Modifier -51 Multiple Procedures: This is for use on physician claims for procedure codes listed subsequent to the first CPT code billed, Ellis says, emphasizing that the modifier is for use on physician claims only. “ASCs should not use the -51 modifier on their codes unless the payer specifically requires its use,” she says. “When more than one procedure—excluding E & M codes— is performed on the same day during the same encounter by the same physi- cian, modifier -51 should be appended to the subsequent procedures on the physician’s claim. The exception to this guideline is if the CPT code is an add- on code, or if it is -51 modifier-exempt.”

Modifier -59 Distinct Procedural Service: “This modifier is used to communicate to the payer that a code normally inclusive in another is sepa- rately billable due to specific circum- stances that make it a ‘separate proce- dure’ and as such, separately payable,” Geise says.

Circumstances in which this modi- fier can be used appropriately are: ■

Procedure was performed in differ- ent compartment

■ ■ ■ ■

Procedure performed at a different site or organ system

Procedure was performed by a sepa- rate incision

Procedure was a different excision area

Procedure was performed on a separate lesion or was a separate injury not normally encountered or performed on the same day by the same surgeon.

The -59 modifier has a higher audit potential with Medicare and other pay- ers, Ellis says.

“In most cases, we

do not use a -59 modifier on the first code listed on the claim form,” she says. “Claims filed with this modifier may be under close review by Medi- care. Do not use this modifier unless it is absolutely necessary, such as when the CPT codes are unbundled and will be denied without use of the -59 modi-

Modifiers are accepted by most payers.”

— Stephanie Ellis, RN Ellis Medical Consulting Inc.

fier. Do not use the -59 modifier, like the -51 modifier, merely to indicate an additional procedure was performed. Not all codes that are unbundled in the Medicare CCI edits are billable to certain payers when appending the -59 modifier; in some cases, unbundled codes should not be billed.”

Modifiers -GY, -GX, -GZ: “A -GY is for non-coverage services, a -GX is when a voluntary advanced benefi- ciary notice (ABN) is sent to a patient explaining what service won’t be cov- ered, and a -GZ is when a provider expects medical necessity denial,” Cadorette says. If your facility is trying to “bill all

payers with the same codes in the same manner, it can be challenging, since some payers, especially Medicare, do not cover all billed codes for proce- dures performed,” Ellis says.

Modifier -73 Terminated/Discontin- ued Out-Patient Hospital/Ambula- tory Surgery Center Procedure Prior to the Administration of Anesthesia: “This modifier is appended to the CPT code for the intended procedure(s) to indicate that a procedure was termi- nated due to medical complications after the patient had been prepared for surgery and taken to the operating room (OR), but before anesthesia was induced,” Ellis says. “The ASC must have ‘expended significant resources’ to charge for the scheduled proce- dures using this modifier, and the patient must be in the OR when the procedure is terminated.”

ASCs sometimes use -73 and -74 without taking the patient to the OR and that is not correct, Cadorette says.

“Sometimes when a patient is taken to an OR, he or she starts having an anxiety attack and makes it unsafe to have surgery,” he says. “That would be an appropriate time to use the modi- fier -73. Or during intubation, if a physician cannot intubate the patient because of spasms in the larynx and has to discontinue the procedure, that would be an appropriate use of -73.”

Modifier -74 Terminated/Discon- tinued Out-Patient Hospital/Ambu- latory Surgery Center Procedure After the Administration of Anes- thesia: “This modifier is appended to the CPT code for the scheduled procedure(s) to indicate that a proce- dure was terminated due to medical complications after anesthesia for the procedure was induced,” Ellis says. “If a patient reacts to an injection of an anesthetic agent and develops rapid heart rate and the sur gery has to be dis- continued, the ASC would use -74,” Cadorette says. “Once the physician has administered anesthesia and then has to stop the procedure, that would be a cor- rect use of the modifier -74.” Each surgery center should have policies in place to ensure appropri- ate use of the -73 and -74 modifiers and to ensure all staff, from clinical to business, understand how the canceled cases are handled and when they are billed or not billed, Geise says. “Most contracted payers—Medicare, Tricare, Department of Labor—all have out- lines for how they reimburse canceled cases,” she says. “Payment of these pro- cedures ensures that you are paid for the resources that you utilized to prepare for the case. For cases canceled prior to the administration of anesthesia, billed with a -73 modifier, many payers allow 50 percent of the scheduled procedure when billed. For cases canceled after administration of anesthesia or the start of the case, billed with a -74 modifier, most payers allow 100 percent of the scheduled procedure.”


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