Part B Insider (Multispecialty) Coding Alert

Published on Sat Nov 14, 2009 PDF

Key: Know how to report professional component.

CMS introduced three new modifiers effective last January, but confusion still lingers about how to use them -- and MACs are not amused.

When practitioners perform erroneous surgeries, CMS requires the hospital outpatient department, ASC, physician, or other entities to append one of the following three modifiers to the surgical code, effective Jan.15, 2009:

• PA -- Surgery wrong body part

• PB -- Surgery wrong patient

• PC -- Wrong surgery on patient.

"Unfortunately, the introduction of these new modifiers has caused much confusion and they are often being submitted incorrectly," says Sandra Jongebreur, CPC-GENSG,CPC, CPC-H, PCS, FCS, coder for Raafat Abdel-Misih, MD in Wilmington, Del.

In particular, "some providers are using the PC modifier to represent the professional component of a service," notes CMS transmittal 1867, which CMS issued on Dec. 4."This is incorrect," the transmittal reminds practices.

The problem: "Medicare created confusion by naming the new modifier PC, since people often think of the professional and technical components as PC and TC, even though the correct modifiers are TC(Technical component) and 26 (Professional component)," says Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CENTC, CHCC, president of CRN Healthcare Solutions.

In addition, some practices are reporting modifier PA to reflect a physician assistant's who assists at a surgery, which is also an incorrect use of the modifier.

Instead: You should report modifier AS (Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery) to Medicare for physicians assistants at surgery, says Shelly  McDonald, CPC, with Resource Anesthesia in Knoxville, Tenn. "It is imperative to have a current HCPCS book to update and confirm all modifiers for Medicare billing, as the changes each year can be great."

MAC action: Part B payers are taking action by returning claims as "unprocessable" if you misuse these modifiers, according to the transmittal. You'll find claim adjustment reason code 4 (Procedure code inconsistent with the modifier) along with remark code MA130 (Your claim contains incomplete and/or invalid information, and no appeal rights are afforded because the claim is unprocessable. Please submit a new claim with the complete/correct information) on your denial.