Part B Insider (Multispecialty) Coding Alert

Published on Tue Jan 01, 2008 PDF

One internal audit reminded a practice to apply the new descriptors to claims

If you haven't tweaked your modifier use to fit the CPT 2008 rules, you might be forfeiting a fortune.

As most practices know, CPT 2008 included revised and expanded descriptors for seven modifiers, plus it added a new modifier to your collection. One subscriber, however, tells the Insider that she was surprised to learn that she was entitled to more reimbursement than she expected, and blamed old modifier descriptions for her error.

Daneele Collins of Oden Orthopaedics submitted a claim to her Part B carrier for a physician assistant's work. The practice had recently hired the PA, and Collins was unfamiliar with nonphysician billing practices.

On the date of service in question, the PA examined a patient who had fallen down the stairs, checked the patient's arm and leg for injuries, and splinted the patient's wrist.

Collins submitted the claim with charges for the splinting, but not the E/M visit. She thought that because CPT indicated that modifier 25 was for a separate -physician- service, she couldn't use it for her PA's claims.

Collins- office manager reviewed the claim as part of a self-audit. When the reviewer gave Collins the results, she was surprised to hear that she could have collected more money. -They said that we should have billed the E/M with modifier 25 on it,- she says. -I am wondering how much more money we would have lost if that claim hadn't been part of the review and I kept on billing more PA claims without modifier 25.-

Fortunately, CPT 2008 revised the instructions for modifier 25, indicating that nonphysicians can indeed use it for their services.

Some modifiers open the door to other practitioners: This year, CPT deleted the term -physician- from the Appendix A explanation for modifier 25, as mentioned above. Now, instead of stating, -the physician may need to indicate - the patient's condition required a significant, separately identifiable E/M service,- the explanation says, -It may be necessary to indicate that on the day a procedure or service identified by a CPT code was performed, the patient's condition required a significant, separately identifiable E/M service.-

Why the change? According to the rationale in the AMA-s CPT 2008 Changes: An Insider's View, removing the term -physician- from the explanation expanded the modifier's use. Now other nonphysician practitioners (such as chiropractors, physician assistants, physical or occupational therapists and others) can report modifier 25 without being challenged.

Explanations for modifiers 59 (Distinct procedural service), 76 (Repeat procedure or service by same physician) and 78 (Unplanned return to the operating/procedure room by the same physician) now also include nonphysician practitioners.

-This is a very important change for us,- says Neil Busis, MD, of the University of Pittsburgh Medical Center in Shadyside. -It may help the coding by our PAs and CRNPs.-

Descriptors better distinguish 58 and 78: For years, coders have confused when to use modifiers 58 and 78. CPT 2008 includes updated descriptors and definitions for each of these modifiers in an attempt to help you correctly report them. The new modifier descriptors are:

- Modifier 58--Staged or related procedure or service by the same physician during the postoperative period
- Modifier 78--Unplanned return to the operating/procedure room by the same physician following initial procedure for a related procedure during the postoperative period.

The primary difference between the modifiers is that 58 represents a planned follow-up procedure, while  78 represents an unplanned follow-up procedure.

Modifier 22 change: The modifier 22 descriptor used to read, -Unusual procedural services,- but CPT 2008 changed it to -Increased procedural services.-

According to An Insider's View, -The language was revised to include that substantially greater services than typically provided must be performed in order to report modifier 22.-