Modifier 33 – Preventive Services usage and guideline policy

 Modifier code and Description


Modifier 33 – Preventive Services: 


Preventive Services: When the primary purpose of the service is the delivery of an evidence based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be identified by adding 33 to the procedure. For separately reported services specifically identified as preventive, the modifier should not be used.


Tips for Billing CPT Modifier 33


The modifier 33 was created to aid compliance with the Affordable Care Act (ACA) which prohibits member cost sharing for defined preventive services for nongrandfathered health plans. The appropriate use of modifier 33 reduces claim adjustments related to preventive services and your corresponding refunds to members.


Modifier 33 is applicable to CPT codes representing preventive care services. CPT codes not appended with modifier 33 will process under the member’s medical or

preventive benefits, based on the diagnosis and CPT codes submitted.


Modifier 33 should be appended to codes represented for services described in the US

Preventive Services Task Force (USPSTF) A and B recommendations, the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and

Prevention (CDC), and certain guidelines for infants, children, adolescents, and women supported by the Health Resources and Services Administration (HRSA) Guidelines.


The CPT® 2016 Professional Edition manual shares the following information regarding the billing of modifier 33, “When the primary purpose of the service is the delivery of an evidence based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive mandates (legislative or regulatory), the service may be identified by adding 33 to the procedure. For separately reported services specifically identified as preventive, the modifier should not be used.”


1. What is modifier 33?


Modifiers are the exceptions to the rule and they are “the additional information”. They are appended directly to the applicable CPT code. In this webinar we introduced the Modifier 33, but there are others. See the following resources for a list and definition of other modifiers: http://www.codingahead.com/2009/08/list-of-modifiers.html.


Modifier 33 is applied to indicate that a preventive or screening service has taken place. The modifier may waive a patient's co-pay, deductible, and co-insurance so that there is no cost sharing. This modifier is only used on claims for commercial payers (BCBS, CIGNA, TUFTS etc). The modifier 33 does not have to be appended to those services that are inherently preventive (annual exams and preventive counseling).


Below is a list of services that the modifier 33 could be applied to. The modifier (as in all modifiers) is appended directly to the applicable CPT code.


*Services rated A or B by the U.S. Preventive Services Task Force (USPSTF);


*Immunizations for routine use in children, adolescents, and adults as recommended by the Advisory Committee on Immunization Practices of the U.S.

Department of Health and Human Services;


*Preventive care and screenings for children as recommended by the Bright Futures program of the American Academy of Pediatrics and the newborn screening recommendations of the American College of Medical Genetics as supported by the Health Resources and Services Administration (HRSA); and


*Preventive care and screenings provided for women (not included in the task force recommendations) in the comprehensive guidelines supported by the

HRSA.


Example: High-risk (for STI) patient presents to the clinic for screening but has some complaints as well. The primary reason service is screening. You bill a 99213 (append the 33 modifier) and the Z codes utilized might be Z11.3 (screening for STIs) and Z72.51 (high-risk heterosexaul behavior). 



 Anesthesia Furnished in Conjunction with Colonoscopy


Section 4104 of the Affordable Care Act defined the term “preventive services” to include “colorectal cancer screening tests” and as a result it waives any coinsurance that would otherwise apply under Section 1833(a)(1) of the Act for screening colonoscopies. In addition, the Affordable Care Act amended Section 1833(b)(1) of the Act to waive the Part B deductible for screening colonoscopies. These provisions are effective for services furnished on or after January 1, 2011.


In the CY 2015 PFS Proposed Rule, CMS proposed to revise the definition of “colorectal cancer screening tests” to include anesthesia separately furnished in conjunction with screening colonoscopies; and in the CY 2015 PFS Final Rule with comment period, CMS finalized this proposal. The definition of “colorectal cancer screening tests” includes anesthesia separately furnished in conjunction with screening colonoscopies in the Medicare regulations at Section 410.37(a)(1)(iii). As a result, beneficiary coinsurance and deductible does not apply to anesthesia services associated with screening colonoscopies.


As a result, effective for claims with dates of service on or after January 1, 2015, anesthesia professionals who furnish a separately payable anesthesia service in conjunction with a screening colonoscopy (HCPCS code 00810 performed in conjunction with G0105 and G0121) shall include the following on the claim for the services that qualify for the waiver of coinsurance and deductible:


* Modifier 33 – Preventive Services: when the primary purpose of the service is the delivery of an evidence based service in accordance with a USPSTF A or B rating in

effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be identified by adding 33 to the

procedure. For separately reported services specifically identified as preventive, the modifier should not be used. 


In addition, deductible is not applied to claim lines with HCPCS 00810 services that are billed with the PT modifier for services on or after January 1, 2015. The deductible is also not applied when the PT modifier is appended to at least either one of the CPT codes within the surgical range of CPT codes (10000-69999) or HCPCS codes G6018-G6028 on the claim for services that were furnished on the same date of service as the procedure. But, MACs will apply deductible and coinsurance to claim lines for HCPCS 00810 services billed without modifier 33 or modifier PT.


When to use modifier 33: preventive service modifier


Modifier 33 was created in response to the preventive service requirements associated with the PPACA. When the primary purpose of the service is the delivery of an evidence-based service in accordance with a U.S. Preventive Services Task Force A or B rating in effect, and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be identified by appending modifier 33, preventive service, to the procedure code.


For services represented by codes which may be used for either diagnostic, therapeutic or preventive services, modifier 33 must be appended to that code on the claim when the service was used for the preventive indication.


• For example, CPT code 45378, colonoscopy, may be performed for the 50-year-old asymptomatic individual as a routine screening for colorectal cancer. In this case, the colonoscopy is performed for preventive screening and modifier 33 should be appended, in addition to a well-person diagnosis code, such as V76.51.

• However, a colonoscopy, using this same code, may be performed in response to symptoms which a person exhibits. In that case, this service represents diagnostic colonoscopy.  The diagnosis code would be one which would signify the symptoms exhibited and modifier 33 would not be appended. 


When a separately submitted service is inherently preventive, modifier 33 is not used.


• Routine immunizations recommended for persons living in the United States to prevent communicable diseases are inherently preventive. Therefore modifier 33 would not be appended to these codes.

• Preventive medicine services (office visit services) represented by codes 99381-99387, 99391-99397, 99401- 99404, and 99406-99412 are distinct from problem-oriented

evaluation and management office visit codes and are inherently preventive. Therefore, modifier 33 would not be utilized with these codes.

• The CPT code for screening mammography is inherently preventive and therefore modifier 33 would not be used.


Billing Guidelines


Modifiers 33 and PT are key components to submitting accurate preventive services claims; as such, it’s important to review and become familiar with the following billing guidance.

 

Modifier 33*The appropriate use of modifier 33 will help reduce claim adjustments related to preventive services and your corresponding refunds to members. Modifier 33 applies to commercial lines of business only.


*CPT modifier 33 is applicable to preventive services that do not have a unique code for such services (e.g., E&M codes such as, 99401 would not require modifier 33 as this code already indicates a preventive medicine service. However, code 99213 would require modifier 33 when the provider indicates that the service was preventive).


*If multiple preventive medicine services are provided on the same day, then the modifier is appended to the codes for each preventive service rendered on that day.


*Modifier 33 should be used when only preventive services were rendered on that date, not when combined with other non-preventive services.


*CPT codes not appended with modifier 33 will process under the member’s medical or preventive benefits, based on the diagnosis and CPT codes submitted.


*CPT codes identified as inherently preventive, (e.g., screening mammography) should not be appended with modifier 33.


*This modifier may be used to identify when a service was initiated as a preventive service, which then resulted in a conversion to a therapeutic service. The most notable example of this is screening colonoscopy (code 45378), which results in a polypectomy (code 45383).


Modifier PT *Modifier PT applies to Medicare products only (Medicare Advantage and Medicare Supplemental). To determine the appropriate use of modifier PT, it’s important to know why the member is presenting for treatment.


Modifier PT indicates that a colorectal cancer screening test was converted to a diagnostic test or other procedure (impacts colonoscopy and sigmoidoscopy codes). The appropriate use of modifier PT will help reduce claim adjustments related to colorectal screenings and your corresponding refunds to members.

Please see the following scenarios for guidance:


*Screening exam only: In a situation where a member presents for treatment solely for the purpose of a screening exam, without any signs or symptoms of a disease, then such a procedure should be considered a screening. The appropriate use of diagnosis codes and screening procedure codes is valuable in promoting appropriate adjudication of the claim. The use of the modifier PT in conjunction with a CPT procedure or HCPCS code that is defined as a screening based on that code’s description is not necessary.


*Treatment due to signs or symptoms to rule out or confirm a suspected diagnosis:


In the instance that a member presents for treatment due to signs or symptoms to rule out or confirm a suspected diagnosis, such an encounter should be considered a diagnostic exam, not a screening exam. In such a situation, the modifier PT should not be used and the sign or symptom should be used to explain the reason for the test. 


*Screening colorectal exam converted to a diagnostic service: In a circumstance where a member presents for a screening exam (without signs or symptoms), and an issue is encountered during that preventive exam, then such a circumstance would warrant the use of the PT modifier. The procedure and diagnosis codes that would typically be used in such an instance may not clearly demonstrate that the service began as a screening procedure, but had to be converted to a diagnostic procedure due to a pathologic finding (e.g., polyp, tumor, bleeding) encountered during that preventive exam. The use of the PT modifier in the instance of a screening colorectal exam being converted to a diagnostic service would clarify that despite the end result the service began as a screening service.



Reimbursement Information: 


Modifiers may be appended to CPT/ HCPCS code(s) if the service or procedure is clinically supported for use of modifiers. A claim should be submitted with the correct modifier-to-procedure code combination. Modifiers should not be appended to a CPT/HCPCS code(s) to circumvent a National Correct Coding Initiative (NCCI)

Procedure to Procedure (PTP) edit if the service or procedure is not clinically supported for the use of a modifier. Claim submissions may be denied if a claim contains an inappropriate modifier-to-procedure code combination. In this case, a corrected claim submission with the correct modifier-to-procedure code combination will be necessary to be considered for reimbursement. Medical records or other documentation should accompany the claim to ensure appropriateness of claim reimbursement.


If billing with more than one modifier, list the modifier that will impact reimbursement first.

The modifiers listed below may appear in some of the material on the applicable state plan’s provider website. The following is not an all-inclusive list and modifiers may be added or removed with appropriate notice.


MODIFIER DESCRIPTION WHEN TO APPEND A MODIFIER

33 Preventive services Append to codes represented for evidence-based services in accordance with a US Preventive Services Task Force A and B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory).

• Modifier 33 should be used for CPT codes representing preventive care services. 

CPT code S5100, S5110,S5102, S5105, S5115 - Day and home care services

Procedure code and Description


 S5100 Day care services, adult; per 15 minutes

S5110 Home care training, family; per 15 minutes

S5102    Day care services, adult; per diem

S5105    Day care services, center-based; services not included in program fee per diem

S5115 Home care training, nonfamily; per 15 minutes 


DEFINITIONS


Please check the definitions within the member benefit plan document that supersede the definitions below.


Custodial Care: Services that are any of the following non-Skilled Care services:


• Non-health-related services, such as help with daily living activities. Examples include eating, dressing, bathing, transferring and ambulating.


• Health-related services that can safely and effectively be performed by trained non-medical personnel and are provided for the primary purpose of meeting the personal needs of the patient or maintaining a level of function as opposed to improving that function to an extent that might allow for a more independent existence.


Place of Residence: Wherever the member makes his/her home. This may include his/her dwelling, an apartment, a relative's home, home for the aged, or a Custodial Care facility. Skilled Care: Skilled nursing, skilled teaching, skilled habilitation, and skilled rehabilitation services when all of the following are true:


• Must be delivered or supervised by licensed technical or professional medical personnel in order to obtain the specified medical outcome, and provide for the safety of the patient

• Ordered by a Physician

• Not delivered for the purpose of helping with activities of daily living, including dressing, feeding, bathing or transferring from a bed to a chair

• Requires clinical training in order to be delivered safely and effectively

• Not Custodial Care, which can safely and effectively be performed by trained non-medical personnel



Indications for Coverage


• Skilled Care in the member’s Place of Residence. Skilled Care includes:

o Skilled nursing

o Skilled teaching

o Skilled rehabilitation (physical therapy, occupational therapy and speech therapy)

• For Skilled Care to be covered in the member’s Place of Residence, the following criteria must be met:

o A plan of care must be established and periodically reviewed and updated by the treating practitioner or specialist

o Be ordered and directed by a licensed practitioner or specialist (M.D., D.O., P.A. or N.P)

o It must not be Custodial Care

o The care must be delivered or supervised by a licensed nurse, technical or professional medical personnel in order to obtain a specified medical outcome

o The care requires clinical training in order to be delivered safely and effectively

o The member’s condition must be documented to be such that they cannot receive the Skilled Care in a setting other than the member’s Place of Residence



OVERVIEW

Adult medical day care services in community-based facilities provide structured, individualized programs to meet the physical and/or cognitive health needs of adults with disabilities, living at home, who are unable to care for themselves for long periods of time. Adult day programs provide a variety of care management, including nursing, nutritional, therapeutic, personal care, educational and family support services in a protective, medically supervised setting during daytime hours. Members return to their home and caregiver(s) at the end of the day. Nursing, functional and social supports are tailored to meet the unique needs of program participants and their family caregivers. Members need to meet, at a minimum, a preventive level of care, as determined by the RI Executive Office of Health and Human Services (EOHHS) Office of Long Term Service Supports, in order to receive adult day care services:


• Member has a chronic illness or disability that requires, at a minimum: 


- Supervision with 2 or more activities of daily living (ADLs) such as, bathing, eating, dressing, toileting, and ambulation/transfers

OR

- Extensive or greater assistance with at least 3 instrumental activities of daily living (IADLs) such as meal preparation, laundry, shopping, and cleaning.

• There must be no other person or agency available to perform these services.

• The criteria will be based on (1) a physician or other licensed practitioner’s assessment and (2) a DHS caseworker or EOHHS nurse’s assessment.

Providers will need to check Member Eligibility on the Healthcare Portal to determine if the recipient is entitled to Adult Day Care Services. If the recipient is enrolled in one of the following waivers then the person qualifies to receive the service: Preventive, Core Community, DEA Community, Habilitation Community, Shared Living and Intellectual Disabilities


CLINICAL COVERAGE CRITERIA


1. The Member must have a medical or mental dysfunction that involves one or more physiological systems and indicates a need for nursing care, supervision, therapeutic services, support services, and/or socialization.


2. The Member must require services in a structured adult day health setting.


3. The Member must have personal physician that can attest to the Member’s need.


4. Adult day health service provider must complete a health assessment for admission; establish an oversight and monitoring process for the program that involves a licensed nurse; and provide standard and ad hoc reporting on this project.


There are two levels of adult day care, basic and enhanced.


– Basic is the provision of services by the ADC provider of an organized program of supervision, health promotion, and health prevention services that include the availability of nursing services and health oversight, nutritional dietary services, counseling, therapeutic activities and case management.


Enhanced is the provision of services by the ADC provider when the participant meets at least one of the five requirements:


• Daily assistance, on site in center, with at least two activities of daily living


• Daily assistance, on site in center, with at least one skilled service, by registered professional nurse (RN) or licensed practical nurse (LPN)


• Daily assistance, on site in center, with at least one ADL which requires a two-person assist to complete the ADL


• Daily assistance, on site in center, with at least 3 ADL’s when supervision and cueing are needed to complete the ADL’s identified


• An individual who has been diagnosed with Alzheimer’s disease or other related dementia, or mental health diagnosis, as determined by a physician, and, requires regular staff interventions due to safety concerns related to elopement risk or other behaviors and inappropriate behaviors that adversely impact themselves or others. Such behaviors and interventions must be documented in the participant’s care plan and in the required progress notes.


Definitions:


Activities of daily living (ADL’s) are defined as basic tasks of everyday life, such as eating, bathing, dressing, toileting, and transferring. Instrumental activities of daily living (IADL’s) are defined as a range of activities that are more complex than those needed for ADLs, including meal preparation, shopping, housework, using the telephone, and taking medications.


*Daily assistance= every day of attendance


Exclusions:


• Individuals who reside in a facility-based setting

• Days or portion of day(s) not attended by Member

• If admission of the individual to adult day health services would result in the individual receiving duplicative or substantially identical services as those provided by any other Medicaid funded service that the individual has chosen, then the individual will not be eligible for adult day health services. Ambulatory care settings include but are not limited to, the home, personal care attendant services, a physician’s office, a hospital outpatient department, a partial care/partial

hospitalization program, and an adult day training program.


• An adult who has partial care/partial hospitalization program services on a particular day is not eligible for adult day health services on the same day.

CPT 99411, 99412 - Preventive counseling group visit

 CPT code and Description


99411 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to individuals in a group setting (separate procedure); approximately 30 minutes N Y Category 2


99412 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to individuals in a group setting (separate procedure); approximately 60 minutes


REIMBURSEMENT GUIDELINES


Preventive Medicine Service and Problem Oriented E/M Service


A Preventive Medicine CPT or HCPCS code and a Problem-Oriented E/M CPT code may both be submitted for the same patient by the Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional on the same date of service. If the E/M code represents a significant, separately identifiable service and is submitted with modifier 25 appended, Oxford will reimburse the Preventive Medicine code plus 50% of the Problem-Oriented E/M

code. Oxford will not reimburse a Problem-Oriented E/M code that does not represent a significant, separately identifiable service and that is not submitted with modifier 25 appended. 


Preventive Medicine Service and Other E/M Service

A Preventive Medicine CPT or HCPCS code and Other E/M CPT or HCPCS codes may both be submitted for the same patient by the Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional on the same date of service. However, Oxford will only reimburse the Preventive Medicine CPT or HCPCS code.


Screening Services

The comprehensive nature of a Preventive Medicine code reflects an age and gender appropriate examination. When a screening code is billed with a Preventive Medicine code on the same date of service by the Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional, only the Preventive Medicine code is reimbursed.


Prolonged Services


Prolonged services codes represent add-on services that are reimbursed when reported in addition to an appropriate

primary service. Preventive medicine services are not designated as appropriate primary codes for the Prolonged

services codes. When Prolonged service add-on codes are billed with a Preventive Medicine code on the same date of

service by the Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional, only

the Preventive Medicine code is reimbursed.


Counseling Services


Preventive Medicine Services include counseling. When counseling service codes are billed with a Preventive Medicine code on the same date of service by the Same Specialty Physician, Hospital, Ambulatory Surgical Center or Other Health Care Professional, only the Preventive Medicine code is reimbursed.


Reasons for Denial


1. Beneficiaries who do not have specific underlining medical condition.

2. Services for preventive medicine counseling and/or risk factor reduction intervention.

3. Services to beneficiaries who require psychiatric services (services should be billed with CPT codes 90801 – 90899).

4. Evaluation and Management services, including Preventive Medicine, Individual Counseling codes 99401 – 99404, and Preventive Medicine, Group Counseling codes 99411 – 99412 billed on the same day as 96150 – 96154.


Questions and Answers


Q: Why does UnitedHealthcare reduce reimbursement to 50% for an E/M service (99201-99205 or 99411-99412 with modifier 25) billed for the same person on the same date of service as a Preventive Medicine Service?


A: UnitedHealthcare recognizes that a visit may begin as a Preventive Medicine Service, and in the process of the examination it may be determined that a disease related condition exists (E/M). When this occurs, the level of decision-making during such a visit may be more complex than the decision-making during a preventive medicine visit. However, there are elements of the Preventive Medicine Service (e.g., making the appointment, obtaining vital signs, maintaining and stocking the exam room, etc.) that are duplicated in the reimbursement for an E/M code; these duplicated practice expense services are 50% of the E/M cost.

Most commonly using Anesthesia Modifiers



Background Information Modifiers

Modifiers are two-character suffixes (alpha and/or numeric) that are attached to a procedure code.

CPT modifiers are defined by the American Medical Association (AMA). HCPCS Level II modifiers are defined by the Centers for Medicare and Medicaid Services (CMS). Like CPT codes, the use of modifiers requires explicit understanding of the purpose of each modifier. Modifiers provide a way to indicate that the service or procedure has been altered by some specific circumstance, but has not been changed in definition or code. Modifiers are intended to communicate specific information about a certain service or procedure that is not already contained in the code definition itself. Some examples are:

• To differentiate between the surgeon, assistant surgeon, and facility fee claims for the same surgery
• To indicate that a procedure was performed bilaterally
• To report multiple procedures performed at the same session by the same provider
• To report only the professional component or only the technical component of a procedure or service
• To designate the specific part of the body that the procedure is performed on (e.g. T3 = Left foot, fourth digit)
• To indicate special ambulance circumstances

More than one modifier can be attached to a procedure code when applicable. Not all modifiers can be used with all procedure codes.

Modifiers do not ensure reimbursement. Some modifiers increase or decrease reimbursement; others are only informational.

Modifiers are not intended to be used to report services that are "similar" or "closely related" to a procedure code. If there is no code or combination of codes or modifier(s) to accurately report the  service that was performed, provide written documentation and use the unlisted code closest to the section which resembles the type of service provided to report the service.

Anesthesia

Anesthesia is the administration of a drug or anesthetic agent by an anesthesiologist or CertifiedRegistered Nurse Anesthetist (CRNA) for medical or surgical purposes to relieve pain and/or induce partial or total loss of sensation and/or consciousness during a procedure. A variety of levels of anesthesia exist, ranging from local through general anesthesia. “As physicians, anesthesiologists are responsible for administering anesthesia to relieve pain and for managing vital life functions during surgery.” (ASA3 )

Supervised Anesthesia

At times a physician will provide medical direction and oversight for a qualified anesthetist (CRNA) or a resident/student performing anesthesia services. The physician may supervise a CRNA, resident, or student nurse anesthetist in a single anesthesia case or the physician may be medically directing 2, 3, or 4 concurrent procedures. Specific modifiers exist to designate the medical direction provided, the number of cases which are supervised, and whether or not the CRNA services were performed under the supervision or medical direction of a physician.


Codes, Terms, and Definitions

Modifier Definitions

Modifier AA Anesthesia services performed personally by anesthesiologist
Modifier AD Medical supervision by a physician: more than 4 concurrent anesthesia procedures
Modifier GC This service has been performed in part by a resident under the direction of a teaching physician
Modifier QK Medical direction of 2, 3, or 4 concurrent anesthesia procedures involving
qualified individuals
Modifier QX Qualified nonphysician anesthetist with medical direction by a physician
Modifier QY Medical direction of one qualified nonphysician anesthetist by an anesthesiologist
Modifier QZ CRNA service: without medical direction by a physician


CRNA

Modifier Description Multiple

QX Anesthesia, CRNA medically directed 50%

QZ Anesthesia, CRNA not medically directed 100% Informational (no additional payment for informational modifiers) Modifier Description

QS Monitored anesthesia care (MAC) servcies (can be billed by CRNA or physician

G8 Monitored Anesthesia Care (MAC) for deep complex, complicated or markedly invasive surgical procedure

G9 Monitored Anesthesia Care (MAC) for patient who has history of severe cardiopulmonary condition

P1 A normal healthy patient
P2 A patient with mild systemic disease
P3 A patient with severe systemic disease
P4 A patient with server systemic disease that is a constant threat to life
P5 A moribund patient who is not expected to survive without the operation
P6 A declared brain-dead patient whose organs are being removed for donor purposes

Medical direction and medical supervision modifiers:

- QY (Medical direction of one qualified non-physician anesthetist by an anesthesiologist)
- QK (Medical direction of 2, 3, or 4 concurrent anesthesia procedures involving qualified individuals)
- AD (Medical supervision by a physician: more than 4 concurrent anesthesia procedures) Similarly, a CRNA should report the appropriate modifier.

when medical direction is provided by an anesthesiologist. When a claim is submitted by an anesthesiologist indicating that medical supervision or medical direction was provided, then a CRNA claim submitted with modifier QZ (CRNA service without medical direction by a physician) is incorrect will be denied. Multiple General Anesthesia Services on Same Day (Both Professional (1500) And Outpatient Facility- (1450)- When multiple anesthesia services are billed for the same day, the anesthesia provider should bill only the general anesthesia service for the procedure with the highest base value, plus the time for all anesthesia services combined. When a claim is received that contains multiple general anesthesia service codes (00100-01999), the highest submitted charge amount will be paid and the secondary anesthesia services will be denied.


Anesthesia Billing Guidelines

Anesthesia Services Providers are reminded of the anesthesia billing guidelines below. Gateway Health requires that all anesthesia services must be submitted with one of the following pricing modifiers in the first modifier position.

Required Anesthesia Modifiers

Modifier Description Reimbursement Percentage

AA Anesthesia Services performed personally by an anesthesiologist 100%
AD* Medical supervision by a physician for more than four concurrent anesthesia procedures 100%
QK Medical direction of two, three, or four concurrent anesthesia procedures involving qualified individuals 50%
QX Qualified non-physician anesthetist with medical direction by a physician 50%
QY Medical direction of one qualified non-physician anesthetist by an anesthesiologist 50%
QZ CRNA service without medical direction by a physician 100%

Informational Modifiers

If reporting CPT modifier 23 or 47 or HCPCS modifier GC, G8, G9 or QS then no additional reimbursement is allowed above the usual fee for that service. Reimbursement

23 Unusual Anesthesia No additionalThis is considered an informational modifier only.

47 Anesthesia by Surgeon No additional - This is considered an informational modifier only.

GC This service has been performed in part by a resident under the direction of a teaching physician No additional - This is considered an informational modifier only.

G8 Monitored anesthesia care (MAC) for deep complex, complicated, or markedly invasive surgical procedure

No additional –

This is considered an informational modifier only which should be billed along with a required anesthesia modifier and not be in the first modifier

G9 Monitored anesthesia care (MAC) for patient who has a history of severe cardiopulmonary condition No additional –

This is considered an informational modifier only which should be billed along with a required anesthesia modifier and not be in the first modifier position

QS Monitored anesthesiology care services (can be billed by a qualified nonphysician anesthetist or a physician)

No additional –

This is considered an informational modifier only which should be billed along with a required anesthesia modifier and not be in the first modifier position

XP Separate practitioner: a service that is distinct because it was performed by a different practitioner

XS Separate structure: a service that is distinct because it was performed on a separate organ/structure

Under certain circumstances, medical services and procedures may need to be further modified. Modifiers commonly used in anesthesia are :

22 Unusual Procedural Services: When the service(s) provided is greater than that usually required for the listed procedure, it may be identified by adding modifier 22 to the usual procedure number. A report may also be appropriate.

23 Unusual Anesthesia: Occasionally, a procedure, which usually requires either no anesthesia or local anesthesia, because of unusual circumstances must be done under general anesthesia. This circumstance may be reported by adding modifier 23 to the procedure code of the basic service.

47 Anesthesia by Surgeon: Regional or general anesthesia provided by the surgeon may be reported by adding modifier 47 to the basic service. (This does not include local anesthesia. Note: Modifier 47 would not be used as a modifier for the anesthesia procedures 00100–01999. The operating surgeon should report the surgical procedure 10021–69990 with modifier 47 appended when billing for anesthesia services.

53 Discontinued Procedure: Under certain circumstances, the physician may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or those that threaten the well-being of the patient, it may be necessary to indicate that a surgical or diagnostic procedure was started but discontinued. This circumstance may be reported by adding modifier 53 to the code reported by the physician for the discontinued procedure. Note: This modifier is not used to report the elective cancellation of a procedure prior to the patient’s anesthesia induction and/or surgical preparation in the operating suite. For outpatient hospital/ambulatory surgery center (ASC) reporting of a previously scheduled procedure/service that is partially reduced or cancelled as a result of extenuating circumstances or those that threaten the well-being of the patient prior to or after administration of anesthesia, see modifiers 73 and 74 (see modifiers approved for ASC hospital outpatient use).

59 Distinct Procedural Service: Under certain circumstances, the medical provider may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. Modifier 59 is used to identify procedures/services that are not normally reported together, but are appropriate under the circumstances.

This may represent a different session or patient encounter, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same physician. However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.

AA Anesthesia Services performed personally by the anesthesiologist: Report modifier AA when the anesthesia services are personally performed by an anesthesiologist. Claims submitted with modifier AA are reimbursed at 100 percent.

AD Medical Supervision by a Physician; More Than Four Concurrent Anesthesia Procedures: Report modifier AD when the anesthesiologist supervises more than four concurrent anesthesia procedures. Claims submitted with modifier AD are reimbursed as described in the preceding section.

G8 Monitored Anesthesia Care (MAC) for Deep, Complex, Complicated or Markedly Invasive Surgical Procedures: Report modifier G8 when monitored anesthesia care is requied for deep, complex, complicated or markedly invasive surgical procedures.

G9 Monitored Anesthesia Care for Patient Who Has a History of Severe Cardiopulmonary Condition:

Report modifier 

G9 when monitored anesthesia care is required  for a patient who has a history of severe cardiopulmonary condition. NT No Time (State Specific Modifier): If the surgeon or attending physician administers a local or regional block for anesthesia during a procedure, the bill should so
indicate with the use of modifier NT for “no time.”

QK Medical Direction of Two, Three, or Four Concurrent Anesthesia Procedures Involving Qualified Individuals: Report modifier QK when the anesthesiologist supervises two, three, or four concurrent anesthesia procedures. Claims submitted with modifier QK are reimbursed at 50 percent.

QS Monitored Anesthesia Care Service: The QS modifier is for informational purposes.

QX CRNA Service with Medical Direction by a Physician: Regional or general anesthesia provided by the CRNA with medical direction by a physician may be reported by adding modifier QX. Claims submitted with modifier QX are reimbursed at 50 percent.

QY Medical Supervision by Physician of One CRNA: Report modifier QY when the anesthesiologist supervises one CRNA. Claims submitted with modifier QY are reimbursed at 50 percent.

QZ CRNA Service without Medical Direction by a Physician: Regional or general anesthesia provided by the CRNA without medical direction by a physician may be reported by adding modifier QZ. Claims submitted with modifier QZ are reimbursed at 100 percent.

Physical Status Modifiers

Six levels of physical status modifiers are consistent with the American Society of Anesthesiologists (ASA) ranking of patient physical status. Physical status is included to distinguish between various levels of complexity of the anesthesia service provided. A listing of physical status modifiers and the modifying units associated with each is provided in Subsection A, Payment Ground Rules for Anesthesia Services.


Modifiers XE, XS, XP, XU, and 59 - Usage Guidelines



Modifiers XE, XS, XP, XU, and 59 - Distinct Procedural Service


Scope

This policy applies to all Commercial medical plans, Medicare Advantage plans, and Oregon Medicaid/EOCCO plans.

Reimbursement Guidelines Effective for dates of service January 1, 2015 and following, Moda Health will accept modifiers XE, XS, XP, and XU and will expect providers to use modifiers XE, XS, XP, and XU in place of modifier 59 when appropriate.

• Modifier 59 should not be used when one of the -X{EPSU} modifiers describes the reason for the distinct procedural service. The -X{EPSU} modifiers are more specific versions of the -59 modifier.

• It is not appropriate to bill both modifier 59 and a -X{EPSU} modifier on the same line. CPT codes submitted with modifiers XE, XP, XS, XU, or 59 appended will be considered separately reimbursable when all of the following apply:

• The clinical edit is eligible for a modifier bypass (e.g. per edit rationale, CCI modifier indicator = “1”, etc.).

• CMS policy on the -X{EPSU} modifiers is evolving. If CMS indicates a specific edit may only be bypassed with a specific -X{EPSU} modifier but is not eligible for a bypass with the other -X{EPSU} modifier options or with modifier 59, Moda Health will follow those specific requirement as well.

“For example, a particular NCCI PTP code pair may be identified as payable only with the -XE separate encounter modifier but not the -59 or other -X{EPSU} modifiers.” (CMS 5 )

• The CPT code is not considered a bundled component of a more comprehensive procedure (code definitions, standards of medical & surgical practice, etc.).

• The modifier and the code have been submitted in accordance with AMA CPT book guidelines, CPT Assistant guidelines, CMS/NCCI Policy Manual guidelines, and any applicable specialty society guidelines.

• The medical records documentation supports the appropriate use of modifiers XE, XP, XS, XU, or 59.

• The procedure code is eligible for separate reimbursement according to the status indicators on the CMS fee schedule for the relevant provider type (physician fee schedule, ASC, OPPS, etc.).

The submission of modifiers XE, XP, XS, XU, or 59 appended to a procedure code indicates that documentation is available in the patient’s records which will support the distinct or independent identifiable nature of the service submitted with modifier XE, XP, XS, XU, or 59, and that these records will be provided in a timely manner for review upon request.

Modifiers XE, XP, XS, XU, and/or 59 do not bypass multiple surgery fee reductions, bilateral fee adjustments, or any other administrative policy other than clinical edits. Appropriate use of modifiers XE, XP, XS, XU, or 59:

Separate surgical operative session on the same date of service (e.g. 8 AM surgery with one procedure, 4 PM surgery with second procedure code).


modifer XE


Modifier XP is a little unclear. Once possible scenario might be:

The patient is seen in the office by a family practice physician, who in the course of the visit encounters a problem outside their scope of ability so calls in (or arranges an immediate transfer to) a specialist physician at the same claim to perform the needed service.

modifer XP 

• May be the same encounter.

• Is definitely the same clinic/TIN.

• Different provider specialties apply.

• E/M service may normally be included in the therapeutic treatment or minor surgical procedure.


Injection into tendon sheath, right ankle (20550) and injection into tendon sheath, left ankle (20550- XS).

modifer XS 

• Same encounter

• Different anatomical site and contralateral structure.

• (Note: 20550 is not eligible for modifiers LT or RT.) Separate injury (or area of injury in extensive injuries).

XS versus

modifer 59

Depending upon your specific circumstances XS or 59 may be most appropriate.

A diagnostic procedure is performed. Due to the findings, a decision is then made to perform a therapeutic/surgical procedure. (This may or may not occur in the same procedure room during the same session/encounter.) For example, diagnostic cardiac angiography leads to therapeutic angioplasty.

See CCI Policy Manual, chapter 1, modifier 59 guidelines. (CMS 2 )

modifier XU versus 59

Depending upon your specific circumstances XU or 59 may be most appropriate.

Benign skin lesion (0.7 cm) removed from left posterior ribs (11401) and benign skin lesion (0.4 cm) removed from right arm (11400-59).

modifier 59

• Same encounter

• Same organ system and/or structure (skin)

• Different lesions.

Diagnostic mediastinoscopy via midline incision (39400) and thoracoscopy of right lateral lung via lateral incision with biopsy of pleura (32609-XS??). Different organ system (e.g. laparoscopy on separate organ systems).

modifier 59
• Same encounter

• Same organ system (respiratory)

• Different incision.

Colonoscopy with snare removal of polyp in transverse colon (45385) and bipolar cautery of polyp in descending colon (45384-59). 59

• Same encounter

• Same incision or orifice (rectum)

• Different/separate lesions.


CMS may in the future release further clarification and/or example scenarios for these modifiers.We’ll update these examples as new information is made available.

Incorrect use of modifiers XE, XP, XS, XU, or 59:

• Procedures in the same anatomical site (e.g. digit, breast, etc.), even with incision lengthening or contiguous incision.

• CPT identified “separate” procedures performed in the same session, same anatomic site, or orifice.

• Laparoscopic procedure converted to open procedure.

• Incisional repairs are part of the global surgical package, including deliveries and cosmetic improvement of a previous scar at the location of the current incision.

• Contiguous structures in the same anatomic site or organ system. (See Coding Guidelines “Different Organs/Contiguous Structures” and CCI Policy Manual, chapter 1. (CMS 2 ))

• Modifier XP should not be used to identify two providers of the same specialty in the same clinic to bypass global surgery package rules, new-patient visit edits, or other same-specialty rules.

• Appending XE, XP, XS, XU, or 59 to Evaluation and Management (E/M) codes instead of using modifiers -24 or -25.


Background Information

Modifiers are two-character suffixes (alpha and/or numeric) that are attached to a procedure code.

CPT modifiers are defined by the American Medical Association (AMA). HCPCS Level II modifiers are defined by the Centers for Medicare and Medicaid Services (CMS). Like CPT codes, the use of modifiers requires explicit understanding of the purpose of each modifier. Modifiers provide a way to indicate that the service or procedure has been altered by some specific circumstance, but has not been changed in definition or code. Modifiers are intended to communicate specific information about a certain service or procedure that is not already contained in the code definition itself. Some examples are:

• To differentiate between the surgeon, assistant surgeon, and facility fee claims for the same surgery

• To indicate that a procedure was performed bilaterally

• To report multiple procedures performed at the same session by the same provider

• To report only the professional component or only the technical component of a procedure or service

• To designate the specific part of the body that the procedure is performed on (e.g. T3 = Left foot, fourth digit)

• To indicate special ambulance circumstances More than one modifier can be attached to a procedure code when applicable. Not all modifiers can be used with all procedure codes. Modifiers do not ensure reimbursement. Some modifiers increase or decrease reimbursement; others are only informational.

Modifiers are not intended to be used to report services that are "similar" or "closely related" to a procedure code. If there is no code or combination of codes or modifier(s) to accurately report the service that was performed, provide written documentation and use the unlisted code closest to the section which resembles the type of service provided to report the service.


Modifier 59 Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.

Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same day, see modifier 25.

Effective for dates of service January 1, 2015 and following, CMS is establishing four new HCPCS modifiers to define subsets of the -59 modifier, a modifier used to define a “Distinct Procedural Service.” These modifiers are XE, XS, XP, and XU, and collectively they are referred to as -X{EPSU}.

The -X{EPSU} modifiers are more selective versions of the -59 modifier. (CMS 4, 5)


Modifier Modifier Definition

Modifier XE Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate

Encounter

Modifier XS Separate Structure, A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure

Modifier XP Separate Practitioner, A Service That Is Distinct Because It Was Performed By A

Different Practitioner

Modifier XU Unusual Non-Overlapping Service, The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service



Definition of Terms Term Definition

Ipsilateral On the same side; affecting the same side of the body; the opposite of contralateral.

In paralysis, this term is used to describe findings on the same side of the body as the brain or spinal cord lesions producing them. Contralateral On the opposite side; originating in or affecting the opposite side of the body, the opposite of homolateral and ipsilateral.

Coding Guidelines

“Modifiers may be appended to HCPCS/CPT codes only if the clinical circumstances justify the use of the modifier. A modifier should not be appended to a HCPCS/CPT code solely to bypass an NCCI edit if the clinical circumstances do not justify its use. If the Medicare program imposes restrictions on the use of a modifier, the modifier may only be used to bypass an NCCI edit if the Medicare restrictions are fulfilled.”


“Modifier 59 and other NCCI-associated modifiers should NOT be used to bypass an NCCI edit unless the proper criteria for use of the modifier are met. Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier used.”

Paired Structures, Ipsilateral versus Contralateral

“It is very important that NCCI-associated modifiers only be used when appropriate. In general these circumstances relate to separate patient encounters, separate anatomic sites or separate specimens. (See subsequent discussion of modifiers in this section.) Most edits involving paired organs or structures (e.g., eyes, ears, extremities, lungs, kidneys) have modifier indicators of “1” because the two codes of the code pair edit may be reported if performed on the contralateral organs or structures. Most of these code pairs should not be reported with NCCI-associated modifiers when performed on the ipsilateral organ or structure unless there is a specific coding rationale to bypass the edit. The existence of the NCCI edit indicates that the two codes generally cannot be reported together unless the two corresponding procedures are performed at two separate patient encounters or two separate anatomic locations. However, if the two corresponding procedures are performed at the same patient encounter and in contiguous structures, NCCI-associated modifiers generally should not be utilized.” 2

Different Procedure or Surgery

“One of the common misuses of modifier 59 is related to the portion of the definition of modifier 59 allowing its use to describe “different procedure or surgery”. The code descriptors of the two codes of a code pair edit consisting of two surgical procedures or two diagnostic procedures usually represent different procedures or surgeries. The edit indicates that the two procedures/surgeries cannot be reported together if performed at the same anatomic site and same patient encounter.


The provider cannot use modifier 59 for such an edit based on the two codes being different procedures/surgeries. However, if the two procedures/surgeries are performed at separate anatomic sites or at separate patient encounters on the same date of service, modifier 59 may be appended to indicate that they are different procedures/surgeries on that date of service.” 2


Different Diagnosis

“Use of modifier 59 to indicate different procedures/surgeries does not require a different diagnosis for each HCPCS/CPT coded procedure/surgery. Additionally, different diagnoses are not adequate criteria for use of modifier 59. The HCPCS/CPT codes remain bundled unless the procedures/surgeries are performed at different anatomic sites or separate patient encounters.” 2

Different Organs/Contiguous Structures

“From an NCCI perspective, the definition of different anatomic sites includes different organs or different lesions in the same organ. However, it does not include treatment of contiguous structures of the same organ. For example, treatment of the nail, nail bed, and adjacent soft tissue constitutes treatment of a single anatomic site. Treatment of posterior segment structures in the ipsilateral eye constitutes treatment of a single anatomic site. Arthroscopic treatment of a shoulder injury in adjoining areas of the ipsilateral shoulder constitutes treatment of a single anatomic site.” (CMS 2 )

“If multiple bacterial blood cultures are performed, including isolation and presumptive identification of isolates, code 87040, Culture, bacterial; blood, aerobic, with isolation and presumptive identification of isolates (includes anaerobic culture, if appropriate), should be used to identify each culture procedure performed. Modifier 59 should be appended to the additional procedures performed to identify each additional culture performed as a distinct service.” 3

Relationship of Modifiers XE, XP, XS, and XU to Modifier 59

“These modifiers, collectively referred to as -X{EPSU} modifiers, define specific subsets of the -59 modifier…The -X{EPSU} modifiers are more selective versions of the -59 modifier so it would be incorrect to include both modifiers on the same line.” (CMS 4 ) “Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used.” (AMA 1 )



Modifier Description

XE Separate encounter Service that is distinct because it occurredduring a separate encounter.

XP Separate practitioner Service that is distinct because it was performed by a different practitioner.

XS Separate structure Service that is distinct because it was performed on a different organ/structure.

XU Unusual nonoverlapping service The use of a service that is distinct because it does not overlap usual components or the main service.




Modifiers

Modifier billings with ClaimsXten

ClaimsXten has some very strict edits on procedure versus modifier. If the modifier is not valid for the procedure, the claim line will be denied. Some examples/guidelines are:

• Modifier 50, bilateral, is not valid on a procedure with bilateral in the description or with PT/OT codes.
• RT or LT is not valid on a procedure with bilateral in the description (i.e. radiology)
• Modifier 26 is not valid with surgical procedures
• Site specific modifiers are not appropriate with Evaluation and Management codes.
• Be sure the modifier is valid by using the CPT and/or HCPCS book.
• Repeat clinical diagnostic lab procedures should be billed with Modifier 91 and NOT with Modifier76.
• Specific finger modifiers (F1-F9 and FA) are not valid with procedures specific to the hand.
• Specific toe modifiers (T1-T9 and TA) are not valid with procedures specific to the foot.
• Modifier AT is only valid with CPT codes 98940-98943
• Modifiers 24 and 25 are only valid with Evaluation and Management codes.

Modifier 25

Modifier 25: Significant, separately identifiable Evaluation and Management service by the same physician on the same day of the procedure or other service. It is important to bill modifier 25 with Evaluation and Management code IF a provider is performing an unrelated separate procedure. For example, when providing a minor surgery service, the visit on that day is included in the payment for the procedure.

However, when performing an E&M service unrelated to the minor surgical procedure, providers should append modifier 25 to the E&M code. If it is appended to the surgery code, the surgery line will be denied for incorrect coding. The same criterion applies when providing other procedures, including chemotherapy administration, allergy injections, chiropractic manipulation, etc. The visit is included in the other procedure codes unless it is a separate and identifiable E&M procedure.

Some criteria for the appropriate use of modifier 25:
• Are there signs, symptoms, and/or conditions that the physician must address before deciding to perform a procedure or service?
• Was the evaluation and management of the problem significant and beyond the normal preoperative and postoperative work?
• Is there more than one diagnosis present that is being addressed and/or affecting the treatment or outcome?

Modifier 59
• Modifier 59: Distinct procedural service. A more detailed article regarding modifier 59 was printed in the September 2010 issue of Providers’ News. Please refer to that article for complete billing instructions.
• Modifier 59 only applies to non-E&M services. If submitted with an E&M service, the E&M service will be denied as incorrect coding.
• Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision or excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual.
• No other established modifier is appropriate, i.e., multiple or bilateral surgery.
• Modifier 59 should be used with caution.
When a procedure is described in the CPT code descriptor as a “separate procedure” but is carried out independently or is unrelated to other services performed at the same session, the CPT code may be reported with modifier 59.




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