Hi, this is Cindy. Today we're going to talk
about Chapter 3, the Modifiers. Modifiers
are reported along with the CPT code to
indicate that something's happened that
modifies the service or the procedure
but does not change its basic definition.
Modifiers are two character codes. When you
hear lectures about them or read about
them in the textbook, you're going to see
a dash (-) that separates the five character
CPT code from the two character Modifier,
such as the example there: 49520-50.
The dash (-) is not used when you're
filing a claim or in most electronic
coding programs (software). In that case, you would
see 4952950 (no dash). Everyone knows the first
five characters are the CPT code and the
last two would be a modifier. Payers have
different rules regarding modifiers and
it really is up to the coder
and/or the biller to know each payer's
specifications; what will and will not
trigger an edit or a denial. Different
sets of modifiers apply to different
services and settings. Some are specific
to physicians, some are specific to
hospital outpatient so if you read the
definition of the modifier, it really
tells you in what case, in which
circumstance that modifier might be used.
For example, -25 is used only with
the evaluation and management (E&M) codes
and those are codes when the physician's
providing a service. Modifiers can
decrease payment or they can increase
payment. It really depends on the
modifier. When you are taking a test with
me in this course, when you work in the
real world, you have your codebook as
your reference. The modifiers are used
inside the front cover of the CPT code
book with all the definitions. It's short
(the one on the inside front cover) those are
short definitions. The full definition or
description is in Appendix A in the back
of the CPT code book. They're also found
in Figure 3.1 in their coding
textbook and Level two national codes
there's some listed on the back of the
front cover but they're also found in
their entirety on the CMS website
There's other uses for modifiers that we
won't spend a lot of time on in this
class. I just want you to know about them.
One is modifier -33 which is preventive
services but it's preventive services
under certain criteria so that is on
page 50 in your (2016) coding textbook.
Category II modifiers have to do with
performance measurement and different
tracking there. The physical status
modifiers are only used with the
anesthesia CPT codes and then there are
CMS guidelines for Medicare transmittals
that are very specific. So these as I
said we will not be talking about much
in this class. I just want you to know
what they are so when a coder is trying
to decide whether or not to use a
modifier, you ask yourself two questions:
Will the modifier add more information
regarding the anatomic site, for example,
is it left or right side of the body? Is
it a specific toe, is it our finger and if so,
which is it? The next question is: will a
modifier help to eliminate the
appearance of duplicate billing or the
appearance of unbundling? Because of the
way the global package and the way
procedures are packaged by the insurance
companies for payment, if a doctor does
something that looks like it's not quite
following that guideline or that rule by
the payer, you can have a denial so the
doctor is trying to avoid the denial by
explaining ahead of time what happened
and why it appears as though it was
unbundled and of course the doctor is
not using the modifiers. That code was
choosing the modifier. What the doctors
do is provide you with the documentation
so that you know which modifier to
choose. Let's look at some case studies
and these are taken from Chapter 3
Review. First one's #2. On April 1,
a patient was treated for a tibial
fracture and on May 15th, the
patient returned (to the hospital) complaining of pain at
the site of the external fixator. The
surgeon immediately returns the patient
to the OR (Operating Room)
to remove the fixator. What modifier
would be appended to the removal of the
fixator due to pain? Well the setting is
a hospital. The event is an unplanned
return to the OR within the
post-operative period for a related
procedure, same doctor. so you're going to
be looking at your dates of service,
April 1st to May 15th. That's about
six weeks. The post-op period for most
payers is 90 days so the physician is
still in that 90-day postoperatove period and
here he is going back to the OR. So he (the physician)
has to explain to the insurance company
through the modifiers what happened, why
they're seeing a bill again for going
back to the OR and modifier- 78 is the
unplanned return to the OR, within
the post-op period for a related
procedure by the same physician.
Modifiers finish the story. If you think
of a case study as giving you a few
lines to tell a story, the modifier
allows you to finish the story, to choose
a way to describe what's happened that
will explain to the payer why they're
seeing another charge. Let's try another
one. Chapter 3 #6, the
patient underwent a percutaneous core needle
biopsy of the right breast with the use
of stereotactic guidance. I'm going to
walk you through this because I know we
haven't done a lot of coding in the book
yet but i want to show you just how you
use the index to find this and that
gives you your code. Then you can
look at a modifier. Now, i know that when
you're doing a biopsy of the right
breast, the modifier you're going to need
is "RT" signifying it is the right
breast. You have to read the code
description to be sure that you're not
using a modify you don't need to use. For
example, if your code description said
right breast, well then you wouldn't need
to add a modifier.l If your description
said unilateral or bilateral and we'll
see another example of this later on, you
don't want to add a modifier that says
its bilateral. So you really have to read
your code description
to know whether or not you will even use
a modifier. In this case, I started in
the index with the main term" biopsy" and
followed it through. I have my pathway
there and it told me that the choice
would be either 19081 or 19082. So
when I went to the CPT book. looked at
that those two codes and I see that 19081
is the first lesion 19082 would
be each additional lesion. My case study
only tells me one lesion so I believe
our code would be 19081 and if we use
the right breast modifier, it would come
out 19081-RT. As I just mentioned to
you, when you are filing a claim or in
electronic computer-assisted coding (software),
you're not going to see that dash (-). It
would just say 19081RT. Let's try
another one. Patient was taken to the
outpatient surgery suite for an
excisional debridement of the skin that
extended into the muscle. The patient was
prepared for surgery but before
anesthesia was administered. the
physician was called for an emergency
surgery of a trauma patient and the
outpatient surgery was cancelled.
Assign the code assigned by the
hospital (i.e. not the doctor). Again you must read
these very carefully because if this had
said assign the code as assigned by
the doctor, it would be different. So
we're going to look at this one first,
assigned by the hospital and we're going
to here, is your indexed agreement,
muscle and you say "why is it debridement,
muscle ?" Well, when you look at your case
study there, it tells you it was a
debridement of the skin that extended
into the muscle so you're going to go to
the deepest layer to find the code that
would work in this case it is 11043.
debridement, muscle and or fascia,
includes epidermis, dermi,s and
subcutaneous tissue, first 20 square
centimeters or less. Now this
particular case study does not tell us
the square centimeters so it really
isn't a good
example. This is taken from your textbook.
Ideally the documentation that you are
getting from the physicians should say
exactly what was excised but I think the
reason why it isn't (is that) this didn't happen.
You see where that surgery was cancelled,.
So the patient didn't go to the OR.
You couldn't choose it by the
centimeters and you see the modifier that
would be used by the hospital is -73
discontinued outpatient procedure before
administration of anesthesia. The
physician would assign 1104353 and (modifier) -53
is discontinued procedure. Ch. 3 #10 the
surgeon performed a laparoscopic
cholecystectomy. The procedure was
complicated due to the fact that the
patient had extensive adhesions that
required over two hours to lysis. Assign
the appropriate code with the modifier
for the surgeon's service. The way
procedures are paid, unless the doctor in
some way communicates to the payer how
much extra time this took, he is not
getting paid that extra time so he has
to have a way to to explain why it took
longer. First we'll look under
cholecystectomy, laparoscopic and that
tells us in the range of 47562 through
47564 and when we go back and look
at those codes in the code book,
47562 does describe laparoscopy, surgical,
cholecystectomy and the modifier is -22
for increased time for procedure. The
surgeon can get paid for these extra two
hours that he spent lysing adhesions.
#12 The surgeon performed an open
reduction with internal fixation for a
right fifth metatarsal fracture. I have
bolded the word "metatarsal" with purple
to make sure that you see that the
fracture metatarsal open treatment is
how you would look at it in the CPT book
and you would only use the modifier RT
for the right metatarsal. Even though you
think of
a metatarsal as a toe, it really isn't.
It's a bone in the foot so you can't use
those F's and T's that are found on the
back of the front cover. For fingers and
toes, you would only use the part of
the body, in this case, the metatarsals
and it's on the right side. I want to go
over now some examples of test questions
that you will see on the exam in this
class and you might also see these types
of questions on the national exam. You
don't see true/false on the national
exam. Those (questions) are all multiple choice but
just to make my point, it's the
content of what might be covered on the
national exam that I'm speaking to. The
correct code assignment for an
arthrocentesis ring finger of the left
hand is 20600LT. Well it's a finger.
It's not a metacarpal so I think it
should probably be "false"
because I think the modifier is going to
be F3 for ring finger, left hand.
Repeating, the F&T modifiers are for
fingers and toes, not the bones of the
foot (metatarsals) or the bones of the
hand (metacarpals). Which of the following
modifiers would be appended to a CPT
code for repair of the right upper eyelid?
Looking on the back of the front
cover you see E3. Code 55250-50
is reported for a bilateral vasectomy.
True or false? What you would do in this
case is you would look up the code 55250
and you would see exactly how that
code description is written and that
would help you know how to answer this
question. The answer is false. No modifier
is needed because the code description
55250 says unilateral or bilateral.
and if a bilateral vasectomy was done,
you don't use the dash 50 (-50).
Here's another one, incision and drainage
of a carbuncle on the left hip is
performed and the correct code
assignment is 10060 LT. This was a
little bit tricky because a carbuncle on
the left hip is really on the skin. It's
not in a joint or some part of the body
that's bilateral so it really is false.
You will not put a modifier at all on a
carbuncle, incision and drainage of a
carbuncle because it's skin you're
working on the skin. You're not working
on a part of the body that has
definitive right and left sides. Okay I
hope that makes sense. A reminder you can
post your questions in discussion board.
You can call me or you can email me. Any
way that you ask a question you must
come to me saying this is how I tried to
find it. Show me the path that you try to
find, which words you use for the main
terms because it's only when we figure
out where you're going wrong that I can
help you and by discussing it on
discussion board everybody can see the
answer because I guarantee if one person
has a question you're not the only
person so let's all learn together.
Thank you so much and have a good day.