Podcast Episode 9: Modifiers (Part I)

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.

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Episode Transcript:

[INTRO]

NEAL SHETH: Hi dad.

PIYUSH SHETH: Hi Neal.

NEAL: How do you code and bill when a surgery takes twice as long as normal? Can you code and bill for an Evaluation and Management service on the same day as a Procedural service? How do you code for a partially completed service? And how do you code for procedures that have laterality such as inguinal hernia repairs?

We’ve talked about ICD and CPT codes on past episodes, but there is a third important component to coding: Modifiers. So, we thought it would be a good idea to dive into Modifiers. Today's episode will focus on modifiers that can be appended to Evaluation and Management CPT codes and possibly lead to increased reimbursements, while our next episode will focus on surgical modifiers.

First off, what are modifiers? Simply put, modifiers are appended to CPT codes and serve to clarify how a CPT code is used. The idea behind them is to further customize a CPT code beyond what is listed in the CPT code description. In addition to being required in many situations, their use can minimize claim denials. There are two types: Level 1 modifiers which are updated by the American Medical Association annually, and Level 2 modifiers, also known as HCPCS modifiers, which are updated by CMS. HCPCS stands for Healthcare Common Procedural Coding System.

So, now that we’ve got a basic definition of modifiers, let’s get started.

PIYUSH: Sure. There is an exhaustive list of modifiers in the CPT code book as well as the HCPCS code book. It’s important to note here that there are a lot of varieties of modifiers. Some modifiers are appended to Evaluation and Management CPT codes and others are appended to procedural CPT codes, and yet others are appended to anesthesia services, ambulance services, hospice services, laboratory services, quality reporting incentive programs, and telehealth services to name a few. This episode and the next one is only going to deal with those modifiers that are confusing and often misused. I hope that we can clear up some of that confusion, so everyone can use these modifiers with confidence.

NEAL: Okay. Where do you want to start?

PIYUSH: How about Evaluation and Management modifiers?

NEAL: Sure. We talked about office and hospital visit CPT codes back in Episode 2, and there are modifiers that can be appended to those types of visit codes, right?

PIYUSH: Yeah. The easiest modifier to talk about is the AI modifier. It is designated for Medicare patients only and identifies the "Principal Physician of Record.” It’s only to be used once at the time of admission by the admitting or attending physician who oversees the patient's care. Let’s say you have a Medicare patient that you are admitting for abdominal pain. You see the patient in the ER and admit them to the hospital for further workup. You consult OB/Gyn to help rule out endometriosis. On the day of admission since you are the admitting physician that will oversee this patient’s care, you would append modifier AI to your CPT E/M code. The OB/Gyn would not use the AI modifier.

NEAL: That’s straightforward. And it seems important and makes it easy for CMS to determine who is managing a patient’s care.

PIYUSH: Here is another straightforward one. Modifier 24. This is used for “an unrelated E/M service by the same physician during a postoperative period”. How do you think this one would be used?

NEAL: Well, I know that certain procedures have global periods of 10 or 90 days, and you cannot bill an E/M visit during that global period. Modifier 24 sounds like it can be used to bill for an E/M visit during the global period.

PIYUSH: You’re absolutely right. There is, however, an important caveat. Modifier 24 can only be used if the E/M visit is for a diagnosis unrelated to the original procedure.

NEAL: Ah! So, it gets around the issue of not being able to bill during an existing global period!

PIYUSH: Yep, as an example, a few years ago I performed a laparoscopic appendectomy on a patient. This procedure has a 90-day global period. The patient did well and was sent home the next day. A week later, the patient came back to the ER with abdominal pain. Turned out, the patient had bleeding from his spleen and a splenectomy was performed. Bleeding from the spleen was completely unrelated to the appendectomy surgery since those two organs are on completely opposite sides of the abdomen. Therefore, the splenectomy would be considered an unrelated procedure during a previous procedure global period. I was able to use modifier 24 on the ER visit CPT code and a surgical modifier on the splenectomy surgery code to get payment for both.

NEAL: So, you got payment for services within a global period! That’s great. I’m beginning to like modifiers.

PIYUSH: Me too. If you use modifiers properly, they can be of significant benefit.

NEAL: The next modifier on our list is Modifier 25. The CPT code book states it is used for “a significant, separately identifiable E/M service by the same physician on the same day of a minor surgery or endoscopy.” Hmm, I’m guessing that the “significant, separately identifiable E/M service" part of that definition is going to be tricky.

PIYUSH: This one is indeed a little tricky. It is often misunderstood and used improperly to get paid for both the E/M service and a procedural service. The key words you must keep in mind are “significant, separately identifiable.” Let me give you some examples to clarify this. Let’s say a patient presents to the office with a thrombosed hemorrhoid. You decide to perform an immediate incisional drainage of the thrombosed hemorrhoid in the office. The only billable service would be for the incisional drainage of the thrombosed hemorrhoid. You can’t bill an E/M service code. In contrast, here is a different scenario. A patient arrives to the endoscopy suite for a scheduled outpatient colonoscopy. He complains of a cough and chest pain that started that morning. You evaluate him for the chest pain, and he is found to have pulled a chest muscle due to excessive coughing. You proceed with the colonoscopy. You can bill for both the E/M service for evaluation of the chest pain with modifier 25, and the colonoscopy procedural code. Both will be reimbursed.

NEAL: Wow. Another modifier that can increase reimbursement in certain situations.  

PIYUSH: Don’t get your hopes up. There are modifiers that can decrease reimbursement. We’ll get to those on the next episode.  

I want to take a little detour to explain global periods. Procedures that have a “10-day” global period actually have an 11-day period where you cannot bill an E/M service. The day of the procedure and the 10 days that follow. For “90-day” global periods, there is a 92-day period where you cannot bill an E/M service. This includes the day prior to the procedure, the day of the procedure, and the 90 days that follow. 

So, we saw that modifier 25 can be used to bill an E/M service on the day of a minor procedure or endoscopy. Modifier 57 is the counterpart and is used to bill an E/M service where an initial decision to perform major surgery is made. I use this modifier for example when I admit a patient with acute cholecystitis and schedule them for surgery for the next day. I code the initial admission visit with modifier 57. 

NEAL: It really pays to know these finer points.  

PIYUSH: Uh-huh. If you don’t know the “how” in using modifiers, you’ll be missing out on reimbursement. Also, if you don’t use the appropriate modifier, your claim can be denied. Having to resubmit claims is quite time consuming. Submitting clean claims initially is more efficient. 

NEAL: I got a question for you. What about the new modifiers FS and FT developed by CMS for Shared/Split visits that we talked about briefly in Episode 8? 

PIYUSH: This is a great example of modifiers that will be used mostly for data collection and analysis by CMS. Just to remind our listeners, Shared/Split services are performed in a facility setting where an NPP and a physician both perform services on a patient and the work each performed is combined to select a CPT code. Modifier FS is to be appended to all Shared/Split services while modifier FT is to be appended to critical care services performed by a surgeon during a global period. Please listen to Episode 8 where we discuss how to use these modifiers. In 2022, the documentation requirements to be able to use these modifiers were made more stringent. In general, a shared/split service can lead to higher reimbursement but with the new stringent requirements, only time will tell if physicians can leverage the modifiers for higher reimbursement. In 2023, CMS is proposing that only time is to be used to determine who can bill for a shared/split service. 

NEAL: Doesn’t that mean that it will be more difficult for a physician to bill a shared / split service. That means that more services will be billed at the NPP level than the physician level and since NPP’s are paid at 85% of the physician fee schedule, CMS will “save” more money. 

PIYUSH: Money is often the driving force for changes in coding and billing rules. But don’t forget, this will have a ripple effect and how this translates to the quality of care provided to patients is yet to be determined. Something to think about is the legal aspect. Since physicians supervise NPP’s, what is their legal risk should a patient develop complications and was only seen by the NPP. To be honest, I’m not sure I want to take on that liability. 

NEAL: So, to bring it full circle, it really seems that on a fundamental level, modifiers exist to help reconcile those special situations where the reality of providing healthcare services isn’t accounted for by the CPT code or medical documentation rules. 

Alright. It seems as if a can of worms has been opened. Thanks for your insight into these modifiers, dad. I can’t wait to hear about surgical modifiers in the next episode. 

Now, before we leave, I’d like to talk about one more thing... 

PIYUSH: What’s that? 

NEAL: The book of course! So, dear listener, you should know that before this podcast even existed, my dad put together a book distilling all of his years of coding knowledge into one easy-to-use resource. It’s called Coding Solutions, General Surgery, and it is THE, and I mean THE, resource on general surgery coding. Now available in a brand new, 2022 edition, I can personally attest to how easy it makes some of the trickiest coding situations. Heck, it even helped me pass my General Surgery Coding Certification exam! Why don’t you tell us a little more about the book? 

PIYUSH: Sure! I wrote this book out of frustration. Frustration that there are too many costly and decentralized resources for rules relating to medical documentation and coding, but nothing truly specialized for general surgery. If I needed a diagnosis code, I had to track down an ICD code book. If I needed a procedural or E/M code, I had to find a CPT code book. And let's not forget the 1995 and 1997 Documentation Guidelines, the 2021 Office and Outpatient Documentation and Billing Guidelines, the Federal Register, and annual Final Rule Changes from CMS. I also needed to know Relative Value Units since I’m paid by my employer based on workRVU’s for services I provide. There was no single resource for all of this information, so I decided to make one. Coding Solutions General Surgery is a book that is less than 150 pages long, so it is very portable. It contains ICD and CPT codes used in general surgery collated by organ systems. Examples of chapters include appendix, breast, Gallbladder, GI, Thyroid, Trauma, and skin and soft tissue. If you need the diagnosis and procedural codes for a gallbladder procedure, simply go to the Gallbladder chapter. I’m serious when I say that 99% of the codes I use for my general surgery, GI endoscopy, surgical oncology, trauma, and wound care practice is in the book. On top of that, you’ve probably realized that medical documentation is very complicated, and I have comprehensive sections on Office and Hospital service documentation including Critical Care and Shared / Split services to name a few. I’m very passionate about accuracy and efficiency in medical documentation and coding and I’ve put that passion into this book. I update the book annually with changes in documentation rules, ICD codes, CPT codes, and workRVU’s. If you are a general surgeon or NPP, or a coder for a general surgery practice, this is a must reference. And to boot, it is much cheaper than buying all the other resources. 

NEAL: Now, for those of you interested in buying the book, it is available at Amazon. You can find a link to it both on our website, unravelingmedicalcoding.com, and in the show notes of this episode. For those of you who listen to this episode and wish that you could tap into an excellent general surgery coding resource ... well, now you can! 

We hope you enjoyed this episode. Please check out the other episodes. Don’t forget to rate and review us and subscribe to Unraveling Medical Coding from wherever you get your podcasts. Also, please share this podcast with friends or colleagues who you feel would benefit from learning about medical coding and documentation. Stay safe and stay healthy.