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Modifier 59 – Facts to Learn

Modifier 59 – Facts to Learn

Modifier 59 – Facts to Learn

Author : Akhil Singhal Post Date : April 15, 2021 Total Views: 106

What is a Medical Coding Modifier?

A medical coding modifier is two-character letters or numbers appended to a CPT® or HCPCS Level II code. Modifiers indicate additional information about the procedure, service, or supply altered by some specific circumstance without a change in its definition or code. They won’t add information or change the outline of service to improve accuracy or specificity.

There are instances when coding and modifier information issued by the CMS differs from the AMA concerning the utilization of modifiers. A clear understanding of Medicare’s guidelines and regulations is vital to assign the suitable modifier(s).

There are numerous instances when a modifier use may be the most appropriate, for example:

  • A service or procedure has both professional and technical components.
  • More than one location is involved.
  • A service or procedure is increased or reduced in comparison to what the code typically requires.
  • More than one provider performs the service or procedure.
  • The procedure is bilateral.
  • The service or procedure is provided to the patient greater than once.

Let us go through some of the most used modifiers in the medical coding & billing industry!

Modifier 59 – Facts to Learn

At times, it is imperative to point out that a procedure or service was distinct or independent from other non-evaluation and management (E/M) service(s) performed on the same day. Modifier 59 indicated usage is for procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances.

It is the most pronounced modifier that affects National Correct Coding Initiative (NCCI) processing

The Medicare NCCI includes edits describe when two Healthcare Common Procedure Coding System (HCPCS) / Current Procedural Terminology (CPT) codes should not be reported together.

A Correct Coding Modifier Indicator (CCMI) of “0” designates the codes should never be reported together by the same provider for the same beneficiary on the same date of service. If these are reported on the same date of service, the column one code is eligible for payment and the column two code is denied.

A CCMI of “1” signifies the codes may be reported together only in defined circumstances, which are identified on the claim using specific NCCI associated modifiers.

CCMI of “9” NCCI editing does not apply.

This modifier may be stated to emphasize that a procedure or service was distinct or independent from other services performed on the same day.

One of the common misuses of this modifier is related to the piece of the definition that allows its use to describe a “different procedure or surgery.”

The code descriptors of the two codes of a code pair edit usually signify different procedures, even though there may be an overlap. The edit indicates that the two procedures should not be collectively reported if performed at the same anatomic site and same patient encounter as those procedures would not be “separate and distinct.”

Modifier is most frequently used are for surgical procedures, non-surgical therapeutic procedures, or diagnostic procedures performed at different anatomic sites not ordinarily performed or encountered on the same day and cannot be described by one of the more specific anatomic modifiers.

Appropriate Use Cases of Modifier 59:

  • A different encounter.
  • Different procedure or surgery.
  • Different anatomical site or organ system: If two procedures are performed at separate anatomical sites or at separate patient encounters on the same date of service separate incision or excision
  • Separate lesion or separate injury (or area in injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual
  • Used for two services described by timed codes provided during the same encounter only when they are performed sequentially.
  • A diagnostic procedure which precedes a therapeutic procedure only when the diagnostic procedure is the basis for performing the therapeutic procedure.
  • No other appropriate modifier is available. Evaluate other modifiers such as the RT/LT identifying right and left, F1 – F0 to identify fingers, T1-T0 to identify toes, and E1-E4 to identify eyelids
  • Evaluate additional modifiers to determine appropriate usage

The CMS established 4 new HCPCS modifiers to provide greater specificity in situations where modifier 59 was previously reported.

  • XE – “Separate encounter, a service that is distinct because it occurred during a separate encounter;” use this modifier only to describe separate encounters on the same date of service
  • XS – “Separate Structure, a service that is distinct because it was performed on a separate organ/structure”
  • XP – “Separate Practitioner, a service that is distinct because it was performed by a different practitioner”
  • XU – “Unusual Non-Overlapping Service, the use of a service that is distinct because it does not overlap usual components of the main service”

Inappropriate Use Cases of Modifier 59:

  • When appended with an E/M  If submitted on E/M codes 99201-99499, E/M codes are processed as though a modifier were not present (i.e., the code pair will be subject to NCCI editing and has an indicator that does not allow bypass)
  • To report a separate and distinct E/M service with a non-E/M service performed on the same date
  • When other valid modifiers exist to identify the services, like RT, LT, E1-E4, TA, etc.
  • When clinical documentation does not support the separate and distinct status
  • When used to indicate multiple administration of injections of the same drug
  • When the NCCI tables lists the procedure, code pair with a modifier indicator of “0”

Important Tips for Coder and Biller

  • Bill all services performed on one day on the same claim
  • Report each service on a different line
  • Apply 59 to the subsequent procedures (if applicable)
  • More than one line with modifier 59 appended to the same procedure code requires submission of supporting information/documentation on the claim
  • Use modifier 59 to identify procedures or services not normally reported together, but is appropriate under certain clinical circumstances
  • Claims reporting modifier 59 on multiple lines for the same procedure code without a narrative or documentation to support the additional lines will receive rejection code 969/standard code 16 (Claim/service lacks information or has submission/billing error(s), needed for adjudication)

The key is that a provider’s clinical documentation must support the use of modifier 59 (or any other modifier).

Use Case 1:

Column 1 Code / Column 2 Code – 17000/11100

CPT Code 17000 – Destruction (e.g., laser surgery, electrosurgery, cryosurgery, chemosurgery, surgical curettement), premalignant lesions (eg, actinic keratoses); first lesion

CPT Code 11100 – Biopsy of skin, subcutaneous tissue and/or mucous membrane (including simple closure), unless otherwise listed.

Single lesion Modifier 59 may be reported with code 11100 if the procedures are performed at different anatomic sites on the same side of the body and a specific anatomic modifier is not applicable. If the procedures are performed on different sides of the body, modifiers RT and LT or another pair of anatomic modifiers should be used, not modifier 59.

Use Case 2:

Column 1 Code / Column 2 Code – 29827/29820

CPT Code 29827 – Arthroscopy, shoulder, surgical; with rotator cuff repair

CPT Code 29820 – Arthroscopy, shoulder, surgical; synovectomy.

Partial CPT code 29820 should not be reported and modifier 59 should not be used if both procedures are performed on the same shoulder during the same operative session because the shoulder joint is a single anatomic structure. If the procedures are performed on different shoulders, modifiers RT and LT should be used, NOT modifier 59.

Reference: https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/Downloads/modifier59.pdf

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Reduce Denials with Your Registration and Scheduling Process

Reduce Denials with Your Registration and Scheduling Process

Reduce Denials with Your Registration

and Scheduling Process

Author : Akhil Singhal Post Date : April 8, 2021 Total Views: 99

Did you know that scheduling and registration errors account for nearly 50% of denied claims? The promising yet also frustrating news is almost 100% of these denials are preventative. In today’s post, we’re going to discuss common reasons why this happens and how you can address the root cause. We’ll also guide you on exactly what information your front desk team needs to be collecting for every visit, regardless of whether it’s a new patient or an existing patient.

The first question you’re probably asking is, why is your front desk team missing these errors? Your initial response may be to reprimand the team for making mistakes. The reality is that we’re all human and make mistakes. However, it’s not as simple as telling your front desk staff to do better and stop making mistakes. Aside from human error, there are several other reasons why front desk denials occur.

Reducing denials is all about being able to identify the trends. How often is someone from your practice reviewing the denial codes and reasons to determine your top denial reasons? If your practice is not doing it currently, the time to start is now or if you’re doing it infrequently, start making it a monthly exercise. The answer to why front-end denials are happening lies in the data. Once you’ve identified the trends, it’s time to figure out the why. Here are three common factors that could answer why your practice is seeing such a high percentage of front-end denials.

Training

Are you confident in your staff’s training? Front desk teams that are improperly trained will, without a doubt, make mistakes. Front desk staff needs to be trained not only on patient interaction and managing the schedule, but they also need an in-depth understanding of insurance and the claims process if they’re expected to collect patient information. Training is also not a one-and-done exercise. If there’s one thing you can count on in healthcare, it’s change, and your practice needs to ensure training on changes is happening. Regular training sessions are imperative to reducing front-end denials. Even if nothing’s changed, reviewing what’s required during scheduling and registration will go a long way.

Lack of Bandwidth

Are the mistakes being caused by the fact that your front desk and scheduling staff are too busy to make sure they’re collecting and verifying patient information? Given your patient volume, is it unrealistic to expect them to collect and verify every patient’s information in addition to their other responsibilities? Keep in mind your front desk staff is also the face of your practice. If patients observe staff running all over the place and so busy they’re unapproachable; your patient satisfaction rate will suffer.

Process

Are you using technology and operational processes that give your front desk staff the best chance to succeed? EMR and practice management software should support the scheduling and registration process. If your team finds it difficult to navigate or time-consuming, it’s time to look at what changes can be made to the current system or evaluate another system that would better support your practice. It’s also good to assess your internal billing operations process from beginning to end to ensure you’ve got the right people in the right position and processes that drive efficiency.

As you’re identifying the cause, here’s a reminder on what patient information must be collected at every patient visit.

  • Verify patient demographics
    • Name
    • Birth Date
    • Address
    • Phone Number
    • Any changes since their last visit
  • Patient insurance information
    • Any changes in insurance coverage
    • Collect or confirm insurance provider
    • Ask about secondary insurance
    • Collect or confirm the patient’s identification number
    • Collect or confirm the patient’s group id
  • Insurance verification
    • Make a copy of the patient’s insurance card
    • Call or visit the payor’s website to confirm the patient’s coverage
    • Confirm patient’s insurance plan details
      • Amount the patient’s deductible
      • Required pre-authorizations
      • Included coverage
      • EDI payor ID
      • Referral requirements
      • Medical necessity LCM and NCD requirements

We understand how frustrating denials can be for practices and the impact they have on your revenue. Hopefully, we’re encouraged you to the first step into addressing your front-end denials by finding the root cause. If you’re still frustrated and are ready to call in an expert, OmniMD is here to help! Click here to schedule a call.

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Recalculated CMS Medicare Physician Fee Schedule Rates for 2021

Recalculated CMS Medicare Physician Fee Schedule Rates for 2021

Recalculated CMS Medicare Physician

Fee Schedule Rates for 2021

Author : Akhil Singhal Post Date : December 29, 2020 Total Views: 51

COVID-19 pandemic hit the world in late 2019 and continued to trouble us all through 2020. Apart from the physical setback, it had a terrible impact on every individual’s social, professional, and psychological well-being. During these challenging times, everything got on hold. Even the biggest of businesses were shut with no positive visibility. This hit the healthcare system too. Even the best of primary healthcare facilities was unsure of keeping themselves open with negligible IPD & OPD. 

This concern was raised by nearly 400 medical organizations, including ACR, as they requested Congress to revisit the year-end legislative package and stop the rate cuts. Along with this, more than 300 congress members also wanted to waive off the budget neutrality adjustment in the 2021 Medicare Physician Fee Schedule so as to mitigate or prevent the cuts. 

In a December statement, the American College of Radiology (ACR) had said that “While the COVID-19 pandemic rages and wreaks havoc on the health care system, providers continue to contend with overflowing hospitals and the financial impact of the spring-summer government-recommended shutdown of most non-urgent medical care. Against this backdrop, double-digit Medicare cuts will be devastating for patients, communities, and providers.” 

Considering the present scenario and to support the healthcare professionals, Congress passed The Consolidated Appropriations Act, 2021 on December 21, 2020, after a COVID-19 stimulus package mitigated budget neutrality cuts finalized in a December rule. As a highlight, the Act ratified a 3.75 % increase in overall Medicare Physician Fee Schedule payments for all providers for 2021.  

To reflect the COVID-19 stimulus package changes, CMS updated the Physician Fee Schedule as of January 7. Here are important glimpses: 

  • 3.75% increase in overall Medicare Physician Fee Schedule payments for 2021 
  • Suspension of payments for Healthcare Common Procedure Coding System (HCPCS) code G2211 for three years
  • Up to 10.2 % cut for certain specialties and services because of a budget neutrality requirement
  • Boost rates for E/M (evaluation and management) services that support primary care and chronic disease management
  • Suspension of the 2 % payment adjustment for the statutory Medicare sequester through March 31, 2021
  • Reinstatement of the 1.0 floor on the work Geographic Practice Cost Index through 2021
  • Revision of the conversion factor for the Physician Fee Schedule in 2021 from $32.26 to $34.89 

As a surprise in 30 years, this finalized policy has the most significant updates for E/M codes. According to the American Medical Association (AMA), “G2211 (an add-on code for the complexity inherent to evaluation and management (E/M) visits) accounted for about $3 billion, or 3 %, of spending in the Medicare Physician Fee Schedule”. But the finalized policy has reduced the burden of the coding system from doctors and rewarded time to be spent on evaluation and management of patient care. With the delay in implementing the code, there will be a reduction in the budget neutrality adjustment. All this will prevent the significant rate cuts for some specialists and services during the COVID-19 pandemic, as laid out in the 2021 Medicare Physician Fee Schedule final rule. 

Also, there is a decrease in the Physician Fee Schedule conversion factor by $3.68 to $32.41. This has been done to reflect a statutory update of 0.00 percent and the adjustment to account for changes in relative value units and expenditures that would result from finalized policies.

To view the revised Consolidated Appropriations Act, 2021, providers can view payment rates in the Downloads section of the CY 2021 Physician Fee Schedule final rule (CMS-1734-F) webpage.

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Billing Codes for Monoclonal Antibody COVID-19 Infusion

Billing Codes for Monoclonal Antibody COVID-19 Infusion

The FDA issued an EUA on November 21, 2020, for the investigational monoclonal antibody therapy, casirivimab and imdevimab, administered together to treat the adult and pediatric patients with mild-to-moderate COVID-19 having positive COVID-19 test results high at risk for progressing to severe COVID-19 and/or hospitalization. The administration can only occur in settings where healthcare providers have immediate access to medications to treat a severe infusion reaction and the ability to activate the emergency medical system (EMS), as necessary.

During the COVID-19 public health emergency (PHE), Medicare ensures coverage and payment for these infusions the same way it does for COVID-19 vaccines, thus allowing coverage for a broad range of providers and suppliers, including home health agencies, nursing homes, and freestanding and hospital-based infusion centers, and entities with whom nursing homes contract for this, to administer these treatments. Medicare will refuse payment for the COVID-19 monoclonal antibody products that providers receive for free. If providers begin to purchase COVID-19 monoclonal antibody products, Medicare anticipates setting the payment rate for the products, which will be 95% of the average wholesale price (AWP) for many healthcare providers, consistent with the usual vaccine payment methodologies. Medicare soon anticipates establishing codes and rates for the administration of the products.

CMS recognized specific code(s) for each COVID-19 monoclonal antibody product and specific administration code(s) for Medicare payment:

EUA effective November 10, 2020, for Eli Lilly and Company’s Antibody Bamlanivimab (LY-CoV555)

Healthcare providers can now use the HCPCS code Q0239 for the injection of 700 mg of Eli Lilly and Company’s investigational monoclonal antibody therapy cocktail and code M0239 for intravenous infusion and post-administration monitoring, according to CMS source on Monoclonal Antibody COVID-19 Infusion

EUA effective November 21, 2020, for Regeneron’s Antibody casirivimab and imdevimab (REGN-COV2) (ZIP) 

Healthcare providers can now use the HCPCS code Q0243 to inject 2,400 mg of Regeneron’s investigational monoclonal antibody therapy cocktail and code M0243 for intravenous infusion post-administration monitoring, according to CMS source on Monoclonal Antibody COVID-19 Infusion

Get the latest and most up to date list of billing codes, payment allowances, and effective dates.

Payment for Product & Infusion

Medicare will not provide payment for the COVID-19 monoclonal antibody products that healthcare providers receive for free, as will be the case upon the product’s initial availability in response to the COVID-19 PHE. If healthcare providers begin to purchase these monoclonal antibody products, CMS foresees setting the payment rate in the same way it was addressed the rate for COVID-19 vaccines.

In order to ensure immediate access during the COVID-19 PHE, Medicare will cover and pay for these infusions per Section 3713 of the Coronavirus Aid, Relief, and Economic Security Act (CARES Act). CMS proposes to address potential refinements to payment for COVID-19 monoclonal antibody infusions and their administration through future notice and comment rulemaking.

Initially, the Medicare national average payment rate for the administration will be $309.60; this payment rate is strictly based on one hour of infusion and post-administration monitoring in the hospital outpatient setting. In the future, CMS may utilize a similar methodology to determine the payment rate for the infusion of additional monoclonal antibody products based on the expected infusion time in line with the FDA EUA or FDA approval of such products.

CMS is hopeful that this Medicare coverage for the two therapies will help providers overcome the hurdles of acquiring and employing new treatments. Yet, it is a known fact that healthcare facilities and providers are still expected to encounter challenges obtaining an adequate supply of such therapies for infected patients.

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Telehealth and Covid-19: 2020 Coding & Billing Tips

Telehealth and Covid-19: 2020 Coding & Billing Tips

Telehealth and COVID-19:

2020 Coding and Billing Tips

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2020 Annual Wellness Visit (AWV) Coding and Documentation Tips

2020 Annual Wellness Visit (AWV) Coding and Documentation Tips

2020 Annual Wellness Visit (AWV)

Coding and Documentation Tips

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