The Coding Sleuth 19
by Tara Conklin
The Case of the Maddening Modifiers - Part II
In our last look at this case we examined modifiers pertaining to E&M services before and after a surgical procedure. How they are used depends on many different situations.
In our second look at these mystifying little numbers, we are going to look at how some of them are used when applied to procedures themselves. They try to be sneaky and confuse us, trick our minds. Information on them can be hard to come by and when found…well, can be expensive to say the least. Why is it coding information seems to come at such a high price these days? We'll just leave that discussion for another time.
Well, don’t I get off track? Getting back on track let’s look at some surgical modifiers.
There are modifiers for bilateral procedures, reduced procedures, discontinued procedures, modifiers for two surgeons, to a team of surgeons, repeat procedures and oh so many others. With so many to choose from, and with some appearing to be so similar, how can we even begin to make sense of them. Easy... start from the beginning. So grab your hat and hop on board.
Walking through their neighborhood can be scary but we’ll tread lightly and take our steps one at a time.
-22 This is the first nuisance we visit along our way, unusual procedural service. The purpose of this modifier is essentially to increase the payment allowed to the surgeon for performing work above and beyond what’s entailed in the actual procedure performed. Perhaps the physicians spend unusual amounts of time taking down adhesions, or opening the incision because the patient is morbidly obese; perhaps the patient required unusual amounts of blood. All of these things would support the addition of modifier -22 to the procedure. The key and moreover the requirement to using this modifier is impeccable documentation by the surgeon. Each detail of why the procedure was more complicated or more unusual should be clearly dictated in the report. This may include extra time, extenuating circumstances, whatever they may be. Also make sure you drop the claim to paper and send the operative report along with it. Medicare is requiring all claims to go over electronically initially, so in their cases you may need to submit the report along with an appeal if the electronic claims get denied on initial submission.
-50 Our next encounter is with bilateral procedures billed with modifier -50. This seems pretty straight forward. When the same procedure is performed on both left and right anatomical sides you bill one procedure code on one line with modifier -50 appended. Now you might have seen the same procedure code billed on two lines with -50 on the second, but what a claim like this is telling the insurance company is you have perhaps a third arm or maybe an eye. The third eye theory may be okay if you’re a Buddhist, but it’s not a physical third eye and it doesn’t work for surgical procedures.
-51 This is usually a pretty harmless modifier. It does normally reduce the payment of the second procedure, but the miraculous thing is that most insurance companies will reduce the second procedure with or without this modifier. How nice of them, don’t you think? Most of the time, it’s not even necessary to add -51 because insurance companies are so diligent in reducing payments when they know they should. So when should you use modifier -51? Basically, when you’re billing the same procedure code twice and it’s not for bilateral purposes, and it doesn’t bundle into itself. For example, two lesions are removed from different sites, however the code used to bill each of them is the same. In order to paint a clear picture on the claim that the procedure wasn’t bilateral and we’re not billing a duplicate code, we append -51 to show a “multiple procedure” was done. Of course you can append this code to any claim when you bill multiple procedures, but not when they bundle. We’ll talk about that modifier in a minute.
Our next two modifiers work closely as a team in order to cause the most confusion. They can both be perplexing indeed. Get them apart, however, and they become less intimidating.
-52 This is used for “reduced procedures”. So what just exactly constitutes a reduced procedure? Did the surgeon decide to go get a low fat Tai Chi Latte somewhere in the middle of a splenic flexure take-down and the lysis of adhesions? Well… maybe. Sometimes during the course of a procedure circumstances may arise that prevent the operating physician from completing the procedure. A blockage in the transverse colon may prohibit the physician from advancing the colonoscope all the way to the cecum for a complete colonoscopy. Extensive arterial blockage might prevent a complete transcatheter thrombectomy and the surgeon decides to schedule an open procedure. Any number of variables can present themselves from performing the complete scope of a procedure. It’s in cases where these variables occur when modifier -52 is used. There are two important factors to remember when determining if -52 is applicable to a certain scenario. The first is to understand this modifier applies when the procedure can not be completed due to some constraint, our blockage for example. Do not apply this modifier when the procedure has to be stopped due to some aspect that causes distress to the patient, such as sudden respiratory arrest, or hypotension. This falls under our next modifier. Patience… be patient we’ll get to that shortly. Secondly, when a particular procedure was scheduled but was discontinued under these circumstances, the original procedure is billed with modifier -52 appended in lieu of a lesser procedure, even if one exists that completely describes the work done. You have to paint a clear picture of what was scheduled vs. what was done. Billing the originally planned procedure code with the proper modifier accomplishes this goal.
-53 The partner in crime to modifier -52 is -53. The difference between these two modifiers is as mentioned above. This is used when the procedure has to be terminated due to extenuating circumstance that, as CPT so eloquently puts is “threatens the wellbeing of the patient”. (check Appendix A… it’s Ragu… it’s in there). This would fall under our example listed above, such as sudden respiratory arrest, sudden drop in blood pressure or vitals. The proper billing of the procedure is still the same as in modifier -52 (bill the CPT code for the procedure scheduled and append -53.) Don’t bill the CPT code or codes for a lesser service or to describe the work done. Remember... paint a clear picture.
-59 This is the leader of the problematic pack, in more ways than one. It’s a problem for coders, when to append it and when not too. It’s a problem for doctors, billers and office management, bill it on everything that bundles…or well, just everything for safety sake. It’s a problem for claims submission, what end of the modifier chain to I add it to? See what I mean? It’s just a genuine pain in the medical ... well, you get the idea. This modifier is known as “The Magic Unbundling Modifier”. It’s always used when more than one procedure is performed on the same day. It also replaces -51 when billing for two or more procedures on the same date of service that bundle into each other. You can have this modifier on one code or ten. What happens when you use this modifier is you are telling the insurance company (or most likely their claims scrubber at their electronic front door) that “you understand the codes you are billing normally bundle into each other. However, under this particular circumstance they were done independently of each other and therefore both (or more) are separately reportable and payable. This modifier can get any physician into a great deal of trouble, hence the reason it is constantly on the OIG Most Wanted List. Unusually high usage of this modifier can put anyone under an uncomfortable amount of scrutiny. Knowing when to use this is modifier can be as simple as asking yourself a simple question “is the bundled code reporting a portion of the procedure that was done as part of the unbundled code”. For example, in order to perform an open procedure on a patient the surgeon has to make a surgical incision, right? Well, you wouldn’t expect to get paid for opening the patient or closing them for that matter when you are billing for the service provided once they were opened up, right? The physician is expected to close/open the patient…it’s part of the procedure. Therefore, the work for it is included in the primary procedure. With this logic you can look at any procedure with the same view. Ask yourself these questions; “Is it a different anatomical site (different incision, different organ or vessel, opposite side for example, remember different codes are being billed).” “Is it for a separate medical reason?” “Is this at a separate encounter (same day)?” If your answer is yes to any of these questions, then your bundled code is most likely billable. If your answer is no, then you should look closely at your procedure again. Most likely the bundled code is included in the larger service and not separately billable. Remember those lysis of adhesions we talked about? In most open procedures, unless this is the only procedure being done, these are almost always bundled into the greater service. Think about it logically, the surgeon most likely had to move them out of the way in order address the main problem. If it took a great deal of time to take them down, then with good dictation, you can always fall back on modifier -22. Since this modifier is the unbundling modifier, it’s going to be the modifier that gets the claim through that proverbial electronic front door. I like to think of a big, bad, scary, electronic bouncer called Chip. Without the right modifier leading the way, the claim will get bounced before it even gets a chance to plead its case. Kind of like the metal detector at the court house. Just be careful to use it wisely. I think every doctor looks better in a white lab coat as opposed to an orange jumpsuit. Besides orange is a hard color to pull off, unless you have a real nice olive skin tone, you know those ones that look good in … Oops, sorry got off track again.
Well, since our minds are beginning to wander we’ll get out of the modifier neighborhood while we’re ahead of ourselves. This is a lot to tackle in one day and much to absorb. I think we’ll come back next time to take on the last of our dastardly criminals of confusion. Like any gang, get each member alone and eventually they all crack. Be sure to grab a buddy getting out of this neighborhood… I don’t want anyone getting left behind.
Until we meet again!
--Tara