Hospital Outpatient Modifiers Can Now Be Used for Medicare Claims

Hospital Outpatient Modifiers Can Now Be Used for Medicare Claims

Hospital Outpatient Modifiers Can Now Be Used for Medicare Claims

outpatient coding cut

Special to ADVANCE

CPT modifiers have long been used by physicians to describe specific circumstances related to a procedure code. Modifiers provide a way for health care providers to indicate that a service or procedure was altered in some way, but not changed in its definition or code. Third-party payer acceptance and use of CPT modifiers is inconsistent at best, but now the Health Care Financing Administration (HCFA) has approved selected CPT modifiers for Medicare claims for hospital outpatients.

For physician billing, CPT modifiers can indicate:

  1. A service or procedure represents only a professional or a technical component. CPT has modifier -26 for professional component, but HCPCS modifier -TC must be used to indicate reporting of only the technical portion of a procedure.
  2. A service or procedure was performed by more than one physician. This modifier would never apply to facility reporting.
  3. Only part of a service was performed.
  4. An adjunctive service was performed.
  5. A bilateral procedure was performed.
  6. A service or procedure was provided more than once.
  7. Unusual events occurred.
  8. A procedure or service was altered in some way from the code description.

However, not all of these uses apply to hospital outpatient facility coding. According to CPT guidelines, modifiers may be reported in two ways:

  1. Appended to the procedure number usually reported. Example: 69436-50.
  2. Reported by using a separate five digit code along with the procedure code. Example: 69436, 09950

The example listed reflects a hospital outpatient surgery reporting a myringotomy with insertion of ventilating tubes under general anesthesia performed for both ears. Up until now, hospitals would report the 69436 code twice to show this.

The Medicare Technical Advisory Group Outpatient Work Group (M-TAG) has reviewed all Level I CPT modifiers and Level II HCPCS modifiers to determine their usefulness and applicability to hospital outpatient usage. As a result of this effort, M-TAG recommended to the National Uniform Billing Committee that modifiers be applied to hospital outpatient billing. This was approved and according to HCFA, Oct. 1, 1997, was the implementation date for Medicare fiscal intermediaries to accept the approved modifiers, with providers required to append them to CPT codes by early April 1998. HCFA is in the process of drafting instructions to clarify the use of the modifiers listed below for outpatient hospital billing.

Modifier -50 Bilateral Procedure
Unless otherwise identified in the listing, bilateral procedures that are performed at the same operative session should be identified by the appropriate five digit code describing the first procedure. The second, or bilateral procedure, is reported by adding modifier -50 to the procedure number or by use of the separate five digit modifier code 09950. The CPT recommended format is 69436, 69436-50. For Medicare reporting purposes, the procedure code (with the appropriate two-digit or two-alphabetic modifier(s) appended should be listed only once on the claim as a single line entry (i.e., 69436-50). Watch the guidelines in the 1998 edition of CPT for clarification or possible change to the HCFA recommended format of listing the code once with the -50 modifier.

There are times when surgery is performed on both sides of the body and it appears to be bilateral, but in fact, it is considered multiple procedures for coding purposes. In these cases, the modifier -50 would not apply. One example is surgery involving the turbinates (“conchas”). There are six turbinates, three on each side: two superior, two middle and two inferior turbinates. If the surgeon removes both superior turbinates, for example, this would be considered bilateral surgery and modifier -50 would be appropriate. If, however, one superior turbinate and one middle and/or inferior turbinate are removed from the other side, the bilateral modifier would not apply for hospital outpatient coding.

Coders should also be aware of any CPT code that contains the word “bilateral” in the description. Because the code already specifies that the procedure is performed on both sides, the modifier is not assigned for that purpose.

Modifier -53 Discontinued Procedure
Under certain circumstances, a physician may elect to terminate a surgical or diagnostic procedure. Due to extenuating circumstances or conditions that threaten the well-being of the patient, it may be necessary to abort a procedure after it is underway. In this situation, modifier -53 may be used. This modifier, however, is not appropriate to report the elective cancellation of a procedure prior to the patient’s anesthesia induction or surgical preparation in the operating suite.

Modifier -59 Distinct Procedural Service
This modifier is used to identify procedures or services that are not normally reported together, but are appropriate during the episode of care at issue. This may represent a different session or 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. The service is not ordinarily performed on the same day by the same physician, yet in this case it is. When any other modifier is more appropriate than modifier -59, it should be used instead. Modifier code 09959 may be used as an alternative to reporting modifier -59.

Modifier -76 Repeat Procedure by Same Physician
A physician may need to indicate that a procedure or service was repeated subsequent to the original service. This circumstance may be reported by adding modifier -76 to the repeated service, or the separate five digit modifier code 09976 may be used.

Modifier -77 Repeat Procedure by Another Physician
A physician may need to indicate that a basic procedure performed by another physician had to be repeated. This situation may be reported by adding modifier -77 to the repeated service or the separate five digit modifier code 09977 may be used.

Level II HCPCS Modifiers Approved for Hospital Outpatient Use
A number of HCPCS modifiers were also approved by the National Uniform Billing Committee for outpatient hospital reporting. See the accompanying list for these modifiers.

Using these modifiers will be a brand new experience for many hospital outpatient department coders, but will provide a method of communicating more specific data reporting for many procedures. Hospital information systems may or may not have a data field for modifiers, and the impact of modifier use for ambulatory patient groups (APG) assignment is not yet known.

* About the author: Rita A. Scichilone is an HIM consultant and a coding and reimbursement specialist with Professional Management Midwest Inc., Omaha, NE.

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