Using Modifiers effectively in Family Practice and Surgery

Using Modifiers effectively in Family Practice and Surgery

The National Correct Coding Initiative (NCCI) was developed by the Centers for Medicare & Medicaid Services (CMS) in 2010. This was formulated to promote national coding methodologies and to control improper coding. The purpose of NCCI edits is to stop improper payments when incorrect code combinations are used. Modifiers are simple two-character designators that alert billing professionals and claims handlers of a change in how the code for a service, treatment, or procedure should be applied on the claim. Using modifiers correctly will add accuracy to your billing practices. In addition, modifiers detail the record of the encounter.


Four New Modifiers to Replace Modifier 59

Modifier 59 - Family Practice and SurgeryModifier 59 is used to define as a “Distinct Procedure Service.” These are services and procedures performed by a physician that are not usually reported together, but are separately billable under certain circumstances. Modifier 59 is added to a CPT code to indicate that the service is distinct and separate from another service or procedure. This modifier is the most used modifier in the billing world, and it is often the most abused. CMS has identified a need to make this modifier more specific, and with ICD-10, changes have occurred to reduce overpayment errors.

Modifier 59 is not going away completely, but new options are available. Before using 59, the biller should see if it can be replaced with XE, XS, XP, and XU. With modifier XE, this means a separate encounter and service that is distinct because it occurred during a different encounter. Modifier XP refers to a separate practitioner. It alerts claims handlers that the service is distinct because it was performed by a different provider. When a separate structure is involved, you must use modifier XS. This indicates that the service or procedure involves a separate structure or organ. Finally, with XU, the unusual non-overlapping services is considered. This modifier denotes the use of a service that does not overlap usual components of the main service.

Use of Other Modifiers

  • Modifier 22 – This denotes increased procedural services, and it may be used with computed tomography (CT) codes when additional slices are required.
  • Modifier 24 – Specifies unrelated E&M service by the same physician during a postoperative time period.
  • Modifier 25 – Corresponds to a significant and separately identified E&M service by the same doctor on the same day as the other service or procedure.
  • Modifier 27 – Specifies increased procedural services.
  • Modifier 33 – Used for preventive services, and claims billed with this are not subject to specific ICD-10 inclusion and/or exclusion criteria.
  • Modifier 47 – Shows that anesthesia was given by the surgeon, and is not to be used with anesthesia codes.
  • Modifier 50 – Denotes a bilateral procedure.
  • Modifier 51 – Shows the claims handler that multiple procedures were performed.
  • Modifier 52 – Indicates reduced services, and it requires “by report” documentation for certain surgery codes.
  • Modifier 53 – Specifies a discontinued procedure, and it requires “by report” documentation.
  • Modifier 54 – This is a “surgical care only” code.
  • Modifier 55 – Used for postoperative management only.
  • Modifier 58 – Indicates a staged or related procedure or service by the same provider during the postoperative time period. It can be used with codes 15002 thru 15429 to address subsequent parts of the staged procedure.
  • Modifier 62 – Specifies that two surgeons were involved in the procedure.
  • Modifier 73 – Used by a hospital outpatient department or surgical center only, and it requires “by report” documentation.
  • Modifier 76 – Used when a repeat service or procedure is performed by the same physician.
  • Modifier 78 – Used when there is an unplanned return to the procedure room or surgical center by the same physician following the initial surgery/procedure.
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