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Okay, modifiers and level 2 HCPCS. So Linda writes, ìCan you please cover the determining
fact between using modifiers 22, 23, 24, 25, etc and the level 2 HCPCS codes? Is the ones
that go on E&M level and the others on the procedure codes things?î ñ Thanks, Linda.
Okay so thatís you know, obviously a big, huge topic. I do have a Modifiers class on
demand thatís available on the website. We also have, as many people have taken advantage
of the modifier grid that Iím about to show you. And this, you can get from the site.
Iíll show you where to get that from. If you go to Free Coding Tools and Downloads,
youíll see the CPT Modifier Decision Grid Tool. You just pop in your name and email
and youíll be able to download it. Itís a PDF and itíll look like this.
What I did with this grid and this presentation that goes along with it is I explailn modifiers
by family versus a numerical order. So first of all, on the slide you know, modifier 22
is gone. That doesnít exist anymore. But if you look at it this way, that will really
help you know when you need to append modifiers and what situation. So I just wanted to briefly
go over this.
The families or the groups of modifiers that Iíve identifiedÖ maybe you can see different
familiesÖ are the first big one, the Global Package modifier familiy. If a patient had
a surgery and theyíre in a global period, your typical major surgery has a 90 day global
period. Some other pairs other than Medicare actually can have a 120-day global period.
And what that means is during that time after the surgery, when they come in for their routine
follow up, that physicianís office cannot bill and E&M because itís been bundled into
the fee they got for the surgery.
But sometimes, thereís exceptions. Maybe, theyíre in the global period but theyíre
coming in for another reason. And thatís what this whole first section of the global
package modifiers on this grid is talking about. 24, if itís an unrelated E&M service
by the same physician that did the surgery, you would use 24 on your E&M. If it was the
day that they decided to do the surgery, youíre allowed to get paid for that. You donít get
paid for the pre-op visit. So 57 helps tell the payer, ìLook, I know this is on the same
claim as the surgery and youíre going to think itís pre-op and youíer going to bundled
it in and not pay it. Iím putting 57 on to tell you that this is not the pre-op visit
so pay it, okay?î
58 is the staged or related procedure so theyÖ the one the always comes to mind is cleft
palate repair. Itís very unlikely that theyíre going to be able to do the whole entire surgery
in one operative session. So they know, maybe in 45 days or 6 weeks, theyíre going to do
stage 2 of the prcoedure. Because thatís within the 90 days of the first procedure,
they would need to use 58 on the second one to say that itís you know, the 2nd stage.
Now the global period will reset from the date of the second surgery.
76 ñ repeat procedures, 77 ñ repeat by another physician, 78 ñ return to the OR for a related
one, 79 ñ unrelated procedure. So maybe they had hip surgery and they fell and broke the
other hip. So itís unrelated to the first one but theyíre being seen by the same specialist
so they would use 79.
So you get the idea. Understand it by family and that will help you know when you need
to even consider modifers at all. If theyríe not in the global period then you can just
skip over this whole group that we just did.
Then we have bundling or CCI modifiers. We did a.. on a previous webinar, a bitÖ a segment
on CCI so you might want to go back and look for that. Thatís correct coding intiative.
In a nutshell, they give us pairs of codes and let us know that these two codes should
not be billed together becuase they consider one bundled into the other. But there are
exceptions to that so thatís where some of these modifiers come in, especially 59.
One of theÖ Linda had asked about 59 specifically and I had answered it on the discussion board
is 59 as to do with bundling. If the two codes, I think her specific question was for intramuscular
injections. If they did 2 intramuscular injections, should you put 59 on the second one? And the
answer you know, I felt was no because if you see 2 separate injectsion, you wouldnít
expect them to be bundled into each other. So 59 is to say, ìI know you normallyÖ these
are normally bundled but in this case, they shouldnít be bundled.î
So an example that I use for that is a patient having an oophorectomyÖ you know, theyíre
going to remove the ovary. And then they close them up and then a few hours a later, something
is going wrong. They got to go back in and open them up and do an exploratory lap to
see whatís going on. Now, the laparotomy is bundledinto the oophorectomy. But because
they did a second one later on, that one they can bill for. So they have to put 59 on it
because otherwise, the payerís going to bundle it in and say, ìNo, thatísÖ you know, that
hits a CCI edit.î So youíd put 59 on the laparotomy to say that this is a distinct
procedural service from the other one Iím normally bundled in to.
Letís see, then weíve got E&M only ones. Those are pretty self-explanatory. Weíve
got numer of surgeon modifiers so I think you can kind of read that and get the idea.
So anyway, I just wanted to you know, draw your attention to this modifier grid. Itís
a free download. The class that goes along with it, the on demand class is you know,
I think one of my very first works I did and I presented that at the AAPC conference for
several years in a row and I get asked to do that in a lot of local chapters. So hopefully,
you will enjoy that.
Alicia: And itís free.
Laureen: Itís free. Oh and Iíll just give you an idea of how I teach you to mark up
your Appendix A and Ruth brought this out on the forums as well that this is where they
actually live, okay. There is a shortened list on the inside cover of CPT but this is
whereÖ Appendix A is where the modifier descriptions live. Did I say modifier 22 is gone? I meant
21. I just realized I had said that. And so what I do is I took my grid and I would do
my arrows. You know, if an arrow is going up into the right, it mens that you know,
without the modifier, it probably wouldnít get considered payment. If the arrow goes
down then Iím expecting the fee to go down because the name of the presentation is Modifiers:
Itís All About the Money. If you think about how appending that modifier to the code will
affect the reimbursement of it, that will help you realize when you need to use it or
not. So anyway, youíll get a copy of this if you do that on demand class as well.