Podcast Episode 10: Modifiers (Part II)
Episode Summary: Modifiers are two-digit codes that can be appended to a CPT code in special situations to justify payment for the service when payment otherwise would be denied. Understanding the proper use of modifiers can lead to better reimbursement. Hosts Neal Sheth and Dr. Piyush Sheth explore some of the most common modifiers used.
Episode Transcript:
NEAL SHETH: . Today we're going to round out our discussion of CPT modifiers by talking about Surgical modifiers. In the previous episode, we discussed modifiers that can be appended to Evaluation and Management services. If you haven’t listened to it yet, I highly recommend you start there and then return to this episode.
PIYUSH SHETH: Surgical modifiers can be broadly classified into those that deal with assistants and co-surgeons, increased or reduced procedural services, multiple or distinct procedures, repeat procedures or return to the operating room procedures, and staged procedures. We are not going to go through every surgical modifier and its uses. Instead, we'll hit the top ones.
NEAL: So, where do you want to start?
PIYUSH: Well, let’s start with Assistant Surgeon modifiers. The 80, 81, and 82 modifiers require the assistant surgeon to be a physician, either an MD or a DO. If the assistant surgeon provides full assistance to the primary surgeon, you should use modifier 80. If the assistant surgeon provided minimal assistance to the primary surgeon, use modifier 81.
A special situation occurs in teaching institutions. Usually, residents are available to assist but if a qualified resident is not available and instead a physician provides the assistance, modifier 82 would be used. You would also have to submit documentation stating that a qualified resident was not available at the teaching institution.
On other occasions, a physician is not available to offer assistant services. In those cases where a non-physician provider is an assistant at surgery such as a Physician Assistant, Advanced Registered Nurse Practitioner, or Certified Nurse Specialist, you would use modifier AS.
All these modifiers are appended to the CPT code billed by the assistant. The reimbursement is 16% of the Physician Fee Schedule for modifiers 80 and 82. When a non-physician provider is the assistant and modifier AS is used, payment is 85% of 16% since non-physician providers are paid at 85% of the Physician Fee Schedule. Of note is that modifier 81 is generally not billed for Medicare patients.
NEAL: What about co-surgeons? Do they require distinctive modifiers than those used for assistant surgeons?
PIYUSH: Co-surgeons are 2 surgeons of different specialties who work together as primary surgeons performing distinct parts of a procedure based on their specialty. Consider a gastroenterologist and a general surgeon who work together to insert a PEG feeding tube. Each specialist performs their respective parts of the procedure. In this scenario, both physicians can bill for the PEG feeding tube insertion with modifier 62. Both physicians will then each receive 62% of the Physician Fee Schedule payment.
NEAL: So, a total payment of 124% is made, split 50/50 between the co-surgeons?
PIYUSH: Yep. This is one of the few instances where a payment is made that is more than the Physician Fee Schedule.
One last thing about this class of modifiers. In a surgical team concept scenario where services of several physicians, often of different specialties, plus other highly skilled specially trained personnel and various types of complex equipment are utilized, you would use modifier 66. You may have seen surgeries of this type sensationalized in movies or on medical dramas such as Gray’s Anatomy.
NEAL: Okay, so this feeds into an area of interest for me: modifiers that can directly affect the payment of a CPT code. Let’s say you schedule a patient for a laparoscopic gallbladder removal and after you start the surgery it becomes painfully clear that the surgery is going to be much more difficult than expected due to extensive inflammation. A surgery that usually takes you 45 minutes to perform becomes a 3-hour ordeal. It seems logical that you should get a higher payment for the additional work and effort.
PIYUSH: Right. That’s where modifier 22 comes in: when the work required to perform a procedural service is substantially greater than typically required. To correctly use this modifier, you need to submit the operative note with the bill, and that operative note must document the reason for the greater work involved, such as increased intensity or time of the procedure, technical difficulty of the procedure, severity of the patient’s condition, or physical and mental effort required. You should also submit a cover letter with the bill listing the amount of specific additional payment you are requesting. That’s hard to quantify but a best guess is preferrable otherwise the additional payment will be significantly minimized by the insurance carrier.
NEAL: That sounds like a lot of hoops to jump through.
PIYUSH: Yes, but the reward is sometimes worth it.
NEAL: On the opposite side of the spectrum, what about this scenario: You begin say a colonoscopy and the patient has a very tight turn that you just can’t navigate around without risking perforation of the colon. You stop the procedure and pull the endoscope out. How do you deal with this?
PIYUSH: In this situation you would use either modifier 52 or 53. For most procedures that you partially perform, you will use the Reduced Services modifier 52. You’ll again need to submit documentation with the bill to substantiate the reason for the reduced service and this will lead to a lower payment. However, your particular example of colonoscopies is different. If the reduced service colonoscopy was for a therapeutic procedure, for example control of a bleeding lesion, you would use modifier 52. But, if the reduced service colonoscopy was a screening or diagnostic procedure, you would use the Discontinued Procedure modifier 53. The official definition for modifier 53 states that it “applies when a physician elects to terminate early a surgery or diagnostic procedure due to extenuating circumstances or those that threaten the well-being of the patient.”
NEAL: Wait. I’m confused. Why have different modifiers for terminating a colonoscopy early based on whether it is screening, diagnostic, or therapeutic?
PIYUSH: Yeah. I wish I had a logical answer as to why, but I also struggle with modifier 52 and 53 and when to use each one in certain circumstance. Here’s another example that actually makes sense in using modifier 52 and not 53. Let’s say a procedure code defines a bilateral procedure but you perform it only as a unilateral procedure, you would use modifier 52. CPT code 27395 – Lengthening of the hamstring tendon, multiple, bilateral, is such a code. When it is performed only on one side, use modifier 52 and don’t forget to use one of the laterality modifiers: LT for left or RT for right.
In the reverse situation, if a procedure is usually unilateral and you perform it bilaterally, you would use modifier 50 and the payment for that code will be at 150%.
NEAL: OK. I think I understand it somewhat.
PIYUSH: Now let’s get into some tricky scenarios.
NEAL: What! Things get even trickier?
PIYUSH: ‘You bet your bippy’ as Walter Jacobson used to say on the evening news in Chicago. Here we go. I’m performing a partial colon resection for cancer in the distal transverse colon and the cancer has extended onto the stomach and I perform an en bloc wedge resection of the stomach. What are your thoughts on this Neal?
NEAL: For one, the surgery was more complex and required the addition of another surgical procedure. I would think that you can bill for the second procedure also.
PIYUSH: You sure can. Modifier 51 comes to the rescue. In this scenario, you are performing an additional procedure through the same incision at the time of another surgery. The partial colectomy has about 40 RVUs and a gastric wedge resection for malignancy has 36. When you add modifier 51 to a secondary procedure, you drop payment for it by 50% so you would want to bill the highest RVU procedure as the primary procedure and the lower RVU procedure as the secondary procedure. In this particular scenario since the higher RVU is the partial colectomy, bill that without a modifier and then bill the gastric wedge resection with modifier 51 to get the highest reimbursement possible. Modifier 51 would also be applied to tertiary procedures and payment for that would drop down to 25% since each additional procedure is cut another 50%.
But now let's really make this confusing. Before you finish the surgery, you notice the patient has a malignant appearing skin lesion on his shoulder. You decide to excise a 2.2 cm diameter malignant skin lesion on the shoulder. How would you bill that?
NEAL: I got a feeling you’re going to tell me it’s not modifier 51.
PIYUSH: Ah, your 6th sense is right. For this part of the procedure, you would use modifier 59. This modifier is used when a “distinct procedure” is performed. A distinct procedure is one that is at a different session, different site or organ system, or involves a separate incision. There are 4 sub modifiers that are to be used with modifier 59. These are XE for separate encounter same day, XS for separate structure or organ, XP for separate practitioner same day, and XU for unusual non-overlapping service. To be honest, sometimes even I am confused on when to use modifier 51 and when to use modifier 59. There are times you even have to use both modifiers such as when you perform a colonoscopy and see two conditions that are each managed with different techniques. Let’s say during colonoscopy you see a polyp and this is removed by snare cautery excision and you also notice an arteriovenous malformation that is treated by thermal ablation. You would add both modifier 51 and 59 to the ablation code. When faced with these types of complex coding situations, your certified professional coder can be invaluable.
NEAL: Hmm. Clear as mud.
PIYUSH: Ready to switch gears again?
NEAL: Sure, what do you have in mind?
PIYUSH: How about the following scenarios?
A surgeon inserts a chest tube for a pneumothorax but later that day the patient is worse and an X-ray shows that the chest tube is not treating the pneumothorax and the surgeon inserts a second chest tube. Essentially that surgeon has performed the same procedure on the same patient on the same day. How do you bill this?
NEAL: That’s easy. Modifier 76. Repeat procedure by the same physician on the same day.
PIYUSH: Nice. What if one of his partners inserts the second chest tube?
NEAL: Still modifier 76 because Medicare considers providers of the same specialty and in the same group as the same physician.
PIYUSH: Awesome! What if another physician like a hospitalist inserts the second chest tube?
NEAL: Modifier 77. Repeat procedure by another physician on the same day.
PIYUSH: Correct. What if a surgeon performs a liver resection for cancer and 10 days later he places an infusaport for chemotherapy access, how would you bill for the infusaport since the liver resection has a 90-day global period?
NEAL: Since the infusaport insertion is not due to a complication from the initial surgery, I’m guessing that there is a modifier for this situation.
PIYUSH: I like your reasoning. To understand this question better, you need some basic information. The concept you need to grasp is the difference between related procedures and staged procedures within a global period.
Related procedures are those that treat complications from the original surgery or assist with expected developments in the healing process. They also include procedures that would not have been needed if the original surgery had never been performed. Reimbursement for related procedures is already included in the global surgery fee for the original surgery so these cannot be billed separately within the global period. An example of this is if after the liver resection the patient develops necrosis of the skin at the surgical incision and that necrosis needs debridement. Here the distinction is that if the wound was debrided at the bedside, it would not be billable. But if the same patient instead had intraabdominal bleeding and the surgeon had to take him back to the operating room, then modifier 78 “unplanned return to the operating room for a related procedure during a global period” can be used.
Staged procedures on the other hand are those that are planned or anticipated and are being performed for the same diagnosis as the original procedure, or those that are more extensive than the first procedure because the desired outcome was not accomplished, or those performed to facilitate therapy. In our scenario question, since the infusaport is being placed for the same diagnosis and it facilitates therapy and is planned, we can use modifier 58.
NEAL: But what if during a global period a patient needs a surgical procedure that is unrelated to the original procedure. Let’s say the liver resection patient develops appendicitis 1 month after the surgery and needs an appendectomy. What then?
PIYUSH: This is a scenario for modifier 79 – “unrelated procedure by the same physician during the global period”.
NEAL: Well, we covered a lot of ground. These concepts can be confusing, and you may need to listen to this episode a few times to understand them better.
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