Modifiers - Articles

New Modifier Required on all Single-Use Drugs
February 13th, 2023 - Chris Woolstenhulme
Attention providers and suppliers, there is a new modifier in town! Starting July 1, 2023, Modifier JZ - Zero Drug wasted will be required on all claims to attest there is no drug leftover, If applicable.

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Modifier FT
November 1st, 2022 - Wyn Staheli
As of January 1, 2022, CMS created a new modifier for an unrelated E/M visit during a postoperative period. It was revised as of April 1, 2022. Learn more about the appropriate use of modifier FT.
Before Requesting a Review on Modifiers, Read This!
August 8th, 2022 - Chris Woolstenhulme
Generally, there is uniformity in the use of modifiers between payers. However, this is not always the case; you may see a difference in payer policies and how modifiers are handled. One way to know if a modifier can be used according to CMS rules can be found when using ...
Significant COVID-19 Code Changes as of October 6
October 8th, 2020 - Wyn Staheli, Director of Research
Significan COVID-19 Code Changes as of October 6
Modifier 50 — Four "Must Know" Tips For Getting Paid
August 10th, 2020 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
Modifiers added to an HCPCS or CPT© code alters the code description, providing clarity about the service for proper claim processing and reimbursement. Here are four things you must know about modifier 50 to ensure proper payment. - Modifiers are either informational or payment related. Informational modifiers provide additional...
Are NCCI Edits Just for Medicare?
July 14th, 2020 - Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
The National Correct Coding Initiative (NCCI) edits were developed by CMS to help promote proper coding and control improper coding that leads to incorrect payments with part B claims. It is important to understand that NCCI edits do not include every possible code combination or every type of un-bundling combination. With that ...
Payment Adjustment Rules for Multiple Procedures and CCI Edits
July 9th, 2020 - Christine Woolstenhulme, QCC, QMCS, CPC, CMRS
Surgical and medical services often include work that is required to be done prior to a procedure and post-procedure. When there are multiple procedures done by the same physician, group, or another qualified healthcare professional on the same day, the pre and post work is only required once. Therefore, CMS ...
MEGA- NCCI Edit Changes - WHO Knew?
June 10th, 2020 - Christine Woolstenhulme, QCC, CMCS, CPC, CMRS
There was no huge announcement when CMS released new files in April. The files that were released on April 7, 2020, actually replaced files to update the NCCI edits on Procedure to Procedure (PTP) edits and Medically Unlikely Edits (MUE).  The updated files included; 291,902 Deleted Procedure to Procedure (PTP) edits 197  Deleted Medically Unlikely ...
Where is the CCI Edit with Modifier 25 on E/M?
May 20th, 2020 - Christine Woolstenhulme, QCC, CMCS, CPC, CMRS
If you are not seeing a CCI edit when reporting an E/M code with a certain procedure, it may be that there is no edit. CMS does not have a CCI edit for every CPT code, however, there are still general coding rules that must be followed.  The use of Modifier 25 is one example ...
More Telehealth Changes Announced by CMS Chiropractic Offices Should Know About
April 7th, 2020 - Wyn Staheli, Director of Research
On March 31, 2020, CMS announced further changes to their telehealth program in response to this unprecedented public health emergency (PHE). The announcement included far more information than is presented in this article which only summarizes the changes to telehealth. In fact, it does change a little of the information included in our March 31st webinar.
More Telehealth Changes Announced by CMS
April 2nd, 2020 - Wyn Staheli, Director of Research
On March 31, 2020, CMS announced further changes to their telehealth program in response to this unprecedented public health emergency (PHE). See this article for further information as well as references & links to CMS information
CMS-Coverage for Therapeutic Shoes for Individuals with Diabetes
March 31st, 2020 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Therapeutic shoes and inserts can play a vital role in a diabetic patient's health. Medicare may cover one pair every year and three pairs of custom inserts each calendar year if the patient qualifies and everything is handled correctly.  Medicare Benefit Policy Manual explains what is needed for a person with diabetes to ...
Providing Telehealth Services During COVID-19 Crisis
March 30th, 2020 - Wyn Staheli, Director of Research
The rules for providing telehealth services during this pandemic have changed and some requirements have been waived. Please keep in mind that “waiving requirements” does not mean that anything goes. Another important consideration is that Medicare and private payers may likely have different rules so you need to make sure that you know individual payer requirements during this time.
Understand the New Codes for Testing & Reporting the COVID-19 Coronavirus (SARS-CoV-2)
March 21st, 2020 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
The current coronavirus pandemic refers to COVID-19, a novel or new type of coronavirus known as severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). The first victim of the virus was identified in Wuhan, Hubei, China at the end of 2019. There is no immunization available to prevent it from spreading and ...
Implementing Telehealth Visits
March 20th, 2020 - Namas
The following is a step-by-step guide on how to convert office-based encounters to telehealth encounters during the current COVID-19 pandemic. These rules may change post-pandemic, as many changes relaxing existing rules were made on a temporary basis by CMS and commercial payers to facilitate patient access and minimize risk of infection. Step ...
Billing for Telemedicine in Chiropractic
January 14th, 2020 - Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP
Many large private payers recognize the potential cost savings and improved health outcomes that telemedicine can help achieve, therefore they are often willing to cover it. While there are several considerations, there could be certain circumstances where telemedicine might apply to chiropractic care.
Denials due to MUE Usage - This May be Why!
January 7th, 2020 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
CMS assigns Medically Unlikely Edits (MUE's) for HCPCS/CPT codes, although not every code has an MUE. MUE edits are used to limit tests and treatments provided to a Medicare patient for a single date of service or for a single line item on a claim form. It is important to understand MUE's are ...
Medicare Changes Bilateral Reporting Rules for Certain Supplies
December 30th, 2019 - Wyn Staheli, Director of Research
DME suppliers must bill bilateral supplies with modifiers RT and LT on separate claim lines or they are being rejected.
Q/A: Q/A: How do I Code a Procedure for the Primary Insurance so the Secondary Can Get Billed?
November 19th, 2019 - Wyn Staheli, Director of Research
Question: How do you modify a code submitted to the primary insurance company to let them know it is not covered by them so you can bill to a secondary?
Medically Unlikely Edits (MUEs): Unlikely, But Not Always Impossible
October 18th, 2019 - Namas
Medically Unlikely Edits (MUEs) were created by the Centers for Medicare & Medicaid Services (CMS) to help lower the error rate for paid Part B claims. MUEs are the maximum units of a HCPCS or CPT code that a provider would bill under most circumstances for the same patient on ...
Vaccine Administration - When The Right Vaccine Code is Not Enough
September 30th, 2019 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Understanding how to apply immunization administration codes properly will support correct reimbursement for vaccinations. Reporting the right vaccine code alone is not enough to guarantee proper billing. The majority of the time, providers can charge for the vaccine/product as well as the administration of the vaccine; always consult your payer ...
Q/A: How Do I Bill a House Call?
September 30th, 2019 - Wyn Staheli, Director of Research
Question If a provider makes a house call to/for a patient, is there a way that it is represented on the claim form? A modifier, or something else? Answer Modifiers are not used to identify that a service was performed in the patient's home. However, other modifier rules must be followed (e.g., modifier GP ...
Understanding Payment Indicators
August 19th, 2019 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Understanding how payment works with Medicare payment indicators and the impact a modifier has on payment is vital to pricing. Even if you are not billing Medicare, most carriers follow Medicare's policies for participating and non-participating rules.  Here is an article from Regence on their policy statement, describing the rules ...
Q/A: I Billed 2 Units of L3020 and Claim was Denied. Why?
August 13th, 2019 - Brandy Brimhall, CPC, CMCO, CCCPC, CPCO, CPMA
Question: We billed 2 units of L3020 but were denied for not using the right modifiers. What should we do? Answer: Rather than submitting two units of the L3020 to indicate that the patient one orthotic for each foot, you would need to use modifiers identifying left foot and right foot. Appropriate coding ...
Q/A: Do I Use 7th Character A for all Sprain/Strain Care Until MMI?
July 15th, 2019 - Wyn Staheli, Director of Research
Question: It is in regards to the Initial and Subsequent 7th digit (A and D) for sprains and strains. Recently, I have been told that I should continue with the A digit until the patient has reached Maximum Medical Improvement (MMI) and then switch over to the D place holder. Is ...
How to Properly Report Monitoring Patients Taking Blood-thinning Medications
June 18th, 2019 - Wyn Staheli, Director of Research
Codes 93792 and 93792, which were added effective January 1, 2019, have specific guidelines that need to be followed. This article provides some guidance and tips on properly reporting these services.
Q/A: For Physical Therapy Claims, What is the Correct Modifier Order?
May 27th, 2019 - Wyn Staheli, Director of Research
Question Page 116 of the 2019 ChiroCode Deskbook shows examples for Medicare modifiers. Is this the specific order for the modifiers to be entered? Our practice management software system is advising the GP or GY should be used as Modifier 1 and not as Mod 2 or Mod 3. Also, it shows the ...
Spinal Cord Stimulator Used for Chronic Pain
April 1st, 2019 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Chronic pain is a condition that can be diagnosed on its own or diagnosed as a part of another condition. When coding chronic pain, there is no time frame defining when pain becomes chronic pain; the provider’s documentation should be used to guide the use of these codes. ICD-10-CM Diagnosis Codes ...
Q/A: I Submitted a Claim to the VA and it’s Being Denied. Why?
April 1st, 2019 - Wyn Staheli, Director of Research
I submitted a claim to the VA and it’s being denied. Why? There are several reasons why your claim might be denied by the Veterans Administration (VA). However, without more information about the claim itself (e.g., services billed), we can only provide the following general information about the VA and chiropractic ...
How to Report Imaging (X-Rays) of the Thumb
March 18th, 2019 - Aimee Wilcox, CPMA, CCS-P, CMHP, CST, MA, MT
If you've ever taken piano lessons, you know that the thumb is considered the first finger of the hand. Anatomically, it is also referred to as the first phalanx (finger). However, when you are coding an x-ray of the thumb, images are captured of the thumb, hand, wrist, and all ...
Billing Guidelines for Repositioning
March 4th, 2019 - Wyn Staheli, Director of Research
Code 95992 has some very limited payer payment guidelines which need to be understood for proper reimbursement. Many payer policies consider this service bundled with Evaluation and Management Services, therefore, it would not be separately payable if there was an E/M service performed on the same date. Some providers have reported having trouble ...
Q/A: What's the Difference Between Q5 and Q6 for a Substitute Provider?
February 22nd, 2019 - Wyn Staheli, Director of Research
It is important to understand that modifiers Q5 and Q6 are not interchangeable. So when do you use each of them?
Separately Report a "Separate Procedure" with Confidence
February 22nd, 2019 - Namas
Many procedures in the CPT® code book are designated "separate procedures," but that doesn't mean you can report those procedures separately in every case. First, you must consider other procedures performed during the same encounter. "Separate" Might Not Mean What You Think It Does You can always identify a designated separate procedure by the inclusion of "(separate ...
Understanding NCCI Edits
February 20th, 2019 - Aimee Wilcox, CPMA, CCS-P, CMHP, CST, MA, MT
Medicare creates and maintains the National Correct Coding Initiative (NCCI) edits and NCCI Policy Manual, which identify code pair edits. When performed on the same patient, on the same day, and by the same provider, the secondary code is considered an integral part of the primary code, and payment for ...
Detection by Nucleic Acid (DNA or RNA) - Amplified Probe Technique
February 13th, 2019 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
This question was asked on the following lab codes used for testing during pregnancy. "Can the codes below be billed together? 87491- 59, 87591-59. 87081, 87150." YES- CPT code 87081 is used when a specific pathogen is suspected and is appropriate. YES- (X2) 87150 is used for culture, typing, and identification by nucleic ...
Coding Medicare Initial Preventive Physical Exams (IPPE)
February 12th, 2019 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
The Medicare Initial Preventive Physical Exam (IPPE), also commonly referred to as the “Welcome to Medicare Physical”, may seem daunting to many, but when broken out to identify the requirements is fairly straightforward. Purpose An IPPE helps the Medicare beneficiary (the patient) get to know their healthcare provider at a time when they ...
Q/A: Do Digital X-rays Have Their Own Codes?
February 7th, 2019 - Wyn Staheli, Director of Research
Question Are you aware if digital x-ray of the spine requires a different code than plain x-ray? If so, where can I find the information specific to digital x-ray codes? Answer There are no separate codes for digital x-rays. However, there may be modifiers that are required to be submitted with the usual ...
Physical Therapy Caps Q/A
February 1st, 2019 - Wyn Staheli, Director of Research
Question: How do I code it so that PT services in a chiropractic office don’t count against their PT visit max? Is there a way to code claims so that they are considered chiropractic only? But still get compensated enough? We have been running into some issues as of late ...
Q/A: Can I Bill a Review of X-Rays?
February 1st, 2019 - Wyn Staheli, Director of Research & Aimee Wilcox, CPMA, CCS-P, CMHP, CST, MA, MT
It is not unusual for a healthcare provider to review x-rays taken and professionally read by another entity. Questions arise regarding how to bill this second review. It is essential to keep in mind that the global (complete) service of taking an x-ray is composed of both a professional and ...
Q/A: Which Code Should I Use for a Lab Interpretation Fee?
January 24th, 2019 - Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP
Question Which code should I use for a lab interpretation fee? Specifically, I have ordered a female hormone saliva test, and would like to charge a fee for time spent on the interpretation and consult. Answer This type of service generally does not involve a third party, so it may be acceptable to ...
How to Report Co-Surgeons Using Modifier 62
January 23rd, 2019 - Aimee Wilcox, CPMA, CCS-P, CMHP, CST, MA, MT
Modifier 62 is appended to surgical claims to report the need for the skills of two surgeons (co-surgeons) to perform a procedure, with each surgeon performing a distinct part of the same procedure, during the same surgical session. An easy way to explain this is to visualize a patient requiring cervical fusion where ...
Home Oxygen Therapy
January 22nd, 2019 - Raquel Shumway
Home Oxygen Therapy Guidelines
CPT Modifiers 96 & 97 for Habilitative and Rehabilitative Services (2018-01-01)
January 22nd, 2019 - Find-A-Code
Effective January 1, 2018, CPT modifiers 96 "habilitative services" and 97 "rehabilitative services" will be in effect. There have been questions on whether modifier 96 will be preferred over HCPCS modifier SZ, which describes the same types of habilitative (but not rehabilitative) services, but payers have not yet indicated which modifier ...
Reporting Unilateral or Bilateral Codes
December 18th, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Generally, Audiology tests are coded as if they were performed on both ears, if the testing was performed only on one ear, you are required to append a modifier to acknowledge there was a reduced service or a unilateral assessment, using modifier 52 - Reduced Services. (Be sure to read...
Reciprocal Billing and Locum Tenens Arrangements Changes
November 26th, 2018 - Wyn Staheli, Director of Research
CMS has made changes to their payment policies for reciprocal billing arrangements and Fee-For-Time compensation arrangements (formerly referred to as locum tenens arrangements). Providers need to be aware of these changes and update their policies as appropriate.
Muscle Testing and Range of Motion Information
November 8th, 2018 - Wyn Staheli, Director of Research
Be sure to understand the unique code requirements for Muscle and Range of Motion Testing.
Anesthesia and Pain Management
October 31st, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Anesthesia and Pain management is under close watch from the OIG according to a report from Anesthesia Business consultants, they stated, "The Health and Human Services Office of Inspector General (HHS OIG) reports in its most recent Semi-annual Report to Congress that in FY 2017 it brought criminal actions against 881 individuals or organizations ...
How to Use Modifier Indicators with NCCI Edits (2018-10-31)
October 31st, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
To verify if clinical circumstances might justify the use of a modifier when billing code pairs, look at the NCCI edits and the modifier indicator.  Medicare may have restrictions on the use of a modifier used to bypass an edit.  This important part of coding can alert a payer or ...
Capped Rental Items
October 26th, 2018 - Find-A-Code
CMS Gives guidance on Capped Rental Items: Items in this category are paid on a monthly rental basis not to exceed a period of continuous use of 13 months. Based on Supplier Standard 5, suppliers are required to advise beneficiaries of the rent/purchase option for capped rentals and inexpensive or routinely purchased items. ...
Use My Code Set to Save Priced Procedures
October 2nd, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Use My Code Set to save priced procedures to refer to commonly used procedures. Once your CCI edits are done and you have your list of Codes, add notes to My Codes. Add all important information to the Code, for viewing again instead of re-working your most commonly used procedures....
When to Use Modifier 25 and Modifier 57 on Physician Claims
October 1st, 2018 - BC Advantage
The biggest thing modifiers 25 and 57 have in common is that they both assert that the E/M service should be payable based on documentation within the record showing the procedure should not be bundled into the E/M. After that, the similarities end, and it is important to know the...
Using Modifiers 96 and 97
August 16th, 2018 - Wyn Staheli, Director of Research
The Affordable Care Act (ACA) requires coverage of certain essential health benefits (EHBs), two of which are rehabilitative and habilitative services and devices. Since the ACA did not define these terms or specify coverage requirements, it is left up to individual states to create benchmark plans to determine coverage requirements. ...
Using Modifiers
August 13th, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Modifiers offer supplemental information and provide additional details without changing the procedure codes definition and are always two digits. Modifiers are required for proper billing and at times used with NCCI edits, however, two or more NCCI -associated modifiers on the same line will be denied. In addition, NCCI modifiers ...
Home Oxygen Therapy -- CMN for Oxygen
June 14th, 2018 - Raquel Shumway
The Certificate of Medical Necessity (CMN) for Oxygen is a required form that helps to document the medical necessity for oxygen therapy. It also documents other coverage criteria for the oxygen use. For payment on a home oxygen claim, the information in the supplier’s records or the patient’s medical record must be substantiated with the information in the CMN.
The Range of Motion Conundrum
June 7th, 2018 - Gregg Friedman, DC, CCSP
As both a chiropractor for 31 years and one who reviews a lot of medical records for the medicolegal arena and has been teaching documentation for many years, the range of motion question comes up frequently. Although we used to get reimbursed very well for a specific range of motion code back in ...
Preventive Medicine: General Procedures
May 9th, 2018 - Find-A-Code™
Preventive Medicine Topics Page General Procedures Procedure Codes 36415: Collection of venous blood by venipuncture 90471: Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid) 90472: Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (List ...
Preventive Medicine: Human Papilomavirus (HPV) Vaccine and Screening
May 9th, 2018 - Find-A-Code™
Preventive Medicine Topics Page Human Papilomavirus (HPV) Vaccine and Screening Procedure Codes 87623: Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), low-risk types (eg, 6, 11, 42, 43, 44) 87624: Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), high-risk types (eg, 16, 18, ...
Preventive Medicine: Medical Nutrition Therapy and Cardiovascular Disease (CVD)/Obesity Prevention
May 9th, 2018 - Find-A-Code™
Preventive Medicine Topics Page Medical Nutrition Therapy and Cardiovascular Disease (CVD)/Obesity Prevention Procedure Codes G0270: Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment regimen (including additional hours needed for renal disease), individual, face to face with the patient, ...
Preventive Medicine: Use of Modifier 33
May 9th, 2018 - Find-A-Code™
Preventive Medicine Topics Page The Use of Modifier 33 Modifier 33 is used to indicate Preventive Services to report quality metrics and is informational only, it has no impact on reimbursement. Modifier 33 should be reported only to private payers, Medicare and Medicaid do not recognize this modifier. ...
Preventive Medicine: Contraceptive Methods
May 9th, 2018 - Find-A-Code™
Preventive Medicine Topics Page Contraceptive Methods Procedure Codes A4261: Cervical cap for contraceptive use A4266: Diaphragm for contraceptive use A4264: Permanent implantable contraceptive intratubal occlusion device(s) and delivery system J7300: Intrauterine copper contraceptive J7301: Levonorgestrel-releasing intrauterine contraceptive system (skyla), 13.5 mg J7303: Contraceptive supply, hormone containing vaginal ring, each J7304: ...
Preventive Medicine: Colorectal Cancer Screening
May 9th, 2018 - Find-A-Code™
Preventive Medicine Topics Page Colorectal Cancer Screening Procedure Codes G0104: Colorectal cancer screening; flexible sigmoidoscopy G0105: Colorectal cancer screening; colonoscopy on individual at high risk G0106: Colorectal cancer screening; screening sigmoidoscopy, barium enema G0121: Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk G0122: Colorectal cancer screening; barium ...
Q/A: Should I be Using Modifier 96 on PT Claims?
April 30th, 2018 - Wyn Staheli, Director of Research
As chiropractors we feel the new modifier 97 is more appropriate than 96 for our PT codes such as stim and traction. Yet Carefirst is asking for 96 only. Should we use this code on all the PT codes and for all the other insurance companies?
Q/A: Modifiers for Injections
April 17th, 2018 - Nicole Olsen QCC
I'm currently receiving a rejection for my billing with BCBS. We've entered 20550 and 20600 as services for the visit....
Billing Nutrition Counseling in a Chiropractic Setting
April 12th, 2018 - Wyn Staheli, Director of Research
Billing nutrition counseling services may not be as straight-forward as you might think. Some providers mistakenly choose Medical Nutrition Therapy (MNT) codes (97802-97804, G0270, G0271) because it states nutrition therapy in the title. However, according to CPT guidelines, when MNT assessment and/or intervention is performed by a physician or qualified healthcare professional ...
Medicare Telemedicine Changes for 2018
March 29th, 2018 - Aimee Wilcox, CPMA, CCS-P, CMHP, CST, MA, MT
Find-A-Code presented a webinar on “Coding and Auditing Telemedicine Services,” on March 29, 2018, which did not include the new and updated CMS information published in the MNL Matters Number: MM10393 on January 2, 2018. New and exciting changes were introduced in this article, which is addressed below. Originating Site Fee Each ...
Q/A: Which Modifiers to Use When Billing 44005 and 36556 Together
March 26th, 2018 - Chris Woolstenhulme QCC, CMCS, CPC, CMRS
I have a denial for 44005 and 36556 being billed together. I added modifiers 51, 59, and Q6 to 36556 but I am afraid it will deny again?
CPT Code for DOT exams
March 13th, 2018 - Wyn Staheli, Director of Research
Question: I have a provider that provides Department of Transportation (DOT) exams. I have found ICD-10 code Z02.4 (encounter for examination for drivers license) but I am unsure which CPT Code to use. Would I still use 99203 or 99204?
Documentation for Surgical Dressings
March 9th, 2018 - Medicare Learning Network
The Medicare Learning Network provides guidance on required documentation for surgical dressings.
Increased Therapy Denials Create Administrative Burden
March 5th, 2018 - Wyn Staheli, Director of Research
Recently, many healthcare providers have begun to experience a downpour of denials when billing therapy services. The states which seem to be experiencing the most difficulty are Illinois, Oklahoma and Texas, particularly for claims submitted to BCBS plans owned by Health Care Service Corporation (HCSC). Since HCSC also owns Blues ...
New Bipartisian Budget Act of 2018 Provisions
March 1st, 2018 - Wyn Staheli, Director of Research
On February 9, 2018, the Bipartisan Budget Act of 2018 was signed into law. There were some changes which will affect Medicare payments. The following is a brief summary, for a more comprehensive summary see the References. Therapy Caps: Some therapy caps (e.g., occupational, physical therapy, speech-language pathology) were discontinued. However, modifier KX will ...
CPT Modifers 96 & 97 for Habilitative and Rehabilitative Services
February 27th, 2018 - Jared Staheli
Effective January 1, 2018, CPT modifiers 96 "habilitative services" and 97 "rehabilitative services" will be in effect. CMS has added modifiers 96 and 97 to their edits (see MLN Matters MM10385 here) and modifier SZ is deleted as of December 31, 2017. Private payers should simply adjust their policies to use ...
OIG Issues Renewed Focus on Chiropractic Services
February 26th, 2018 - Wyn Staheli, Director of Research
The OIG recently released a "Portfolio" regarding chiropractic service which stated (emphasis added): This portfolio presents an overview of program vulnerabilities identified in prior Office of Inspector General (OIG) audits, evaluations, investigations, and legal actions related to chiropractic services in the Medicare program. It consolidates the findings and issues identified in ...
New Modifiers Released in 2018
February 13th, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
There were 13 new modifiers released in 2018, be sure you are using them if appropriate.     FY X-ray taken using computed radiography technology/cassette-based imaging    JG Drug or biological acquired with 340b drug pricing program discount    QQ Ordering professional consulted a qualified clinical decision support mechanism for this service and the related data was ...
Reporting Tooth Numbers and Oral Cavity Areas
February 1st, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
When billing for dental procedures you need to identify the exact tooth and/or location in the oral cavity. Qualifiers are used to report the location and tooth number. When billing procedures on teeth and the oral cavity, the JP qualifier is used to identify the tooth number(s) and the JO ...
Medicare Requiring Modifier GP on Physical Therapy Services
February 1st, 2018 - Wyn Staheli, Director of Research
Medicare's MLN Matters Number: MM10176 was recently revised to identify services subject to their therapy cap. The revision became effective on January 1, 2018 and some providers have begun to receive claim rejections because they are not using the appropriate modifier. The article states the following (emphasis added): Services furnished under the Outpatient ...
Paravertebral Joint/Nerve Blocks - Diagnostic and Therapeutic
January 29th, 2018 - Find-A-Code
According to Medicare article A50443, a facet joint level refers to the zygapophyseal joint or the two medial branch nerves innervating that zygapophyseal joint. Use CPT codes 64491 and 64492 in conjunction with 64490. Do not report CPT code 64492 more than once per day. Use CPT codes 64494 and 64495 in conjunction with 64493. Do not report CPT code 64495 more than once per day. For injection of ...
Anesthesia Documentation Modifiers - Jurisdictions: J8A, J5A, J8B, J5B
January 29th, 2018 - Christine Woolstenhulme, QCC, CMCS, CPC, CMRS
Documentation Modifiers direct prompt and correct payment of the anesthesia claims submitted. Documentation modifiers (AA, QK, AD, QY, QX and QZ) must be billed in the first modifier field. If a QS modifier applies, it must be in the second modifier field. Processing delays and denials may occur for claims submitted ...
What's the definition of an Office Visit and Can I Bill it With a Chiropractic Treatment?
January 18th, 2018 - Brandy Brimhall, CPC CPCO CMCO CPMA QCC
What is the definition of Office Visit? Can It be billed with a Chiropractic Treatment? What about using code 99123 E&M code for office visits? Can we bill of office visits even though we are giving chiropractic care?
Patient Relationship Codes
January 16th, 2018 - Wyn Staheli, Director of Research
Section 1848(r)(4) of MACRA requires that claims submitted for items and services furnished by a physician or applicable practitioner on or after January 1, 2018, include codes for the following: care episode groups patient condition groups patient relationship categories Previously, CMS decided to use procedure code modifiers to report patient relationship codes on Medicare ...
$4.6 million in Claims Paid Incorrectly by CMS when Using KX Modifier
January 16th, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
$4.6 Million was paid by CMS for claims that did not comply with Medicare requirements.  The claims were paid in 2017 and reported by the Office of Inspector General (OIG) stating, "A 2017 Office of the Inspector General (OIG) report noted that, in some cases, pharmacies incorrectly billed Medicare Part B ...
Medicare Requiring Specific Modifiers on Therapy Services
January 15th, 2018 - Wyn Staheli, Director of Research
Medicare's MLN Matters Number: MM10176 was recently revised to identify services subject to their therapy cap. The revision became effective on January 1, 2018 and some providers have begun to receive claim rejections because they are not using the appropriate modifier. The article states the following: Services furnished under the Outpatient ...
Billing with a GP Modifier
January 15th, 2018 - Wyn Staheli, Director of Research
Q: When patients have a true Medicare secondary insurance we've always billed other Medicare non-covered codes such as G0283 for electric stimulation with modifier GY because we are aware Medicare will not pay for that service but the secondary insurance does. We just were notified by our MAC that GY is not a valid modifier and I have to enter a GP or other therapy modifier. What is the new proper modifier to enter?
Advance Beneficiary Notice of Noncoverage (ABN) Modifier Guidelines
January 11th, 2018 - Find-A-Code
The Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131 may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.Effective from April 1, 2010, non-covered services should be billed with modifier GA, GX, GY, or GZ, as ...
Intensive Outpatient Treatment (IOP)
January 11th, 2018 - Wyn Staheli, Director of Research
Intensive Outpatient Programs (IOPs) are considered to be an intermediate level of care which is commonly considered after the patient has been discharged from inpatient care. For some patients and/or conditions they can also provide an effective level of care when hospitalization is not clinically indicated or preferred. The following ...
Diagnosis billing with J0888
January 9th, 2018 - Find-A-Code
The following information is from LCD L36276. The diagnosis codes listed below require the use of the EC modifier (ESA administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy) when submitting claims for J0888. In addition, these diagnosis codes are marked with an * indicating they require a dual diagnosis. The ...
Preventive Medicine with a New Patient
January 9th, 2018 - Find-A-Code
When coding for preventive care, be sure to use the correct encounter code with the procedure as well as the appropriate modifier if required. New Patient: A patient that has not received any professional services i.e., E&M or any other face to face service from the physician or group within the ...
Outpatient Rehabilitation Modifiers
January 9th, 2018 - Jared Staheli
Modifiers are used for outpatient rehabilitation services to identify the type of service performed. This is necessary for payers to determine service coverage for beneficiaries. For services delivered under an outpatient plan of care use modifier: GN for speech-language pathology GO for occupational therapy GP for physical therapy In addition to using the correct modifier, ...
Physical Therapist can now bill for a substitute Physical Therapist
January 4th, 2018 - Find-A-Code
As of 6/13/2017 Medicare contractors shall accept claims from Physical Therapists, Provider Specialty 65 – Physical Therapist in Private Practice, for services provided by a substitute physical therapist under a fee-for-time compensation arrangement when submitted with the Q6 modifier. The A/B MAC Part B may pay the patient’s regular physician for physicians' ...
Modifiers 54-55, split surgical and postoperative care
January 4th, 2018 - Find-A-Code
54 -Surgical care only; Surgeon is performing only the preoperative and intra-operative care 55 - Postoperative management only; Physician, other than surgeon, assumes all or part of postoperative care Modifiers should be placed on the surgical code Used on 10 day and 90 day surgical procedures Both the surgeon and the physician providing the postoperative ...
Filing a CMS-1500 Claim form to Medicare PUB-100
January 4th, 2018 - Find-A-Code
An independent clinical laboratory may file a paper claim form shall file Form CMS-1500 for a referred laboratory service (as it would any laboratory service). The line item services must be submitted with a modifier 90. An independent clinical laboratory that submits claims in paper format) may not combine non-referred (i.e., ...
Billing Negative Pressure Wound Therapy (NPWT) (disposable device)
January 4th, 2018 - Find-A-Code
Per CMS: Disposable NPWT services are billed using the following Current Procedural Terminology® (CPT®) codes: 97607 - Negative pressure wound therapy, (e.g., vacuum assisted drainage collection), utilizing disposable, non-durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) surface area less than or ...
Acute Post-Operative Pain Management
January 4th, 2018 - Find-A-Code
CPT codes 62320, 62322 should be used when the analgesia is delivered by a single injection.These codes should only be used when the catheter or injection is not used for administration of anesthesia during the operative procedure. Modifier 59 should be used when billing these services to indicate that the catheter or injection was a ...
Erythropoietin Stimulating Agents (ESA)
November 27th, 2017 - Wyn Staheli, Director of Research
Coverage ESA is typically covered for the following condition(s): Treatment of anemia associated with chronic renal failure (whether or not that patient is on dialysis) Treatment of significant anemia in patients with non-myeloid malignancies where anemia is due to the effect of concomitantly administered chemotherapy Treatment of anemia due to AZT and/or other Nucleoside Reverse Transcriptase Inhibitors (NRTI) used in treatment of HIV/AIDS Treatment of selected ...
New Policy from UnitedHealthcare
September 22nd, 2017 - Shannon DeConda, CPC, CPC-I, CEMC, CMSCS, CPMA, CEMA
In the June 2017 UHC Network Bulletin, there was an article that addressed UHC's decision to no longer pay for consultation services.....
Global Surgical Package: When to Bill and When Not to Bill, that is the Question
September 8th, 2017 - Stephanie Allard, CPC, CEMA, RHIT
The global surgical package is inclusive of the services that would normally be provided to the patient following surgery. Depending on the global period assigned to a CPT code, the pre-operative, intra-operative and post-operative services could be included in the global surgical package.....
Modifier JW With Drug Codes
June 27th, 2017 - Find-A-Code
Modifier JW In the past, some Medicare Administrative Contractors have required providers to report wasted drugs with modifier JW (Drug amount discarded/not administered to any patient). Use of the modifier was at the contractor’s discretion, and some contractors told providers not to report it. But effective January 1, 2017, all providers ...
Modifier 59
June 5th, 2017 - Find-A-Code
Definition - The “-59” modifier is used to indicate a distinct procedural service. The physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. This may represent a different session or patient encounter, different procedure or surgery, different site, ...
Covered colonoscopy is attempted but cannot be completed due to extenuating circumstances
December 21st, 2016 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Medicare will pay for the interrupted colonoscopy as long as the coverage conditions are met for the incomplete procedure. However, the frequency standards associated with screening colonoscopies will not be applied by CWF. When a covered colonoscopy is next attempted and completed, Medicare will pay for that colonoscopy according to ...
Modifier 52 vs. 53
December 29th, 2015 - Seth Canterbury, CPC, ACS-EM
So you’ve read the descriptions for both Modifiers 52 and 53, but you’re still on the fence as to which one is appropriate for a certain surgical case. This brief article will try to better differentiate between these two often-confused modifiers. Modifier 53 is appropriate when a...
Modifiers in Postoperative Periods
December 29th, 2015 - Allison Singer, CPC
Modifiers in Postoperative Periods Introduction Documenting the events of a patient visit is not always the simplest and most straightforward of processes. Many variables affect which information must be included in order to report a procedure or service accurately. Global periods are one of...
Pre-op visits: True or False?
December 29th, 2015 - Codapedia Editor
Are the following statements true or false? • The PCP cannot be paid to do a pre-op assessment of a Medicare patient prior to surgery because of the new consult rules. • The surgeon can never be paid to do a pre-op visit if s/he is going to take the patient to surgery. • The...
What Does It Mean To Scrub An Insurance Claim?
December 29th, 2015 - David Greene, MD
During the rigorous training physicians undergo to learn their craft, very little education is received on how to deal with submitting claims to insurance companies. It’s unfortunately a necessary evil, as surgeons who contract with insurance companies rely on that reimbursement as the...
Reporting Administration Codes with Vaccines
December 29th, 2015 - Allison Singer, CPC
When it comes to billing for vaccines, the rules for reporting administration codes can be tricky. Reporting the right vaccine code alone is not enough to guarantee proper billing. Most billing scenarios allow providers to charge for both the vaccine product and the administration of the vaccine...
Coding Excisions and Wound Repairs
October 15th, 2015 - Allison Singer, CPC, CPMA
Chart audits frequently examine coding associated with lesion removals and wound repairs. In order to assign the appropriate procedure code, certain documentation must be included in the medical record, such as lesion type, excision size, wound repair, and location. Without these important details,...
How do I tell if a code is defined as unilateral or bilateral
October 15th, 2015 - Codapedia Editor
There are some procedures which are defined as unilateral procedures, and some defined as bilateral procedures. If the procedure is defined as unilateral but performed bilaterally, then the physician is paid 150% of the fee schedule amount when performed on both sides. If the code is defined as...
Post-operative Hospital Visits
October 15th, 2015 - Betsy Nicoletti, M.S., CPC
In 1992, CMS developed the concept of the Global Surgical Package, which pays for surgical services with a single payment. The full description of services that are included in this payment is described in the Medicare Claims Processing Manual, Chapter 12, Section 40 and in a CMS Fact Sheet.
Modifier 24
July 27th, 2015 - Codapedia Editor
Modifier 24 is appended to an Evaluation and Management service by the same physician during a post op period. See the CPT® book for the complete definition. This modifier may only be used with E/M services. When a physician bills for a surgical procedure, the post op care for that procedure...
Modifier 25
July 27th, 2015 - Codapedia Editor
Modifier 25: Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service. Refer to the CPT® book for the complete definition. Modifier 25 is appended to the E/M service, never to a procedure. The decision about whether to bill for...
Can we bill a low level E/M with every procedure?
June 1st, 2015 - Codapedia Editor
Can’t we bill a low level E/M with every procedure? No! Medicare says this: Per CCI (chapter 11, Letter R.): “The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E/M service. ...
Preventive medicine and office visit, same day
June 1st, 2015 - Codapedia Editor
Can I use modifier 25 on an E/M service on the same day as a preventive medicine exam Let’s review what a preventive medicine service is, in order to answer that question. Preventive medicine services are: • The description given by CPT® for “annual physicals” •...
QW Modifier for CLIA waived tests
October 1st, 2013 - Codapedia Editor
QW is a HCPCS modifier defined as: CLIA waived test. Append it to lab services that are on the CLIA waived test list. Download the up to date list of CLIA waived tests from CMS's web site. The link is the citation. There are two issues: Some tests do not require the QW modifier, and may...
Modifier 59 no longer an option for repeat services
October 1st, 2013 - Scott Kraft
If you’re starting to see denials when you append modifier 59 (distinct procedural service) to your claims that involve repeating the same procedure on the same date of service for the same patient, blame a change in Medicare claims policy that took effect on July 1, 2013. Medicare...
Hospice Care
August 28th, 2013 - Codapedia Editor
Patients who sign up with hospice waive their rights to receive Medicare Part B services, and must look to the hospice organization to provide care related to the terminal illness. The hospice provider receives a daily payment to care for the patient on hospice. The patient’s own attending...
Modifier -25 or -57?
April 24th, 2013 - Debra Sanders
When the physician is making a decision for surgery on a procedure with a 0-10 day global period a -25 modifier is used on the E/M. If the procedure discussed has a 90 day global period the -57 modifier would then apply to the E/M. Ex: 20610 = 0 day global Code as: 99213-25, 20610 Ex:...
How do you report bilateral procedures? One line or two?
October 14th, 2009 - Mary LeGrand
Bilateral Total Knees—How to Submit the Claim From Question: How do I report bilateral procedures, one line or two? Answer: Great question, unfortunately the payors have made this simple concept of bilateral procedures challenging from a reimbursement standpoint! Survey your payors...
Transphenoidal hypophysectomy--how is this coded?
August 10th, 2009 - Kim Pollock
Question: How do we code a transphenoidal hypophysectomy when we do the procedure with an ENT doctor? The ENT doctor says he has his own codes to bill. Answer: There are two codes to report this procedure. First, CPT® 61548 (Hypophysectomy or excision of pituitary tumor, transnasal or...
Facet Joint Injection Services and Modifier 50
August 5th, 2009 - Codapedia Editor
CMS posted a transmittal 7-31-09 about the appropriate use of modifier 50 for Facet Joint Injection Services. It is attached as a resource. Effective date is 8-31-09.
Chemotherapy Infusion and E/M on the same day
July 3rd, 2009 - Codapedia Editor
Is it appropriate to bill an E/M service with a chemotherapy infusion? Here is how Nancy Maguire answered that question: If a significant separately identifiable evaluation and management service is performed, the appropriate E & M code should be reported utilizing modifier 25 in addition to...
Using Modifer -59
March 31st, 2009 - Crystal Reeves
By Crystal Reeves, CPC, CMPE, Principal Modifier -59 is probably one of the most misunderstood, misused, and most-feared of all CPT® modifiers. Some practices avoid using it all together because they don’t want to be guilty of unbundling. Some practices do not use it because they are not...
Global Surgical Package
March 29th, 2009 - Codapedia Editor
The concept of paying surgeons a global payment for all services related to a surgery started in 1992, with the implementation of the Resource Based Relative Value System (RBRVS). This concept describes the components of the global package, and established the post op period for surgical services,...
Modifier -22 Unusual Procedural Services
March 25th, 2009 - Alyce Kalb
Modifier 22 is used when services provided are greater than usually required for the listed procedure and not covered under any other procedure code. This modifier can used in the following sections of the CPT® code set: Anesthesia Surgery Radiology Laboratory and...
Modifier 58
March 25th, 2009 - Codapedia Editor
Modifier 58 is appended to a surgical service to indicate that the physician performed a procedure during the global period that was planned at the time of the original procedure (staged), was more extensive than the original procedure, or is the therapeutic service following a diagnostic procedure....
Modifier 78
March 25th, 2009 - Codapedia Editor
Modifier 78 is used to indicate that the physician who performed a surgery which had a 10 or 90 day global period took the patient back to the OR for a related problem, typically, a complication. Do not use it for staged or related procedures--that is reported using modifier 58. For unrelated...
Modifier 79 Unrelated procedure or service
March 25th, 2009 - Codapedia Editor
Modifier 79 is appended to a procedure to indicate that the same surgeon took the patient back to the operating room during the global surgical period for an unrelated problem. The second procedure must be unrelated to the original procedure. See modifier 78 for return trips to the OR that are...
Modifier 77
March 25th, 2009 - Codapedia Editor
Modifier 77 is used to indicate that the same procedure was performed on a patient, but the service was done by a different physician than the first procedure. Use this modifier on the same day or during the global period of the first service. Use the same CPT® code. The procedure report...
Modifier 76 Repeat Procedure or Service by Same Physician
March 25th, 2009 - Codapedia Editor
Modifier 76 is used to report the service when the same procedure is performed by the same physician, on the same patient either the same day of the previous procedure or doing the global period. The modifier tells the payer that this is not a duplicate bill, but that the same procedure was...
Modifier 54 and modifier 55
March 21st, 2009 - Codapedia Editor
The global surgical package includes the care of the patient pre-operatively, intra-operatively and post-operatively. In some cases, however, the surgeon has performed only part of those services. For example, a tourist at a ski resort who falls and requires surgery will return to their own home...
Diagnostic test interpretation
March 21st, 2009 - Codapedia Editor
Many-- but not all-- diagnostic tests are composed of a technical and a professional component. These tests are identified in the Medicare Physician Fee Schedule. When the physician practice performs both components, the service is billed globally, with no modifier. If the technical component is...
Modifier 79
March 18th, 2009 - Codapedia Editor
Modifier 79 is used to indicate that the physician performed a surgical service that required a return trip to the OR for an unrelated problem during the global post op period. Modifier 79 is appended to procedures. See the CPT® book for the complete definition. It is appended when: A...
Modifier 57
March 18th, 2009 - Codapedia Editor
Modifier 57 is a modifier that is appended to an E/M service to indicate that this was the visit at which the physician decided to perform surgery. It is only used on procedures with a 90 day global period, per CMS, although this is not a CPT® rule. It is only used the day of or before a major...
Two surgeons operating on the same patient, same session
March 18th, 2009 - Codapedia Editor
Most surgeries with two surgeons are reported and performed as the primary surgeon (no modifier on the CPT® code) and the assistant surgeon (modifiers 80, 81, 82, and AS). Some surgeries, however, require two surgeons (modifier 62) or a surgical team (modifier 66). How does a physician or...
Stress test coding
March 10th, 2009 - Codapedia Editor
Stress test codes are different than many other diagnostic tests which have two components: a professional component and a technical component. Stress tests have three components: Technical Interpretation and report (physician service) Supervision (physician service) The...
Using modifier 66 (team surgery) Q&A
March 4th, 2009 - Mary LeGrand
General Surgery Multiple Surgeons, Different Procedures Question: Do I use modifier 66 (team surgery) when our General surgeon is operating on a child during the same session as a plastic surgeon doing a cleft palate repair or a urologist performing a urologic procedure such as a...
Modifier 21
March 4th, 2009 - Codapedia Editor
Modifier 21 was deleted from the 2009 CPT® book. It was a modifier that was not recognized by many payers, and did not give the practice any additional payment. See the add on, prolonged services codes 99354--99357 to report prolonged services. See the Codapedia articles about this topic.

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