Transcript Part 4 Filing 3rd Party Claims

Part 5
Filing 3rd Party Claims
Addressing:
• CPT Code Modifiers and When to Use
Them
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Disclaimers
This information was prepared by the 3rd Party
Consultant to the Nebraska Optometric
Association, Ed Schneider OD.
To the best of his knowledge, it was current and
accurate at the time it was prepared. It is not
guaranteed to be error or omission free.
It was prepared as general information to assist
doctors and staff, and is not intended to grant
rights or impose obligations.
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Disclaimer
• The ultimate responsibility for the correct
submission of claims and compliance with provider
contracts lies with the provider of services.
• The Nebraska Optometric Association, and its
presenters, agents, consultants and staff make no
representation, warranty, or guarantee that this
presentation and/or its contents are error-free or
omission-free, and will bear no responsibility or
liability for the results or consequences of the
information contained herein.
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Coding the Services You
Provided
Must correctly code the level of care provided
• Practitioner is ultimately responsible for correct
coding
•
•
Under-coding is as incorrect as over-coding
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BOTTOM CMS-1500 Service & Materials Supplied
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Exam Coding Modifiers
http://www.wpsmedicare.com/j5macpartb/resources/modifiers/
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http://www.wpsmedicare.com/j5macpartb/resources/modifiers/
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Modifier 24
•
Unrelated Evaluation & Management Service by the
Same Physician During a Postoperative Period.


http://www.wpsmedicare.com/j5macpartb/resources/modifiers/
Example: GLC follow-up exam and fields during
cataract post-op period.
• Cataracts 90 days
• Punctal plugs 10 days
• Foreign body 0 days
• http://www.cms.hhs.gov/pfslookup/02_PFSsearch.asp?agree=yes&next=Accept
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Modifier 25

Significant, Separately Identifiable Evaluation &
Management Service by the Same Physician on the
Day of a procedure


http://www.wpsmedicare.com/j5macpartb/resources/modifiers/
Example: Eyelash abrasion detected requiring epilation during a GLC
follow-up exam.
• Use on E&M (99000) code;
• Documentation for E&M should be separate in record from procedure (each
dated & initialed)
• Separately identifiable entry (different page?)
• with separate signature
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Modifier TC
Technical Component
http://www.wpsmedicare.com/j5macpartb/resources/modifiers/
Some codes can be broken down into a professional
component and a technical component
•Professional Component is done by the doctor
•Technical Component is done by a technician
• No need to break down if both doctor and technician are present
when the service is provided. (Possible exception: HPSA)
• Use breakdown if technician is testing when patient’s own doctor
is not present (but there must be a doctor [associate] on the
premises.)
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Modifier TC
Technical Component
•
•
Example: technician
performing 92083-TC
while patient’s own OD is
not on the premises
OD and OMD codes that qualify
Cannot charge Medicare if
no doctors are on the
premises
Sensorimotor Exam
92060TC
Orthoptic/Pleoptic
92065TC
Visual Fields
92081,2,3TC
Scanning Laser
92135TC
Fundus Photos
92250TC
Color Vision
92283TC
Dark Adaptation
92284TC
External Photography
92285TC
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Modifier 26
•
Professional Component


http://www.wpsmedicare.com/j5macpartb/resources/modifiers/
Example: Doctor’s evaluation of 92083-26 results done
the day after technician performed fields (while a
different doctor was on the premises).
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Modifier 32
•
Mandated Service
•
•
•
http://www.wpsmedicare.com/j5macpartb/resources/modifiers/
Example: driver license exam
Not covered by Insurer…patient responsible
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Modifier 50

Bilateral Procedure

•
•
http://www.wpsmedicare.com/j5macpartb/resources/modifiers/
Some services are paid as binocular tests, some as
monocular tests
If a test is paid as monocular, but you do both eyes, the
the 50 modifier is used (with units of 1).
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Modifier 50

Bilateral Procedure

•
http://www.wpsmedicare.com/j5macpartb/resources/modifiers/
To determine whether a procedure is bilateral, go to
https://www.cms.gov/apps/physician-fee-schedule/search/search-criteria.aspx
•
•
•
•
•
•
•
•
Start Search ->
Accept ->
Click ‘Payment Policy Indicators’
Click ‘Single HCPCS code’
Enter Code you are inquiring about
Select ‘All modifiers’
Submit ->
Scroll Look at “Bilt Surg” column
•
•
•
•
0
1
2
3
means
means
means
means
bill each eye separately – bilateral does not apply
paid 100%, 50%, 25% for 1st, 2nd, 3rd unit, respectively
bill once for both eyes
bill each eye separately
https://www.highmarkmedicareservices.com/partb/reimbursement/mfsdbhelp.html
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Modifier 51

Multiple Procedures

http://www.wpsmedicare.com/j5macpartb/resources/modifiers/
Example: multiple (four) foreign bodies in one eye.
• With four FBs in one eye
– First FB filed without a modifer, 65222
– Balance would be filed with 51 modifer –65222-51 ,
and units of 3 in the units column in this case.
• Reimbursement diminishes with 51s
•
•
Medicare does not recommend using modifier 51, but
simply increasing “units” instead (65222 with units of 4)
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930.0
No
65222
65222 51
1
1
$
3x$
1
3
65222
1
4x $
4
Reimbursement: 100%, 50%, 25%, 25% …
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Modifier 52

Reduced Service


•
http://www.wpsmedicare.com/j5macpartb/resources/modifiers/
Some services are paid as binocular tests, some as
monocular tests
If a test is paid as binocular, but you do only one eye,
the the 52 modifier could be used.
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Modifier 53

Discontinued Procedure


http://www.wpsmedicare.com/j5macpartb/resources/modifiers/
Example: Discontinued punctal plug insertion during the
process because patient became ill.
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Modifier 54

Surgical Care Only


•
http://www.wpsmedicare.com/j5macpartb/resources/modifiers/
Indicates post-op care done by another provider
Example: Cataract surgery – used by surgeon only
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Modifier 55

Postoperative Management Only


•
•
•
•
http://www.wpsmedicare.com/j5macpartb/resources/modifiers/
Example: cataract post-op care
Append to the procedure code that describes the
surgical procedure. Example: 66984 RT 55
Surgery has a 10 or 90-day postoperative period.
The claim must show the date of surgery as the date
of service.
Indicate the date care assumed and date relinquished
in Item 19 of the CMS-1500 claim form or the
electronic equivalent.
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Surgeon’s name
Surgeons NPI
Date assumed care; date relinquished care
366.12
V43.1
01012009
68984 RT 55
2
Date of surgery
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Modifier 59

• Distinct Procedural Service
identifies
procedures/services not normally reported together, but appropriately
billable under these circumstances.


http://www.wpsmedicare.com/j5macpartb/resources/modifiers/
Example: OCT and retinal photos on same day (OCT for GLC, photos
for AMD.) Normally denied when claimed together
– Documentation indicates two separate procedures performed on
the same day by the same physician
– Represented by a different session or patient encounter, different
procedure or surgery, different site, or separate injury (or area of
injury)
– Use Modifier 59 with the secondary, additional or lesser procedure
of combinations listed in Correct Coding Initiative (CCI) edits.
– Use Modifier 59 when there is NO other appropriate modifier.
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Modifier GA
•
Used to indicate patient has signed an
Advanced Beneficiary Notice (ABN)


•
http://www.wpsmedicare.com/j5macpartb/resources/modifiers/
Used when it is expected Medicare will deny payment
for the item as not reasonable and necessary.
To collect fee from patient must have ABN signed by
the beneficiary on file.
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New ABN Required November 1st
release date
of 03/11
printed in
lower left
hand corner
https://www.noridianmedicare.com/dme/forms/docs/cms-r-131.pdf
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Modifier GA
•
In the ABN’s “reason” box, the provider should state
why Medicare will most likely not cover the item:
– Medicare will probably not cover this item due to
your particular diagnosis or circumstance
•
Medicare paperwork to patient, and your Remittance
Advice, will then come back with patient responsible
for payment.
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Modifier GZ
http://www.wpsmedicare.com/j5macpartb/resources/modifiers/


The provider or supplier expects a medical
necessity denial; however, did not provide an
Advance Beneficiary Notice (ABN) to the
patient.
This will result in claim payment denial, and the patient can
NOT be held responsible for payment (provider is out the fee).
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Modifier GW
http://www.wpsmedicare.com/j5macpartb/resources/modifiers/
•
•
Used for Hospice Patient’s Claims for services
not related to the hospice patient’s terminal
condition.
Otherwise Hospice Patient claims can be denied.
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Modifier GY
http://www.wpsmedicare.com/j5macpartb/resources/modifiers/
•
•
•
Used to indicate that the item or service is
statutorily non-covered (not a Medicare Benefit).
It is filed at the request of the patient or to instigate subsequent
payment by another insurer.
Example: refraction 92015GY.
29
Modifier KX
[Used for Durable Medical Equipment]
https://www.noridianmedicare.com/dme/news/docs/2007/06_jun/modifiers.html
•
•
Item is covered under some circumstances (if
ordered by a physician**).
In this case it was ordered by the physician and is medically
necessary.
•
You must document why in the patient’s record.
•
**Note: ODs are categorized as physicians under Medicare
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Modifier EY
[Used for Durable Medical Equipment]
https://www.noridianmedicare.com/dme/news/docs/2007/06_jun/modifiers.ht
ml
•
Item is covered under some circumstances (if
ordered by a physician**).
•
In this case it was NOT ordered by the physician and is not
medically necessary.
Patient preference item
Patient responsible for payment with this modifier
•
**Note: ODs are categorized as physicians under Medicare
•
•
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http://nebraska.aoa.org/prebuilt/NOA/2009-08%203RD%20PARTY%20NEWLSETTER.pdf
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Thank You for Listening
We hope this information has been helpful.
Thank you for listening!
See our NOA Website for more 3rd Party
Educational Videos.
3rd Party Services
Nebraska Optometric Association
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