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Using modifiers to avoid Medicare audits and enhance revenue
These codes specify procedures and the circumstances under which they are performed, so physicians can optimize Medicare payments.
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Modifiers have become an integral part of the Medicare billing process since the implementation of Physician Payment Reform in 1992. Each two-digit code — numbers, letters or a combination — conveys specific information regarding the procedure or service to which it is appended. The use of modifiers permits the physician to indicate circumstances in which a procedure, as performed, differs in some way from that described by its usual HCPCS/CPT code.
With today’s decreased reimbursements, it is more important than ever to ensure that claims are submitted in a timely manner with the appropriate modifiers to avoid claim delays or denials. Correct use of modifiers can be a crucial step in ensuring payment for covered services that would otherwise be denied if the modifiers were not used.
Multiple services reported to Medicare without the addition of an appropriate modifier could give the appearance that the provider is engaging in the practice of “unbundling.” Appending the appropriate modifiers indicates that the services were performed under circumstances that did not involve this practice.
Following is a list of the most common modifiers used in and ophthalmologist’s offices and ambulatory surgery centers.
Modifier 24
Unrelated service by the same physician during a postoperative period.
Basically used when an examination or evaluation is performed during the global fee period and the reason for the examination or the evaluation is not related to the underlying condition for which the surgery was performed or the surgical episode itself, eg, complications.
For example, modifier 24 would be applicable when a patient presents during the global fee period of cataract surgery complaining of foreign body sensation in the fellow eye. This examination is considered unrelated and billable with modifier 24. Or a diabetic patient returns to the office for a scheduled diabetic retinopathy follow-up visit on the same eye following a ptosis repair. Since the retina follow-up is unrelated to the ptosis repair, this modifier is appropriate.
Modifier 24 cannot be used for postoperative visits related to complications during the global fee period of a surgical procedure.
Modifier 25
Significant, separately identifiable service by the same physician on the day of a minor procedure.
To be used when an examination performed on the day of minor surgery (0- to 10-day global fee) is not just incidental to the surgery but a standalone, separately identifiable examination not part of the minor surgical procedure. The diagnosis no longer has to be different from the examination.
One example is that a patient comes to the office with a complaint of foreign body sensation following trauma. A slit-lamp examination is performed and the foreign body is removed. No other examination of the eye is performed. This is nonbillable.
Or a patient visits the office complaining of pain and foreign body sensation after being hit in the eye with a tree limb. A complete examination is performed to determine the cause of the pain and the foreign body is removed. This examination would be billable with modifier 25 along with the removal of the embedded foreign body.
Modifier 26
Professional component.
Certain diagnostic tests are a combination of a professional and a technical component. When the professional component is reported separately, the service may be identified by adding modifier 26 to the procedure code for the professional service only. Procedures with which this modifier can be used are identified on your Medicare fee disclosure report.
Modifier 26 would be used, for example, for the interpretation only of fluorescein slides or visual fields sent to you by another physician for evaluation only (the patient was not seen). It should also be used to bill for the second IOL calculation before the second eye cataract surgery (code 76519-26).
Modifier 50
Bilateral procedures.
Bilateral surgical procedures performed at the same operative session should be identified by the appropriate procedure code and modifier 50. Payment will be made at 150% of Medicare’s allowed amount for the service.
Some Medicare carriers also permit unilateral diagnostic tests to be billed with modifier 50 (eg, codes 92225, 92226, 92135, 92235, etc.). Payment is then reimbursed at 200% of the Medicare fee schedule amount. Most carriers prefer two line items with the RT, LT modifiers. Check with your individual Medicare carrier before using modifier 50 with diagnostic tests.
Modifier 51
Multiple procedures.
Multiple surgical procedures performed at the same time require the use of modifier 51 to identify the secondary procedures. The primary procedure (the one with the highest allowable) is reported with no modifier. Each additional procedure is identified by adding modifier 51 to the procedure code.
Reimbursement will be based on 100% of the Medicare approved amount for the primary procedure and 50% for the second, third, fourth and fifth procedure.
If more than five procedures are performed and billed at the same time, special hard copy claim submission is required with an explanation of why that many procedures were medically necessary.
Modifier 52
Reduced services.
Sometimes a physician elects to partially reduce or eliminate a certain service or procedure. With the creation of modifier 53 (discontinued procedures), modifier 52 is seldom used in ophthalmology anymore for a surgical procedure.
However, modifier 52 must be applied to bilateral ophthalmic diagnostic tests that are performed on only one eye. For example, a visual field performed on the left eye only would be billed as 92083-52. Most Medicare carriers expect you to reduce your fee by 50% as well. Again, check with your Medicare carrier if you are unsure about the use of this modifier.
Modifier 53
Discontinued procedures.
This is used to designate that a surgical procedure was terminated before completion. Modifier 53 is to be appended to the surgeon’s fee only.
Most Medicare carriers require a claim for a discontinued procedure to be submitted on paper with a copy of the operative note explaining in detail the reason the procedure was discontinued. Remember, a procedure can be aborted only if it has begun. In other words, if the surgical opening has not been prepared, there can be no billing by the surgeon.
Modifier 54
Surgical care only.
The basic coverage requirement for the comanagement of a patient is that when a physician other than the surgeon provides all or part of the postop care of a patient, the surgeon must initiate the notification to Medicare by using modifier 54 with the claim for surgery.
This modifier includes the preoperative and intraoperative services and will result in a 20% reduction of the surgical fee. The date of service should be the same date as the surgical procedure.
Comanagement requires that a transfer-of-care agreement be signed by the patient and filed in the patient’s medical chart.
Modifier 55
Postoperative management only.
If the surgeon provides the initial postop care, which is normally the standard of care, then the surgeon would bill for his or her portion of care by submitting a second line item entry on the claim using the same surgical procedure code and modifier 55. The surgeon must also indicate the number of days for which care was provided for the patient and the date care was relinquished.
When another physician performs all or part of the postop care, the comanager would submit a claim to Medicare with the surgical procedure and modifier 55 using the date of surgery as the date of service. The date care is assumed and the exact number of days of care provided for the patient must also be identified on the claim form.
A copy of the signed transfer of care agreement must also be kept in the comanager’s record.
Modifier 57
Decision for surgery.
Use this modifier when the initial evaluation or consultation during which the surgical decision was made is performed the day before or the day of major surgery. For example, a patient presents with decreased vision after having cataract surgery 18 months ago. The physician determines that the patient has a cloudy capsule and recommends a YAG laser capsulotomy. The patient is then taken to the laser suite and the procedure performed. The office visit is billable with modifier 57. You would also append the modifier to the examination if the YAG was performed the next day.
This modifier should not be used for a re-examination of the patient after the surgical decision has been reached.
Modifier 58
Staged or related procedure or service by same physician during the postoperative period.
This indicates when a service or procedure during the postop period was planned prospectively at the time of the original procedure, more extensive than the original procedure or for therapy following a diagnostic surgical procedure.
This modifier is not to be used to report treatment of a problem that requires a return to the operating room.
For example, a trabeculectomy (code 66170 or 66172) following a trabeculoplasty, iridotomy or iridectomy would require the use of modifier 58. Another example would be a scleral buckle (code 67107 or 67108) following a pneumatic retinopexy or cryopexy. Modifier 58 would be appended to code 67107 or 67108.
The most common example of when to use modifier 58 is for a trabeculectomy patient receiving 5-fluorouracil injections following surgery. Modifier 58 should be appended to code 68200.
The Centers for Medicare & Medicaid Services has specifically stated that modifier 58 does not apply to CPT laser procedures (codes 65855, 66761, 66762, 66821, 67031, 67145, 67201, 67228).
Modifier 59
Distinct procedural service.
This modifier should be used when it is necessary to indicate that a procedure or service was distinct or independent from other services performed on the same day. This may represent a different procedure, surgery or site, or a separate incision, excision, lesion or injury (or area of injury in extensive injuries).
For example, a diagnostic gonioscopy (code 92020) was performed during the exam to check the angles, and an emergency argon laser trabeculoplasty (code 65855) had to be performed to correct the pressure. The gonioscopy should be billed with modifier 59. If the gonioscopy was performed as part of a scheduled ALT, then the gonioscopy would not be billable in addition to the surgery.
Use of this modifier to unbundle surgical procedures that are bundled under CCI is ill-advised because this is a highly audited modifier. Frequently, another already established modifier has been defined that describes a situation more specifically. In the event a more descriptive modifier is available, it should be used in preference to modifier 59.
Modifier 62
Two surgeons.
Co-surgeons will continue to use this code. Reimbursement for this setting is 125% of the fee schedule, which is equally split between the two surgeons.
Co-surgery exists when two physicians perform one surgical procedure. When two surgeons perform separate, distinct surgical procedures, each surgeon bills separately for the surgery they performed.
Modifier 73
Discontinued outpatient hospital/ambulatory surgery center (ASC) procedure prior to the administration of anesthesia.
This modifier was created to identify ASC facility fees for services provided for a scheduled surgery that was canceled before the administration of anesthesia. Medicare has very detailed criteria for the documentation of services provided that must be submitted by the ASC when reimbursement is sought from Medicare. With proper documentation, the facility will be reimbursed approximately 50% of the facility fee for the procedure.
A point to remember is that no reimbursement will be made by Medicare should the surgery be canceled for an elective reason, ie, the patient does not show for the scheduled surgery.
This modifier would be appended to the surgical code in addition to the SG modifier, ambulatory surgical center facility service.
Modifier 74
Discontinued outpatient hospital/ ambulatory surgery center (ASC) procedure after administration of anesthesia.
This was created to identify ASC facility fees for services provided for a scheduled surgery that was canceled after the administration of anesthesia, but before the procedure was completed. Again, Medicare has very detailed criteria for the documentation of services provided that must be submitted by the ASC when reimbursement is sought from Medicare. With proper documentation, the facility will be reimbursed the full facility fee for the procedure.
This modifier would be appended to the surgical code in addition to the SG modifier, ambulatory surgical center facility service.
Modifier 78
Return to the operating room for a related procedure during the postoperative period.
This is to be used when a related surgical procedure is performed during the global fee period that requires a return to the OR. An operating room is defined by Medicare as a place of service specifically equipped and staffed for the sole purpose of performing procedures. It would include a hospital or ASC operating room, a laser suite or a dedicated surgical suite in a physician’s office. It does not include an exam lane or testing room.
If a paracentesis of the anterior chamber for elevated pressure following cataract or glaucoma surgery is performed in the examining lane, it is not billable with modifier 78. When this procedure is performed in a dedicated surgical room in the physician’s office or the ASC, it is billable with this code. When this modifier is used, reimbursement is limited to about 70% of the Medicare allowed amount. The use of modifier 78 does not begin a new global fee period.
Modifier 79
Unrelated procedure or service by the same physician during the postoperative period.
This modifier applies to any unrelated surgical procedure performed during the global fee period, eg, a different condition or a procedure performed on the other eye. This would include cataract surgery on the fellow eye, panretinal photocoagulation on the same eye following a YAG laser procedure, etc.
When a focal laser is performed and followed by a PRP within 90 days, append modifier 79 to the PRP.
Modifiers 80, 82
Assistant surgeon.
Medicare permits assistant-at-surgery services for a limited number of ophthalmological procedures. Medicare no longer permits assistant-at-surgery for cataract procedures.
Assistant-at-surgery services by a physician requires the use of modifier 80. Assistant-at-surgery services performed in a teaching setting will continue to require modifier 82.
Reimbursement for both modifiers 80 and 82 is 16% of the Medicare fee schedule amount. A complete listing of procedures that warrant an assistant at surgery can be obtained from your Medicare carrier.
Modifiers E1, E2, E3, E4
Services reported on the upper and lower lid of each eye.
Medicare has developed separate modifiers to report services performed on the upper and lower eyelid of each eye.
E1: Upper left eyelid
E2: Lower left eyelid
E3: Upper right eyelid
E4: Lower right eyelid
Some examples of procedures that would require these modifiers would be trichiasis epilation; repair of blepharoptosis; excision and repair of eyelid or reconstruction of eyelid; and removal of lesions.
Close attention should be paid to the CPT description of the procedure being performed before using the “E” modifiers. For example, procedure code 67805, excision of chalazion (multiple, different lids) would not require the modifier because the reimbursement for this procedure is based on multiple eyelids as opposed to a single eyelid.
Modifier GA
Advance Beneficiary Notice on file.
This code was created to indicate that a signed advance beneficiary notice (ABN) is on file and in the patient’s record. The advance notice indicates to the patient that while Medicare covers certain procedures when medically necessary, the provider believes that Medicare could consider the services indicated in the notice medically unnecessary and that payment will be the beneficiary’s responsibility. Having the signed ABN permits physicians to bill the patient for any services denied as not medically necessary.
Failure to use this modifier will result in inappropriate beneficiary liability information printed on the patient’s explanation of Medicare benefits. In other words, the patient will be advised that he or she will not be liable for payment of the denied service.
Since refractions are never covered by Medicare, this service does not require an ABN or modifier GA.
Modifier GC
Service performed in part by a resident under the direction of a teaching physician.
Services performed by a resident in a teaching hospital must be identified with modifier GC. The teaching physician must be present during the key elements of the service as documented in the medical record made by the resident and the teaching physician.
Modifier GE
Service performed by a resident without the presence of a teaching physician under the primary care exception.
Lower and mid-level evaluation and management services performed by a resident in a teaching hospital that meets the primary care exception must be identified with modifier GE.
Modifier GY
Item or service statutorily excluded or does not meet the definition of any Medicare benefit.
This is used to bill Medicare for a service that you know is statutorily excluded or not covered by Medicare. Its use would permit you to receive denials required to bill secondary payers.
An example of when to use modifier GY would be when a noncovered corneal relaxing incision or limbal relaxing incision is performed on the same day as cataract surgery. You would append the modifier GY to code 65772 to let Medicare know that this is noncovered service when performed at the same time as cataract surgery. Modifier GY would permit you to receive a Medicare denial in order to bill a secondary payer if applicable.
It is still not clear if Medicare is going to require the use of this new modifier for refractions.
Modifier GZ
Item or service expected to be denied as not reasonable and necessary.
This code informs Medicare that you do not have a signed ABN on file but the patient desires a denial anyway. You would only append this modifier if you do not intend to bill the patient for any denied services.
Modifier QB
Physician providing services in a rural HPSA.
This is to be used for physicians who are eligible for a 10% incentive payment when their services are covered by Medicare and are performed within the geographic boundaries of a rural Health Professional Shortage Area.
Eligibility for the incentive payment is determined by the location where the service is performed, such as the office, patient’s home, nursing home or in a hospital located in an HPSA.
Modifier QB must be reported with the appropriate procedure code for the service performed. A postpayment review will verify that the information on the claim is correct and the physician is eligible for incentive payments.
Modifier QS
Monitored anesthesia care (MAC) service.
Used to identify services related to monitoring the patient’s condition pre-, intra- and postoperatively by an anesthesiologist, certified registered nurse anesthetist (CRNA) or anesthesia assistant. It is an informational modifier that requires an additional anesthesia payment modifier, such as modifier QX or QZ. This modifier is appended to the appropriate anesthesia code 00100, or codes 00140 through 00148 when the six components for MAC are met.
Modifier QU
Physician providing service in an urban HPSA.
Used for physicians who are eligible for a 10% incentive payment when their services are covered by Medicare and are performed within the geographic boundaries of an urban HPSA.
Eligibility for the incentive payment is determined by the location where the service is performed, such as the office, patient’s home, nursing home or in a hospital located in an HPSA.
Modifier QX
Anesthesia service furnished by the medically directed certified registered nurse anesthetist (CRNA).
This must be appended to the anesthesia procedure code to let Medicare know the service was performed by a medically directed CRNA.
When MAC is performed, modifier QX must be used in conjunction with modifier QS as a pricing indicator for the monitored anesthesia care.
Modifier QY
Medical direction of one CRNA by an anesthesiologist.
Used by an anesthesiologist to identify the medical direction of one CRNA. Modifier QY permits reimbursement to be split equally between the anesthesiologist and the CRNA.
Modifier QZ
CRNA service: without medical direction by a physician.
This must be appended to the anesthesia procedure code to inform Medicare the service was performed by a non-medically directed CRNA. When MAC is performed, modifier QZ must be used in conjunction with modifier QS as a pricing indicator for monitored anesthesia care.
Modifier SG
Ambulatory surgical center (ASC) facility service.
This modifier was created to identify ASC facility services filed with Medicare. It is to be used with all services filed by the ASC except when the ASC is charging for supplies, such as V2785 (processing, preserving and transporting of corneal tissue).
Modifier TC
Technical component only.
Modifier TC is to be used with the appropriate procedure code to let Medicare know that you are billing for the “technical only” component of the service provided. This can apply to any diagnostic test and is normally not used for a test performed inside the clinic. When it is necessary to purchase the technical component from an outside source, modifier TC is required.
Other modifiers
There are other modifiers that might apply such as hospital services or teaching physicians. You should review the complete list of modifiers found in the CPT 2002 coding book for additional modifiers and their use.
For Your Information:
- E. Ann Rose is president of Rose & Associates. She can be reached at 402 W. Wheatland, Suite 150, Duncanville, TX 75116; (800) 720-9667; fax: (972) 780-8546; e-mail: results@roseandassociates.com.