Part B Insider (Multispecialty) Coding Alert

Published on Mon Aug 17, 2015 PDF

These modifiers may not be common, but they could be helpful.

Sure, you’ve got modifiers 25 and 59 committed to memory—but you may not know how to use some of the more unusual modifiers that CPT^® has to offer. Take a look at the following three modifiers and get to know how they can help payers more readily pay your claims.

Modifier 66 Describes Team Surgeries

If more than two providers of different specialties perform work on the same surgery, often using complex surgical equipment, you’ve got yourself a team. When this happens, you’ll append modifier 66 (Surgical team) to the claim.

Background: Under some circumstances, highly complex procedures are carried out under the surgical team concept. Such circumstances may be identified by each participating individual with the addition of modifier 66 to the basic procedure number used for reporting services.

The record must show medical necessity for having a team of surgeons working together because team surgeries are paid for on a “by-report” basis. Your physician(s) must provide details in his documentation describing the procedure performed and stating that he was a part of a team. Each provider reports the same procedure code with modifier 66 attached. This tells the payer that the amount for the procedure should be divvied up between a team of providers instead of being paid to just one. The documentation of all of the providers involved is necessary to determine if team surgery can be billed or if some services should be billed by one person, some billed as an assistant, or some billed as the team approach.

Medicare: If you see a “0” or “9” in the” TEAM SURG” column, you should never apply modifier 66 to that code. The zero indicates that team surgeons are not permitted for the procedure, and the nine indicator means the concept does not apply. Medicare will never allow billing for a surgical team with any procedure that includes a “0” or “9” indicator in the fee schedule’s “TEAM SURG” column.

If you find a “1” in the” TEAM SURG” column, Medicare may allow modifier 66 with supporting documentation that establishes medical necessity for the surgical team. If you find a “2” in the “TEAM SURG” column, Medicare will permit modifier 66 with that code. 

Modifier 27 Helps You Collect for Subsequent Hospital E/M Services

There are times when a patient will need more than one hospital outpatient visit with various physicians on one day. When facing this clinical scenario, you need to inform your payers that the E/M visit performed by your physician is separately reimbursable from the other E/M services on that date. You’ll accomplish this by using modifier 27 (Multiple outpatient hospital E/M encounters on the same date).

The purpose of modifier 27 is to draw attention to the second outpatient hospital visit in the same hospital or system, so that the second visit isn’t thought to be posted in error. Therefore, if the visits were on the same date, in the same outpatient facility, 27 would be appropriate.

For instance, a cancer patient might go to a multispecialty facility and see his cardiologist, oncologist and diabetes specialist on the same date. He would have three E/M visits in one day, which is normally not acceptable when done by the same specialty, but since these are different specialties being billed by the same facility/entity, they need to use modifier 27 to distinguish that.

Attach modifier 27 to the second/subsequent outpatient hospital E/M visit on the same date, to codes in the following range:

• E/M codes 99201-99499 

• General ophthalmological services 92002-92014 

• HCPCS codes G0101 (Cervical or vaginal cancer screening; pelvic and clinical breast examination) and G0175 (Scheduled interdisciplinary team conference [minimum of three exclusive of patient care nursing staff] with patient present).

Modifier 99 Denotes Additional Modifiers

When only a few modifiers just won’t do, modifier 99 (Multiple modifiers) could be your friend.

For instance, suppose your health professional shortage area physician performs an E/M service for another physician in the practice who falls ill suddenly. You have a signed advance beneficiary notice (ABN) on file for the patient, who received chemotherapy earlier that day by the same physician.

In this case, report the appropriate E/M service (99211-99215, Office or other outpatient visit for the evaluation and management of an established patient, … ) with Q6 (Service furnished by a locum tenens physician) attached. You also need to attach modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) because the patient received chemotherapy earlier that day by the same physician.

Additionally, you need modifier AQ (Physician providing a service in an unlisted health professional shortage area [HPSA]) because the physician is providing the service in a HPSA. Plus, because your office has an ABN a signed by the patient on file, you need to include GA (Waiver of liability statement issued as required by payer policy, individual case).

You may put modifier 99 in box 24D on the same line as the service and list the other four modifiers in box 19. If you had fewer than four modifiers, modifier 99 wouldn’t be necessary.

Make a call: You should ask your payers how they want you to report the modifiers because there are differences of opinions on how to report multiples. Some of the preferences you’ll hear include:

• List 99 first and follow it with all other applicable modifiers in box 24D

• Put 99 in modifier box 24D and list all of the other modifiers in box 19, separated by commas

• Some payers don’t require modifier 99 when more than one modifier applies to a procedure

• List the modifiers that directly affect reimbursement first and follow them with the informational modifiers.

CMS opinion: You can typically expect a claim denial from Medicare payers if there are any other modifiers on a line of service with 99.

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