outpatient rehabilitation facility (CORF) or a rehabilitation agency.

Audiology services may be furnished and billed by audiologists and, when these services are furnished by an audiologist, no physician supervision is required.

The interpretation and report shall be written in the medical record by the audiologist, physician, or NPP who personally furnished any audiology service, or by the physician who supervised the service. Technicians shall not interpret audiology services, but may record objective test results of those services they may furnish under direct physician supervision. Payment for the interpretation and report of the services is included in payment for all audiology services, and specifically in the professional component if the audiology service has a professional component/technical component split.

1. Billing under the MPFS for Audiology Services Outside the Facility Setting

The individuals who furnish audiology services in all settings must be qualified to furnish those services. The qualifications of the individual performing the services must be consistent with the number, type and complexity of the tests, the abilities of the individual, and the patient’s ability to interact to produce valid and reliable results. The physician who supervises and bills for the service is responsible for assuring the qualifications of the technician, if applicable are appropriate to the test.

a.Professional Skills.

When a professional personally furnishes an audiology service, that individual must interact with the patient to provide professional skills and be directly involved in decision-making and clinical judgment during the test.

The skills required when professionals furnish audiology services for payment under the MPFS are masters or doctoral level skills that involve clinical judgment or assessment and specialized knowledge and ability including, but not limited to, knowledge of anatomy and physiology, neurology, psychology, physics, psychometrics, and interpersonal communication. The interactions of these knowledge bases are required to attain the clinical expertise for audiology tests. Also required are skills to administer valid and reliable tests safely, especially when they involve stimulating the auditory nerve and testing complex brain functions.

Diagnostic audiology services also require skills and judgment to administer and modify tests, to make informed interpretations about the causes and implications of the test results in the context of the history and presenting complaints, and to provide both objective results and professional knowledge to the patient and to the ordering physician.

Examples include, but are not limited to:

*Comparison or consideration of the anatomical or physiological implications of test results or patient responsiveness to stimuli during the test;

*Development and modification of the test battery and test protocols;

*Clinical judgment, assessment, evaluation, and decision-making;

*Interpretation and reporting observations, in addition to the objective data, that may influence interpretation of the test outcomes;

*Tests related to implantation of auditory prosthetic devices, central auditory processing, contralateral masking; and/or

*Tests to identify central auditory processing disorders, tinnitus, or nonorganic hearing loss.

Audiology codes may be billed under the MPFS by audiologists, physicians, and NPPs using their own NPI in the rendering loop when those professionals personally furnish the test. Physicians and NPPs may not bill for these codes when an audiologist has furnished the service.

b.Technician Skills.

There may be subtests, or parts of a battery of tests, that may be appropriately furnished by an educated and experienced technician using a specific protocol under the direction of a supervising physician. These services are identified by local contractor determination as services that do not require professional skills. They may be furnished by a qualified technician under the direct supervision of a physician, but not under the supervision of an audiologist or an NPP. The supervising physician is responsible for rendering and documenting all clinical judgment and for the appropriate provision of the service by the technician.

A technician may not perform any part of a service that requires professional skills. A technician also may not perform a global service. For example, a technician may not interpret test results or engage in clinical decision-making.

c.Professional Component (PC)/Technical Component (TC) Split Codes.

*The PC of a PC/TC split code may be billed by the audiologist, physician, or NPP who personally furnishes the service. (Note this is also true in the facility setting.) A physician or NPP may bill for the PC when the physician or NPP furnish the PC and an (unsupervised) audiologist furnishes and bills for the TC. The PC may not be billed if a technician furnishes the service.  A physician or NPP may not bill for a PC service furnished by an audiologist.


*The TC of a PC/TC split code may be billed by the audiologist, physician, or NPP who personally furnishes the service. Physicians may bill the TC for services furnished by technicians when the technician furnishes the service under the direct supervision of that physician. Audiologists and NPPs may not bill for the TC of the service when a technician furnishes the service, even if the technician is supervised by the NPP or audiologist.

*The “global” service is billed when both the PC and TC of a service are personally furnished by the same audiologist, physician, or NPP. The global service may also be billed by a physician, but not an audiologist or NPP, when a technician furnishes the TC of the service under direct physician supervision and that physician furnishes the PC, including the interpretation and report.

d.Tests that are Not Described by Specific CPT Codes. Tests that have no appropriate CPT code may be reported under CPT code 92700 (Unlisted otorhinolaryngological service or procedure).

e.Tests that are Contractor-Priced. For codes valued by contractors, the contractor determines whether and how much, if applicable, to pay for the service. The contractor sets the requirements for personnel furnishing the tests.

2.Billing for Audiology Services Furnished to Hospital Outpatients.

All codes may be reported for audiology services furnished in the hospital outpatient setting and, in such cases, the code represents the facility service for the diagnostic test. All audiology services furnished to hospital outpatients must be billed and paid to the hospital under the OPPS or other applicable hospital payment system. The hospital bills its fiscal intermediary or Medicare administrative contractor (A/B MAC) and is paid for the facility resources required to furnish the services, regardless of whether the service is furnished by a physician, NPP, audiologist, or technician.

Physicians, NPPs, and audiologists cannot bill and be paid for the TC of PC/TC split codes when these services are furnished to hospital outpatients. The associated professional services (represented by the PC or the CPT code for the audiology test which has no PC/TC split) of an enrolled audiologist, physician, or NPP who has reassigned benefits may be billed by the hospital to the carrier or A/B MAC, as appropriate.

Alternatively, if the physician, NPP, or audiologist has not assigned benefits, the professional would bill his/her carrier or A/B MAC for the professional services furnished.

The appropriate revenue code for reporting audiology services is 0470 (Audiology; General Classification). Providers are required to report a line-item date of service per revenue code line for audiology services.

3.Billing for Audiology Services Furnished to Skilled Nursing Facility (SNF) Patients.


Payment for the facility resources (including the TC of PC/TC split codes) of audiology services provided to Part A inpatients of SNFs is included in the PPS rate. For SNFs, if the beneficiary has Part B but not Part A coverage (e.g., Part A benefits are exhausted), the SNF may elect to bill for audiology services but is not required to do so. As explained in Pub. 100-04, chapter 7, section 40.1, since audiology services furnished during a noncovered SNF stay are not bundled with speech-language pathology services, payment can be made either to the SNF or to the audiology service provider/supplier.

Audiologists, physicians, and NPPs enrolled in Medicare may bill directly for services rendered to Medicare beneficiaries who are in a SNF stay that is not covered by Part A but who have Part B eligibility. Payment is made based on the MPFS, whether on an institutional or professional claim. For beneficiaries in a noncovered SNF stay, audiology services are payable under Part B when billed by the SNF on an institutional claim as type of bill 22X, or when billed directly by the provider or supplier of the service (the audiologist, physician, or NPP who personally furnishes the test) on a professional claim. For PC/TC split codes, the SNF may elect to bill for the TC of the test on an institutional claim but is not required to bill for the service.

C - Implant Processing

Payment for diagnostic testing of implants, such as cochlear, osseointegrated or brainstem implants, including programming or reprogramming following implantation surgery is not included in the global fee for the surgery.

The diagnostic analysis of a cochlear implant shall be billed using CPT codes 92601 through 92604.

Osseointegrated prosthetic devices should be billed and paid for under provisions of the applicable payment system. For example, payment may differ depending upon whether the device is furnished on an inpatient or outpatient basis, and by a hospital subject to the OPPS, or by a Critical Access Hospital, physician’s clinic, or a Federally Qualified Health Center.

D - Aural Rehabilitation Services

General policy for evaluation and treatment of conditions related to the auditory system.

For evaluation of auditory processing disorders and speech-reading or lip-reading by a speech-language pathologist, use the untimed code 92506 with “1” as the unit of service, regardless of the duration of the service on a given day. This “always therapy” evaluation code must be provided by speech-language pathologists according to the policies in Pub. 100-02, chapter 15, sections 220 and 230. The codes 92620 and 92621 are diagnostic audiological tests and may not be used for SLP services.

For treatment of auditory processing disorders or auditory rehabilitation/auditory training (including speech-reading or lip-reading), 92507, and 92508 are used to report a single encounter with “1” as the unit of service, regardless of the duration of the service on a given day. These codes always represent SLP services. See Pub. 100-02, chapter 15, sections 220 and 230 for SLP policies. These SLP evaluation and treatment services are not covered when performed or billed by audiologists, even if they are supervised by physicians or qualified NPPs.

For evaluation of auditory rehabilitation to instruct the use of residual hearing provided by an implant or hearing aid related to hearing loss, the timed codes 92626 and 92627 are used. These are not “always therapy” codes. Evaluation of auditory rehabilitation shall be appropriately provided and billed by an audiologist or speech-language pathologist.

Also, these services may be provided incident to a physician’s or qualified NPP’s service by a speech-language pathologist, or personally by a physician or qualified NPP within their scope of practice. Evaluation of auditory rehabilitation is a covered diagnostic test when performed and billed by an audiologist and is an SLP evaluation service covered under the SLP benefit when performed by a speech-language pathologist.

Medicare Part B advance beneficiary notices AND ITS MODIFIER

Medicare Part B allows coverage for services and items deemed medically reasonable and necessary for treatment and diagnosis of the patient. For some services, to ensure that payment is made only for medically necessary services or items, coverage may be limited based on one or more of the following factors (this list is not inclusive):

▪Coverage for a service or item may be allowed only for specific diagnoses/conditions. Always code to the highest level of specificity.

▪Coverage for a service or item may be allowed only when documentation supports the medical need for the service or item.

▪Coverage for a service or item may be allowed only when its frequency is within the accepted standards of medical practice (i.e., a specified number of services in a specified timeframe for which the service may be covered).

If the provider believes that the service or item may not be covered as medically reasonable and necessary, the patient must be given an acceptable advance notice of Medicare’s possible denial of payment if the provider does not want to accept financial responsibility for the service or item. Advance beneficiary notices (ABNs) advise beneficiaries, before items or services actually are furnished, when Medicare is likely to deny payment.

Patient liability notice
The Centers for Medicare & Medicaid Services’ (CMS) has developed the Advance Beneficiary Notice of
Noncoverage (ABN) (Form CMS-R-131), formerly the “Advance Beneficiary Notice.” Section 50 of the Medicare

Claims Processing manual provides instructions regarding the notice that these providers issue to beneficiaries in advance of initiating, reducing, or terminating what they believe to be noncovered items or services. The ABN must meet all of the standards found in Chapter 30. Beginning March 1, 2009, the ABN-G and ABN-L was no longer valid; and notifiers must use the revised Advance Beneficiary Notice of Noncoverage (CMS-R-131).

Reproducible copies of Form CMS-R-131 ABNs (in English and Spanish) and other BNI information may be found at http://www.cms.gov/Medicare/Medicare-General-Information/BNI/index.html.

ABN modifiers

When a patient is notified in advance that a service or item may be denied as not medically necessary, the provider must annotate this information on the claim (for both paper and electronic claims) by reporting modifier GA (waiver of liability statement on file) or GZ (item or service expected to be denied as not reasonable and necessary) with the service or item.

Failure to report modifier GA in cases where an appropriate advance notice was given to the patient may result in the provider having to assume financial responsibility for the denied service or item.

Modifier GZ may be used in cases where a signed ABN is not obtained from the patient; however, when modifier GZ is billed, the provider assumes financial responsibility if the service or item is denied.

Note: Line items submitted with the modifier GZ will be automatically denied and will not be subject to complex medical review.

GA modifier and appeals

When a patient is notified in advance that a service or item may be denied as not medically necessary, the provider must annotate this information on the claim (for both paper and electronic claims) by reporting the modifier GA(wavier of liability statement on file).

Failure to report modifier GA in cases where an appropriate advance notice was given to the patient may result in the provider having to assume financial responsibility for the denied service or item.

Nonassigned claims containing the modifier GA in which the patient has been found liable must have the patient’s written consent for an appeal. Refer to the Address, Phone Numbers, and Websites section of this publication for the address in which to send written appeals requests.

what is Pre-operative Period Billing and post operative billing ? Which modifier can use ?

Pre-operative Period Billing

E /M Service Resulting in the Initial Decision to Perform Surgery

Evaluation/ Management (E/M) services on the day before major surgery or on the day of major
surgery that result in the initial decision to perform the surgery are not included in the global surgery
payment for the major surgery and, therefore, may be billed and paid separately. In addition to the CPT E/M code, modifier “-57” (Decision for surgery) is used to identify a visit that results in the initial decision to perform surgery. The modifier “-57” is not used with minor surgeries because the global period for minor surgeries does not include the day prior to the surgery. Where the decision to perform the minor procedure is typically done immediately before the service, it is considered a routine pre-operative service and a visit or consultation is not billed in addition to the procedure. Carriers/MACs may not pay for an E/M service billed with the CPT modifier “-57” if it was provided on the day of or the day before a procedure with a 0 or 10 day global surgical period.

Day of Procedure Billing

Significant, Separately Identifiable E/M Service by the Same Physician on the Same Day of the Procedure Modifier “-25” (Significant, separately identifiable E/M service by the same physician on the same day of the procedure), indicates that the patient’s condition required a significant, separately identifiable E/M service beyond the usual pre-operative and post-operative care associated with the procedure or service.

•Use modifier “-25” with the appropriate level of E/M service.
•Use modifiers “-24” (Unrelated E/M service by the same physician during a post-operative period) and “-25” when a significant, separately identifiable E/M service on the day of a procedure falls within the post-operative period of another unrelated, procedure.

Different diagnoses are not required for reporting the E/M service on the same date as the procedure or other service. Both the medically necessary E/M service and the procedure must be appropriately and sufficiently documented by the physician or qualified nonphysician practitioner in the patient’s medical record to support the claim for these services, even though the documentation is not required to be submitted with the claim.

Claims for Multiple Surgeries
Multiple surgeries are separate procedures performed by a single physician or physicians in the same group practice on the same patient at the same operative session or on the same day for which separate payment may be allowed. Co-surgeons, surgical teams, or assistants-at-surgery may participate in performing multiple surgeries on the same patient on the same day. Surgeries subject to the multiple surgery rules have an indicator of “2” in the Physician Fee Schedule look-up tool. The multiple procedure payment reduction will be applied based on the MPFS approved amount and not on the submitted amount from the providers. The major surgery may or may not be the one with the larger submitted amount.

Multiple surgeries are distinguished from procedures that are components of or incidental to a primary procedure. These intra-operative services, incidental surgeries, or components of more major surgeries are not separately billable.
There may be instances in which two or more physicians each perform distinctly different, unrelated surgeries on the same patient on the same day (for example, in some multiple trauma cases). When this occurs, the payment adjustment rules for multiple surgeries may not be appropriate.

Claims for Co-Surgeons and Team Surgeons

Under some circumstances, the individual skills of two or more surgeons are required to perform surgery on the same patient during the same operative session. This may be required because of the complex nature of the procedures and/or the patient’s condition. In these cases, the additional physicians are not acting as assistants-at-surgery. The following billing procedures apply when billing for a surgical procedure or procedures that require the use of two surgeons or a team of surgeons:

•If two surgeons (each in a different specialty) are required to perform a specific procedure, each surgeon bills for the procedure with a modifier “-62” (Two surgeons). Co-surgery also refers to surgical procedures involving two surgeons performing the parts of the procedure simultaneously, i.e., heart transplant or bilateral knee replacements. Certain services that require documentation of medical necessity for two surgeons are identified in the MPFS look-up tool.
•If a team of surgeons (more than 2 surgeons of different specialties) is required to perform a specific procedure, each surgeon bills for the procedure with a modifier “-66” (Surgical team). Certain services, as identified in the MPFS look-up tool, submitted with modifier “-66” must be sufficiently documented to establish that a team was medically necessary. All claims for team surgeons must contain sufficient information to allow pricing “by report.”

• If surgeons of different specialties are each performing a different procedure (with specific CPT codes), neither co-surgery nor multiple surgery rules apply (even if the procedures are performed through the same incision). If one of the surgeons performs multiple procedures, the multiple procedure rules apply to that surgeon’s services.

Post-Operative Period Billing

Unrelated Procedure or Service or E/M Service by the Same Physician During a Post-operative Period

Two CPT modifiers are used to simplify billing for visits and other procedures that are furnished during the post-operative period of a surgical procedure, but not included in the payment for surgical procedure.

• Modifier “-79” (Unrelated procedure or service by the same physician during a post-operative period). The physician may need to indicate that a procedure or service furnished during a post-operative period was unrelated to the original procedure. A new post-operative period begins when the unrelated procedure is billed.

• Modifier “-24” (Unrelated E/M service by the same physician during a post-operative period). The physician may need to indicate that an E/M service was furnished during the post-operative period of an unrelated procedure. An E/M service billed with modifier “-24” must be accompanied by documentation that supports that the service is not related to the post-operative care of the procedure.

Specific Modifiers for Distinct Procedural Services

New coding requirements related to Healthcare Common Procedure Coding System (HCPCS) modifier -59 could impact your reimbursement.

Change Request (CR) 8863 notifies MACs and providers that the Centers for Medicare and Medicaid Services (CMS) is establishing four new HCPCS modifiers to define subsets of the - 59 modifier, a modifier used to define a "Distinct Procedural Service"

The Medicare National Correct Coding Initiative (NCCI) has Procedure to Procedure (PTP) edits to prevent unbundling of services, and the consequent overpayment to physicians and outpatient facilities. The underlying principle is that the second code defines a subset of the work of the first code. Reporting the codes separately is inappropriate. Separate reporting would trigger a separate payment and would constitute double billing.

CR 8863 discusses changes to HCPCS modifier- 59, a modifier which is used to define a "Distinct Procedural Service." Modifier - 59 indicates that a code represents a service that is separate and distinct from another service with which it would usually be considered to be bundled.

The 59 modifier is the most widely used HCPCS modifier. Modifier -59 can be broadly applied. Some providers incorrectly consider it to be the "modifier to use to bypass (NCCI)." This modifier is associated abuse and high levels of manual audit activity; leading to reviews, appeals and even civil fraud and abuse cases.

The primary issue associated with the 59 modifier is that it is defined for use in a wide variety of circumstances, such as to identify:
•    Different encounters;
•    Different anatomic sites; and
•    Distinct services.

The 59 modifier is
•    Infrequently (and usually correctly) used to identify a separate encounter;
•    Less commonly (and less correctly)used to define a separate anatomic site; and
•    More commonly (and frequently incorrectly) used to define a distinct service.

The 59 modifier often overrides the edit in the exact circumstance 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.
CR 8863 provides that CMS is establishing the following four new HCPCS modifiers (referred to collectively as - X{EPSU} modifiers) to define specific subsets of the 59 modifier:
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.

CMS will continue to recognize the 59 modifier, but notes that Current Procedural Terminology (CPT) instructions state that the 59 modifier should not be used when a more descriptive modifier is available. While CMS will continue to recognize the 59 modifier in many instances, it may selectively require a more specific - X {EPSU} modifier for billing certain codes at high risk for incorrect billing. For example, a particular NCCI PTP code pair may be identified as payable only with the - XE separate encounter modifier but not the 59 or other - X {EPSU} modifiers. The - X {EPSU} modifiers are more selective versions of the 59 modifier so it would be incorrect to include both modifiers on the same line.

The combination of alternative specific modifiers with a general less specific modifier creates additional discrimination in both reporting and editing. As a default, at this time CMS will initially accept either a 59 modifier or a more selective - X {EPSU} modifier as correct coding, although the rapid migration of providers to the more selective modifiers is encouraged.
However, please note that these modifiers are valid even before national edits are in place. MACs are not prohibited from requiring the use of selective modifiers in lieu of the general 59 modifier, when necessitated by local program integrity and compliance needs.

Global Surgery Coding and Billing Guidelines - what modifier to use

Physicians Who Furnish the Entire Global Package

Physicians who furnish the surgery and furnish all of the usual pre-and post-operative work may bill for the global package by entering the appropriate CPT code for the surgical procedure only. Separate billing is not allowed for visits or other services that are included in the global package. When different physicians in a group practice participate in the care of the patient, the group practice bills for the entire global package if the physicians reassign benefits to the group. The physician who performs the surgery is reported as the performing physician.

Physicians Who Furnish Part of a Global Surgical Package

More than one physician may furnish services included in the global surgical package. It may be the case that the physician who performs the surgical procedure does not furnish the follow-up care. Payment for the post-operative, post-discharge care is split among two or more physicians where the physicians agree on the transfer of care. When more than one physician furnishes services that are included in the global surgical package, the sum of the amount approved for all physicians may not exceed what would have been paid if a single physician provided all services, except where stated policies allow for higher payment. For instance, when the surgeon furnishes only the surgery and a physician other than the surgeon furnishes pre-operative and post-operative inpatient care, the resulting combined payment may not exceed the global allowed amount. The surgeon and the physician furnishing the post-operative care must keep a copy of the written transfer agreement in the beneficiary’s medical record. Where a transfer of care does not occur, the services of another physician may either be paid separately or denied for medical necessity reasons, depending on the circumstances of the case. Split global-care billing does not apply to procedure codes with a zero day post-operative period.

Using Modifiers “-54” and “-55”

Where physicians agree on the transfer of care during the global period, services will be distinguished by the use of the appropriate modifier:

• Surgical care only (modifier “-54”); or

• Post-operative management only (modifier “-55”). For global surgery services billed with modifiers “-54” or “-55,” the same CPT code must be billed. The same date of service and surgical procedure code should be reported on the bill for the surgical care only and post-operative care only. The date of service is the date the surgical procedure was furnished. Modifier “-54” indicates that the surgeon is relinquishing all or part of the post-operative care to a physician.

• Modifier “-54” does not apply to assistant-at-surgery services.

• Modifier “-54” does not apply to an Ambulatory Surgical Center (ASC’s) facility fees. The physician, other than the surgeon, who furnishes post-operative management services, bills with modifier “-55.”

• Use modifier “-55” with the CPT procedure code for global periods of 10 or 90 days.

• Report the date of surgery as the date of service and indicate the date care was relinquished or assumed. Physicians must keep copies of the written transfer agreement in the beneficiary’s medical record.

• The receiving physician must provide at least one service before billing for any part of the post-operative care.

• This modifier is not appropriate for assistant-at- surgery services or for ASC’s facility fees.

Exceptions to the Use of Modifiers “-54” and “-55”

Where a transfer of care does not occur, occasional  post-discharge services of a physician other than the surgeon are reported by the appropriate E/M code. No modifiers are necessary on the claim.
Physicians who provide follow-up services for minor procedures performed in emergency departments bill the appropriate level of E/M code, without a modifier. If the services of a physician other than the surgeon are required during a post-operative period for an underlying condition or medical complication, the other physician reports the appropriate E/M code. No modifiers are necessary on the claim. An example is a cardiologist who manages underlying cardiovascular conditions of a patient.



GLOBAL SURGERY PERIOD

Louisiana Medicaid’s global surgery period (GSP) policy differs from Louisiana Medicare policy.

• Medicaid does not pay for the day before, the day of, and the assigned GSP after surgery. Louisiana Medicaid assigns a GSP 1, 10, or 90 days. If you look at the  Professional Fee Schedule, the Global Surgery Period can be found in column 11.

• If a procedure has a GSP of “1”, the provider cannot bill for an evaluation and management service (E/M) the day before or the day of the procedure.

• If a procedure has a GSP of “10”, the provider cannot bill for an E/M service the day before, the day of, or 10 days following the procedure.

• If a procedure has a GSP of “90”, the provider cannot bill for an E/M service the day before, the day of, or 90 days following the procedure.

• Error code 690 (payment included in surgery fee) results when an E/M service is denied for a date of service within the GSP of the surgery or procedure that has been paid.

• Error code 691 (visit paid in GSP; void visit, rebill surgery) results when a surgery or procedure is denied because an E/M service has been paid for a date of service within the GSP of the surgery or procedure. The paid claim for the E/M service must be voided before the claim for the surgery or procedure can be considered for payment.

• E/M services should be billed separately only if the diagnosis and service rendered are unrelated to the diagnosis of the GSP procedure. If a visit is to be billed for a date of service within the GSP for unrelated diagnosis, it should be filed on a claim form separate from that of the GSP surgery or procedure.




Surgeons and Global Surgery

A national definition of a global surgical package has been established to ensure that payment is made consistently for the same services across all carrier jurisdictions, thus preventing Medicare payments for services that are more or less comprehensive than

intended. The national global surgery policy became effective for surgeries performed on and after January 1, 1992.

The instructions that follow describe the components of a global surgical package and payment rules for minor surgeries, endoscopies and global surgical packages that are split between two or more physicians. In addition, billing, mandatory edits, claims review, adjudication, and postpayment instructions are included.

In addition to the global policy, uniform payment policies and claims processing requirements have been established for other surgical issues, including bilateral and multiple surgeries, co-surgeons, and team surgeries.

Definition of a Global Surgical Package

Field 16 of the Medicare Fee Schedule Data Base (MFSDB) provides the postoperative periods that apply to each surgical procedure. The payment rules for surgical procedures apply to codes with entries of 000, 010, 090, and, sometimes, YYY.

Codes with “090” in Field 16 are major surgeries. Codes with “000” or “010” are either minor surgical procedures or endoscopies.

Codes with “YYY” are carrier-priced codes, for which carriers determine the global period (the global period for these codes will be 0, 10, or 90 days). Note that not all carrier-priced codes have a “YYY” global surgical indicator; sometimes the global period is specified.

While codes with “ZZZ” are surgical codes, they are add-on codes that are always billed with another service. There is no postoperative work included in the fee schedule payment for the “ZZZ” codes. Payment is made for both the primary and the add-on codes, and the global period assigned is applied to the primary code.

A.Components of a Global Surgical Package


Carriers apply the national definition of a global surgical package to all procedures with the appropriate entry in Field 16 of the MFSDB.

The Medicare approved amount for these procedures includes payment for the following services related to the surgery when furnished by the physician who performs the surgery. The services included in the global surgical package may be furnished in any setting, e.g., in hospitals, ASCs, physicians’ offices. Visits to a patient in an intensive care or critical

care unit are also included if made by the surgeon. However, critical care services (99291 and 99292) are payable separately in some situations.

*Preoperative Visits - Preoperative visits after the decision is made to operate beginning with the day before the day of surgery for major procedures and the day of surgery for minor procedures;

*Intra-operative Services - Intra-operative services that are normally a usual and necessary part of a surgical procedure;

*Complications Following Surgery - All additional medical or surgical services required of the surgeon during the postoperative period of the surgery because of complications which do not require additional trips to the operating room;

*Postoperative Visits - Follow-up visits during the postoperative period of the surgery that are related to recovery from the surgery;

*Postsurgical Pain Management - By the surgeon;
*Supplies - Except for those identified as exclusions; and
*Miscellaneous Services - Items such as dressing changes; local incisional care; removal of operative pack; removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes.

B.Services Not Included in the Global Surgical Package

Carriers do not include the services listed below in the payment amount for a procedure with the appropriate indicator in Field 16 of the MFSDB. These services may be paid for separately.

*The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery. Please note that this policy only applies to major surgical procedures. The initial evaluation is always included in the allowance for a minor surgical procedure;

*Services of other physicians except where the surgeon and the other physician(s) agree on the transfer of care. This agreement may be in the form of a letter or an annotation in the discharge summary, hospital record, or ASC record;

*Visits unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery;

*Treatment for the underlying condition or an added course of treatment which is not part of normal recovery from surgery;

*Diagnostic tests and procedures, including diagnostic radiological procedures;
*Clearly distinct surgical procedures during the postoperative period which are not re-operations or treatment for complications. (A new postoperative period begins with the subsequent procedure.) This includes procedures done in two or more parts for which the decision to stage the procedure is made prospectively or at the time of the first procedure. Examples of this are procedures to diagnose and treat epilepsy (codes 61533, 61534-61536, 61539, 61541, and 61543) which may be performed in succession within 90 days of each other;

*Treatment for postoperative complications which requires a return trip to the operating room (OR). An OR for this purpose is defined as a place of service specifically equipped and staffed for the sole purpose of performing procedures. The term includes a cardiac catheterization suite, a laser suite, and an endoscopy suite. It does not include a patient’s room, a minor treatment room, a recovery room, or an intensive care unit (unless the patient’s condition was so critical there would be insufficient time for transportation to an OR);

*If a less extensive procedure fails, and a more extensive procedure is required, the second procedure is payable separately;

*For certain services performed in a physician’s office, separate payment can no longer be made for a surgical tray (code A4550). This code is now a Status B and is no longer a separately payable service on or after January 1, 2002. However, splints and casting supplies are payable separately under the reasonable charge payment methodology;

*Immunosuppressive therapy for organ transplants; and
*Critical care services (codes 99291 and 99292) unrelated to the surgery where a seriously injured or burned patient is critically ill and requires constant attendance of the physician.


C.Minor Surgeries and Endoscopies

Visits by the same physician on the same day as a minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately identifiable service is also performed. For example, a visit on the same day could be properly billed in addition to suturing a scalp wound if a full neurological examination is made for a patient with head trauma. Billing for a visit would not be appropriate if the physician only identified the need for sutures and confirmed allergy and immunization status.

A postoperative period of 10 days applies to some minor surgeries. The postoperative period for these procedures is indicated in Field 16 of the MFSDB. If the Field 16 entry is 010, carriers do not allow separate payment for postoperative visits or services within 10 days of the surgery that are related to recovery from the procedure. If a diagnostic biopsy with a 10-day global period precedes a major surgery on the same day or in the

10-day period, the major surgery is payable separately. Services by other physicians are not included in the global fee for a minor procedures except as otherwise excluded. If the Field 16 entry is 000, postoperative visits beyond the day of the procedure are not included in the payment amount for the surgery. Separate payment is made in this instance.

D.Physicians Furnishing Less Than the Full Global Package B3-4820-4831
There are occasions when more than one physician provides services included in the global surgical package. It may be the case that the physician who performs the surgical procedure does not furnish the follow-up care. Payment for the postoperative, post- discharge care is split between two or more physicians where the physicians agree on the transfer of care.

When more than one physician furnishes services that are included in the global surgical package, the sum of the amount approved for all physicians may not exceed what would have been paid if a single physician provides all services (except where stated policies, e.g., the surgeon performs only the surgery and a physician other than the surgeon provides preoperative and postoperative inpatient care, result in payment that is higher than the global allowed amount).

Where a transfer of care does not occur, the services of another physician may either be paid separately or denied for medical necessity reasons, depending on the circumstances of the case.

E.Determining the Duration of a Global Period

To determine the global period for major surgeries, carriers count 1 day immediately before the day of surgery, the day of surgery, and the 90 days immediately following the day of surgery.

EXAMPLE:

Date of surgery - January 5 Preoperative period - January 4
Last day of postoperative period - April 5

To determine the global period for minor procedures, carriers count the day of surgery and the appropriate number of days immediately following the date of surgery.

EXAMPLE:

Procedure with 10 follow-up days:

Date of surgery - January 5
Last day of postoperative period - January 15

Assistant surgery modifiers 80, 81, 82, AS, SA

Assistant Surgeon Modifiers

Modifier 80, 81, 82: Denote assistant surgeons. Should be submitted on those surgical procedures where an assistant surgeon is warranted. NOTE: Physicians acting as assistants cannot bill as co-surgeons. Benefits will be derived based on CMS designation for Assistant Surgeon.


Supervision of Physician Assistant, Advanced Practice Nurse or Certified Registered Nurse First Assistant

The following modifiers should be used by the supervising physician when he/she is billing for services rendered by a Physician Assistant (PA), Advanced Practice Nurse (APN) or Certified Registered Nurse First Assistant (CRNFA):

AS Modifier: A physician should use this modifier when billing on behalf of a PA, APN or CRNFA for services provided when the aforementioned providers are acting as an assistant during surgery. (Modifier AS to be used ONLY if they assist at surgery)

SA Modifier: A supervising physician should use this modifier when billing on behalf of a PA, APN, of CRNFA for non-surgical services. (Modifier SA is used when the PA, APN, or CRNFA is assisting with any other procedure that DOES NOT include surgery.)


–80 Modifier: PA’s, APN’s, and CRNFA’s who are billing with their own National Provider Identifier (NPI) will not need to bill a modifier, unless they are billing as an Assistant Surgeon, then they must use the –80 modifier.

Appropriate use of assistant at surgery modifiers and payment indicators

First Coast Service Options Inc. (First Coast) would like to remind providers within jurisdiction N (JN) of the appropriate use of assistant at surgery modifiers and payment under the Medicare physician fee schedule (MPFS).

An assistant at surgery is a provider who actively assists the physician in charge of a case in performing a surgical procedure. A physician, nurse practitioner, physician assistant or clinical nurse specialist who is authorized to provide such services under state law can serve as an assistant at surgery.

Medicare considers advanced registered nurse practitioner (ARNP), physician assistant (PA), and clinical nurse specialist (CNS) as non-physician practitioners. Medicare does not recognize a registered nurse first assistant (RNFA) as a qualified Medicare provider.

To report services of an assistant surgeon, the following surgical modifiers should be appended:

• 80 -- Assistant Surgeon: This modifier pertains to physician’s services only. A physician’s surgical assistant services may be identified by adding the modifier 80 to the usual procedure code. This modifier describes an assistant surgeon providing full assistance to the primary surgeon, and is not intended for use by non-physician providers.

• 81 -- Assistant Surgeon: This modifier pertains to physician’s services only. Minimal surgical assistance may be identified by adding the modifier 81 to the usual procedure code, and describes an assistant surgeon providing minimal assistance to the primary surgeon. This modifier is not intended for use by non-physician providers.

Note: This modifier is used in the private insurance industry and is not commonly used in Medicare billing.

• 82 -- Assistant surgeon (when a qualified resident surgeon is not available in a teaching facility): This modifier applies to physician’s services only. The unavailability of a qualified resident surgeon is a prerequisite for use of this modifier and the service must have been performed in a teaching facility. The circumstance explaining that a resident surgeon was not available must be documented in the medical record. This modifier is not intended for use by non-physician providers.

• AS -- Non-physician provider as assistant at surgery: This modifier applies when the assistant at surgery services are provided by a PA, ARNP, or CNS.

Payment information

Medicare reimburses services rendered for assistant at surgery by a physician performing as a surgical assistant at 16 percent of the MPFS amount. Services rendered for assistant at surgery by non-physician providers are reimbursed at 85 percent of 16 percent (i.e., 13.6 percent) of the MPFS amount.

When reporting services provided by non-physician practitioners acting as assistants at surgery, append modifier AS to the procedure code used to report the surgeon’s service.

If a physician appends modifier AS to procedure codes for which he/she acted as assistant at surgery, these codes will be denied (see above for modifiers that should be used by physicians).

Medicare physician fee schedule database (MPFSDB) assistant at surgery payment indicators

The MPFSDB is a file layout that carriers and A/B MACs use to display the total fee schedule amount, related component parts, and payment policy indicators. The assistant at surgery payment indicator describes when assistant at surgery may be paid or not. Valid indicators are:

• 0 = Payment restriction for assistants at surgery applies to this procedure unless supporting documentation is submitted to establish medical necessity.

• 1 = Statutory payment restriction for assistants at surgery applies to this procedure. Assistant at surgery may not be paid.

• 2 = Payment restriction for assistants at surgery does not apply to this procedure. Assistant at surgery may be paid.

• 9 = Concept does not apply.

If multiple services are submitted with modifiers indicating assistants at surgery, each service is independently reviewed (based on the above-listed indicators) to determine payment.


Assistant-at Surgery-Services


For assistant-at-surgery services performed by physicians, the fee schedule amount equals 16 percent of the amount otherwise applicable for the surgical payment.

Contractors may not pay assistants-at-surgery for surgical procedures in which a physician is used as an assistant-at-surgery in fewer than five percent of the cases for that procedure nationally. This is determined through manual reviews.

Procedures billed with the assistant-at-surgery physician modifiers -80, -81, -82, or the AS modifier for physician assistants, nurse practitioners and clinical nurse specialists, are

subject to the assistant-at-surgery policy. Accordingly, pay claims for procedures with these modifiers only if the services of an assistant-at-surgery are authorized.

Medicare’s policies on billing patients in excess of the Medicare allowed amount apply to assistant-at-surgery services. Physicians who knowingly and willfully violate this prohibition and bill a beneficiary for an assistant-at-surgery service for these procedures may be subject to the penalties contained under §1842(j)(2) of the Social Security Act (the Act.) Penalties vary based on the frequency and seriousness of the violation.