Wiki Modifier on unlisted codes

Jeaux35

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The official rule is No Modifiers on Unlisted codes. Which makes sense as far as pricing modifiers like -22 or -52. But what about -26 for unlisted radiology or lab procedures? Or -62, Co-surgeons on a case? Or -66, Team surgery (think face transplant). Or -78, Unplanned return to the OR in the post-op period? -82 for assistant surgeon?

I would agree that not all modifiers would be appropriate for all unlisted codes, but the blanket statement of "no modifiers" seems extreme. I wanted to send this to the CPT Assistant, but I can't find a way to submit the question without joining the AMA for $250.

Does anyone agree? And does anyone know how to submit this scenario to the AMA for review in the CPT Assistant?

Thanks!
 
Just my thoughts here, but I think the rationale for this rule is that all unlisted codes, by definition, require a record review to determine the exact nature of the service, and in performing a record review, you would presumably identify be able to identify any of the relevant information that would involve any modifier assignment. Since the addition of a modifier serves to, well, modify the base procedure, there is no purpose served by using one since the procedure isn't itself defined. In other words, the unlisted code itself already contains everything you can code about a particular service; no payer could make a determination as to whether any of those particular modifiers is valid or not for an unlisted code, since the code itself doesn't have any fixed definition.
 
I recently wrote a blog about “sometimes you have to “break the guidelines” I feel that if you are performing an unlisted code in the global of another procedure, you might want to use your 58, 78, or 79 modifier to let the payer know why the service is performed and is payable in the global.

I believe that those following the rule and advocates for the rule feel that since we need to appeal most unlisted codes that we use, we can accept the denial and then appeal with the details of why the procedure is being performed in the global period of the prior service. I can understand their position but still like to give as much information to the payer up front as possible.

As for 22, 52, 26 or TC, etc, you can use the modifier when you put the cpt code you are equating the unlisted code to in Box 19 on the claim, saying that the unlisted code is equivalent to CPT code 12345-22, representing 150% of the work, risk and effort.

We can also use the 58, 78 and 79 in the equivalent statement in box 19 if you do not want to break the rule when a procedure in the global of another, so that the reason for performing a service in the global of another is communicated.
 
The answer is no. It is not appropriate to append a modifier to an unlisted CPT code. Modifiers exist solely to amend a specific and established definition of a procedure or service. By their very nature, unlisted CPT codes are undefined; amending them with a modifier will not make them any more specific. Clear guidance for this situation is provided by the American Medical Association's CPT Assistant: "Because unlisted codes do not include descriptor language that specifies the components of a particular service, there is no need to 'alter' the meaning of the code."
 
"Unlisted CPT of HCPCS codes are used to identify an item, service or procedure that not have a specific CPT or HCPCS code. One of the problems that occurs is that the unlisted CPT code descriptor does not describe the specific procedure or service performed. Examples of unlisted codes are 32999, 49999, and 64999. Modifiers offer additional information about the service or procedure being provided. The modifier does not alter the actual description of the code. An unlisted CPT code does not specifically identify a specific service and or procedure and it would be inappropriate to assign a modifier in most cases.
An exception to this is when the unlisted code is performed on an anatomical structure that can further be specified with the use of a laterality modifier. In those cases a HCPCS level II modifier may be appended to the code. Examples of when a HCPCS II modifier may be assigned on an unspecified code are : 14999 unlisted procedure breast, 27599 unlisted procedure femur or knee, 27899 unlisted procedure leg or ankle, and 67999 unlisted procedure eyelid, in the first three procedures noted, RT or LT may be appropriate to identify laterality. For 67999 the modifiers E1 through E4 may be assigned to identify right or left eyelids as well as upper or lower eyelid."
 
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