Welcome to your first Basic Coding lecture! Let’s begin by answering the question: what is medical coding? The foundation of medical coding involves transforming descriptions of medical diagnoses, services, procedures, supplies, and drugs into numeric and alpha numeric codes.
There are three coding manuals used in coding processes. The purpose of coding is to track and report diseases and conditions and to report services and medical supplies provided by a physician or care giver to insurance companies for payment. Providers use a standardized claim form to report services to third party payers. For example, outpatient facilities and provider offices use the CMS-1500 form to request reimbursement from insurance companies. Whereas, hospitals use the CMS 1450, formerly called the UB-92, to report inpatient services.
The International Classification of Disease, 9th Edition, Clinical Modification, commonly referred to as ICD-9-CM, uses numeric and alphanumeric codes to track all diseases and reasons for patient care including conditions such as diabetes mellitus, heart disease, nor virus, the flu, and athlete’s foot, to name a handful. These diagnosis and procedure codes are used by government health programs, private health insurance companies, workers' compensation carriers, and Medicare. The codes are maintained by the National Center for Health Statistics and the Centers for Medicare and Medicaid Services or CMS.
There are three coding manuals used in coding processes. The purpose of coding is to track and report diseases and conditions and to report services and medical supplies provided by a physician or care giver to insurance companies for payment. Providers use a standardized claim form to report services to third party payers. For example, outpatient facilities and provider offices use the CMS-1500 form to request reimbursement from insurance companies. Whereas, hospitals use the CMS 1450, formerly called the UB-92, to report inpatient services.
The International Classification of Disease, 9th Edition, Clinical Modification, commonly referred to as ICD-9-CM, uses numeric and alphanumeric codes to track all diseases and reasons for patient care including conditions such as diabetes mellitus, heart disease, nor virus, the flu, and athlete’s foot, to name a handful. These diagnosis and procedure codes are used by government health programs, private health insurance companies, workers' compensation carriers, and Medicare. The codes are maintained by the National Center for Health Statistics and the Centers for Medicare and Medicaid Services or CMS.
The Current Procedural Terminology manual, or CPT codes, transform medical, surgical, and diagnostic services or procedures rendered by health care providers into five digit numerical codes. This is comparable to how the town or city in which you live is identifiable by a five digit zip code. The codes are used by providers to communicate the type of service to be paid for by the third party payer, usually an insurance provider, to physicians, healthcare organizations, and other healthcare providers such as physical therapists, nurses, and psychologists. For example, when a new patient is seen for a new patient office visit, code 99203 may be used to report the examination of the patient. Additionally, analyzing CPT codes can be useful in tracking physician productivity and can help with scheduling, planning, research, conducting quality studies, and marketing. The Healthcare Common Procedure Coding System, or HCPCS, is a two-part system developed in 1983 by the Centers for Medicare and Medicaid Services to standardize the coding system used to process Medicare claims. The CPT was soon after adopted by all insurance carriers as many insurance companies required use of several different coding systems to report services. Standardizing the use of codes helped streamline the billing process so all third parties could use the same type of codes. Level II HCPCS includes national codes. These alphanumeric codes are used to report supplies and procedures not found in the CPT manual such as ambulance services, injectable medications, and durable medical equipment, which is abbreviated DME, such as wheelchairs, walkers, and crutches. Believe it or not, items as small as hot water bottles and ice caps are coded under HCPCS.
In this course, we will focus on CPT coding.
The CPT code set is maintained by the American Medical Association through the CPT Editorial Panel. The codes are published, copyrighted, owned, and operated by the American Medical Association, also known as the AMA.
The CPT manual is updated each November for the following year. Each year, new codes are added and other codes are deleted or revised. You can find the code changes in Appendix B of the manual. Most insurance companies require providers to begin using the new edition of codes beginning by January first of each year, and there is no grace period. Reporting incorrect or outdated codes will cause over payments, under payments, rejections, denials, and audits of provider claims. Accuracy is essential!
The CPT is divided into three categories. Category I CPT codes are the five-digit numeric codes included in the main body of CPT. Category I is the section that coders usually identify with when talking about CPT. These codes represent procedures that are widely performed and accepted by the medical community. Procedures or services in this category have been approved by the Food and Drug Administration (FDA) and are procedures or services commonly performed or provided by health care professionals nationwide. Category II includes supplementary tracking codes used for performance measures, and Category III includes temporary codes used for emerging technology.
CPT Category II codes are optional codes developed to support performance measurement. The codes have been developed to monitor the care provided and patient outcomes in certain clinical conditions such as: asthma, chronic stable coronary artery disease, congestive heart failure, hypertension, osteoarthritis, prenatal care and preventive care. Category II codes have four digits followed by a letter. For example, a physician would use the code 1000F to code that tobacco use was assessed in a patient with coronary artery disease.
CPT Category III Codes are temporary codes for new and emerging technology, services, and procedures. Category III codes are different from Category I in that they identify services that are not performed by many healthcare professionals across the country and do not have FDA approval. These codes have five digits with four numbers and the letter T at the end. If the code does not become a category I within five years, the code is retired.
Category I is broken down into six separate sections: Evaluation & Management, abbreviated E/M, Anesthesia, Surgery, Radiology, Pathology & Laboratory, and Medicine.
In this course, we will spend most of our time discussing the E/M, Anesthesia, and Surgery sections. The ability to identify what section you are working in will simplify the coding process. You may want to have your CPT manual handy so you can explore each section during the lecture. You may also find it helpful to tab the beginning of each section with a bookmark or post-it note labeled with the section name for easy reference.
In this course, we will focus on CPT coding.
The CPT code set is maintained by the American Medical Association through the CPT Editorial Panel. The codes are published, copyrighted, owned, and operated by the American Medical Association, also known as the AMA.
The CPT manual is updated each November for the following year. Each year, new codes are added and other codes are deleted or revised. You can find the code changes in Appendix B of the manual. Most insurance companies require providers to begin using the new edition of codes beginning by January first of each year, and there is no grace period. Reporting incorrect or outdated codes will cause over payments, under payments, rejections, denials, and audits of provider claims. Accuracy is essential!
The CPT is divided into three categories. Category I CPT codes are the five-digit numeric codes included in the main body of CPT. Category I is the section that coders usually identify with when talking about CPT. These codes represent procedures that are widely performed and accepted by the medical community. Procedures or services in this category have been approved by the Food and Drug Administration (FDA) and are procedures or services commonly performed or provided by health care professionals nationwide. Category II includes supplementary tracking codes used for performance measures, and Category III includes temporary codes used for emerging technology.
CPT Category II codes are optional codes developed to support performance measurement. The codes have been developed to monitor the care provided and patient outcomes in certain clinical conditions such as: asthma, chronic stable coronary artery disease, congestive heart failure, hypertension, osteoarthritis, prenatal care and preventive care. Category II codes have four digits followed by a letter. For example, a physician would use the code 1000F to code that tobacco use was assessed in a patient with coronary artery disease.
CPT Category III Codes are temporary codes for new and emerging technology, services, and procedures. Category III codes are different from Category I in that they identify services that are not performed by many healthcare professionals across the country and do not have FDA approval. These codes have five digits with four numbers and the letter T at the end. If the code does not become a category I within five years, the code is retired.
Category I is broken down into six separate sections: Evaluation & Management, abbreviated E/M, Anesthesia, Surgery, Radiology, Pathology & Laboratory, and Medicine.
In this course, we will spend most of our time discussing the E/M, Anesthesia, and Surgery sections. The ability to identify what section you are working in will simplify the coding process. You may want to have your CPT manual handy so you can explore each section during the lecture. You may also find it helpful to tab the beginning of each section with a bookmark or post-it note labeled with the section name for easy reference.
The first section of the manual is the E/M section. The guidelines are found on page one and the code descriptions begin on page nine. Let’s use this section to discuss what your text refers to as the “format of the terminology.” The format of the terminology began as standalone descriptions of medical procedures. “Stand alone” means codes are given a full description of the service or procedure. However, to conserve space and to avoid having to repeat common terminology, some of the procedure descriptions in CPT are not repeated. Codes with shortened descriptions are referred to as indented codes.
What does this mean? Pay close attention. Here’s an example:
Turn to code 99238 which is for hospital discharge day management; 30 minutes or less. Now, look code 99239 which is just below 99328. Notice how the words across from those codes are indented. Code 99239 states more than 30 minutes and includes all of the wording from code 99238 before the semicolon, but to save space the wording is not reprinted. If the wording was printed, the code would read: hospital discharge day management; more than 30 minutes. If full paragraph descriptions were printed for each code, the CPT manual would be too heavy to carry!
Each section within the CPT manual is divided by section, subsection, subheading, and category. Let’s use code the page with code 99328 as an example. At the top of the page you should see code range 99234-99238. This tells us the code range found on the page. Next to the code range you will see our section which is Evaluation and Management followed by a / and the words Hospital Inpatient Services. This is our subsection. Just like each section contains its own guidelines, each subheading or category contains its own set of guidelines which are referred to as notes. Notes in parenthesis are called parenthetical notes.
Within each subsection are subheadings and/or categories which also contain important notes and guidelines. Our subheading above code 99238 is Hospital Discharge Services, which is listed under the Hospital Inpatient Services subsection. Notice the notes below the heading Hospital Discharge Services. Before selecting your code, you should always read the notes thoroughly.
Throughout the CPT manual symbols appear that alert the coder to specific information about particular codes. The guide to the meaning of these symbols can be located at the bottom of each page and inside the front cover of the manual. The symbols are shown on this side. We will go over each point individually in the following slides.
A bullet symbol next to a code indicates a new code for the current year. It is important to remember that all new codes are also listed in Appendix B.
A Triangle with the point on top lets the coder know that code has been changed from previous years. These changes are usually revision to the wording of the code. Let’s look at an example of a code that has been revised from a previous CPT edition. Turn to code 99305 in the E/M section which describes an initial nursing facility visit. Do you see the triangle next to the code? If you turn to Appendix B on page 384 of the CPT, you can locate code 99305. Within the code description you will see that a line has been drawn through the wording “with the patient and/or family or caregiver.” The line indicates the text has been omitted from the 2010 code description.
The arrow symbol indicates that the AMA has published reference material in CPT Changes: An Insider’s View or in the CPT Assistant newsletter on that particular code. CPT Changes: An Insider’s View is published once a year and includes educational instructions related to new, revised, and deleted codes. CPT Assistant is the AMA’s monthly authoritative coding newsletter that also contains educational instruction related to new, revised, or deleted codes. These are two resources that will be useful to you as you continue your studies and enter the workforce.
Right and left triangles at the beginning and end of text point out that the text has been changed or added in that part of the terminology of the code description. Take a moment to turn back to the Medicine section and look up code 93701. If you look below code 93701 you will see notes that begin with a right triangle and end with a left triangle. An example if text changes can be seen on the slide.
The plus sign before a code indicates that the code is an add-on code and must be used with another code. An add-on code is never used alone. Let’s look at an example of an add-on code. Why don’t we move away from the E/M section so you have an opportunity to view other sections of the CPT manual? Let’s find code in the Surgery section and the integumentary system subsection.
The code we will find is in the Integumentary subsection of the Surgery section which is located after the E/M and Anesthesia sections. Locate code 11200 which is used for removal of skin tags. Did you find the code? If not, turn to page 48. Don’t worry; finding codes takes a lot of practice. Code 11200 reads Removal of skin tags, multiple fibrocutaneous tags, any area; up to and including 15 lesions. Code 11201, which is listed below code 11200, has the plus symbol indicating it is an add-on code. Code 11201 says each additional 10 lesions or part thereof (list separately in addition to code for primary procedure). This means, if more than 15 skin tags were removed, both code 11200 and 11201 would be used to report the procedure. For example, if a physician removed 20 skin tags, we would report code 11200 for the first 15 skin tags, and code 11201 for the remaining 5 skin tags. Code 11201 can never be reported without code 11200. You can reference the full list of add-on codes in Appendix D.
A circle with a line, the universal sign for “no,” shows that modifier 51, multiple procedures, cannot be used with this code. Multiple procedures mean two or more procedures are performed at the same time. Modifiers are two digits added to the end of CPT codes which indicate that services or procedures were changed or altered by specific circumstances, but the actual code description remains unchanged. Appendix A provides a complete list of CPT and HCPCS modifiers with guidelines. The inside cover of the CPT manual also has a list of modifiers with short definitions as an easy reference. If you aren’t sure when to use a particular modifier, you should reference Appendix A for the full description of the modifiers usage. Appendix E lists all modifier 51 exempt codes. Don’t worry if modifiers seem a little confusing right now. We will spend more time discussing modifiers later in this lecture.
The lightning bolt alerts the CPT user that the vaccine is not approved by the Food and Drug Administration, commonly known as the FDA. An example is CPT code 90663, the current influenza virus vaccine, pandemic formulation. This vaccine is not currently approved by the FDA. Once the FDA approves the vaccine, the lightning bolt symbol will be removed.
The last three symbols are those most recently added to the CPT manual.
The transparent circle means the code has been reinstated or recycled from a previous year.
The last symbol is the number symbol (#) which is new to the 2010 edition. The number symbol indicates that a code is out of numerical sequence. There are only a handful of codes that are out of numerical sequence in 2010. A list of the codes can be found in Appendix N. The codes are out of sequence because they were new codes or revised codes added to related code groups, or families, where a new number was not available. Instead of renumbering an entire category within the manual to insert the code, it saved the publishers’ time by using the out of sequence code and the number symbol to alert the user of the numerical order.
It is important to notice that throughout the CPT manual, you will see notes that indicate a code has been deleted from the previous edition. For example, in the 2010 edition, quite a few changes were made within the Surgery section. Let’s look at an example. Take a moment to find code 14300. If you are having trouble finding the code it is because code 14300 was deleted. In its place is a parenthetical note. Remember, left and right arrows indicate a change to the edition. Inside the arrows is a note that reads 14300 has been deleted. To report, see 14301, 14302. These notes assist the coder in determining the best course of action to code correctly when a code has been deleted. Appendix B shows deleted codes by drawing a dark line through the code description. To stay up to date as a coder, Appendix B should be checked with each edition to reference code deletions and changes.
CPT codes and modifiers are reported in the same area of the CMS 1500 claim form. On this slide, you will see a portion of the CMS 1500 form showing where the CPT codes are supposed to be placed. Item 24D on the CMS 1500 form is where the CPT/HCPCS code is entered. The modifier, if needed, is inserted on the right. Six CPT of HCPCS codes may be listed on the CMS 1500. Only one code is listed per line. A total of 4 modifiers can be listed on each line.
The CPT manual provides extensive appendices from A to M. Some of these appendices have been referenced throughout this lecture. You should spend some time on your own reviewing each of these appendices. Coders can refer to the appendices for quick reference on exempt codes, examples, and a variety of other topics. The use of some of the appendices can vary by type of facility or medical practice. Examples of some of the information found in the appendices are Appendix F which lists codes exempt from modifier 63; Appendix G lists codes that include moderate sedation; and Appendix H lists clinical conditions and measurements that are used with Category II codes.
When trying to locate codes within the CPT manual, you will need to use the Alphabetic Index to look up the codes. The Alphabetic Index is located after the appendices in the CPT manual. Once a code or range of codes is found in the Index, the codes will need to be crosschecked in the Tabular sections of the manual where the codes are described. The alphabetic index is NOT a substitute for the main text of CPT. The user must refer to the main text to ensure that the code selection is accurate. The alphabetic index is concise, but more information is available in the main section, information that could let the coder know to look for another code.
The index is organized so that codes can be found in one of four ways. Sometimes a coder has to try different terms to find the code location. The main headings are procedures or services, organ or anatomic site, condition or synonyms, eponyms, or abbreviations. Under procedures or services, you would find colonoscopy or office visit. Under the heading organ or anatomic site, you would find heart or abdomen. Under condition or symptoms you would find fracture or acid reflux, and a good example of an eponym is a Whipple procedure. An eponym is a procedure or condition that is named after the person who first used the procedure or discovered a disease.
Let’s briefly discuss code ranges in the index. Whenever more than one code applies to a given index entry, a code range is listed. A code range is indicated with a hyphen between codes. Reconstruction, mandible, with implant lists two code ranges: 21244-21245 and 21248-21249. If several non-sequential codes apply, they will be separated by a comma. For example: Leukocyte count 85032, 85048, 89055. It is important when you have multiple codes or code ranges that you check the codes within the Tabular section. You could not accurately code a procedure by just choosing a code within a range.
As we discussed earlier, codes can be looked up in four ways in the Index. Frequently, the Index lists cross references or “see” notes. This reference is used often for synonyms, eponyms, and abbreviations. For example, the when looking up the abbreviation ECG, you will find the note See Electrocardiography. A list of common abbreviations can be found on the back inside cover of the Standard edition of the CPT in the event you cannot locate an abbreviation in the Index. It is also a good idea to have your medical dictionary on hand in case you come across a term you do not know.
Another example is when you are referred to a different area of the body. If you were to look up the body part Flank you will find a cross reference that says “See Back/Flank.”
Reviewing and understanding the basics of the CPT manual is the first step to becoming an effective coder.
Let’s spend the remainder of this lecture discussing modifiers. Modifiers are essential tools in the coding process. Modifiers are two digit numeric or alphanumeric characters. They enhance code descriptions to explain special circumstances of each procedure or service. Modifiers enable more accurate, effective communication between payers and providers and should be used consistently with all payers, unless a payer rejects claims with modifiers.
Throughout this chapter of your textbook, you will see references to NCCI guidelines and the appropriate use of modifiers with certain codes. NCCI stands for the National Correct Coding Initiative which was developed by CMS to promote national correct coding methods and to control inappropriate payment on Part B Medicare claims. The NCCI guidelines are intended only for beneficiaries of government programs such as Medicare; however, many third-party payers have adopted the NCCI guidelines. When using codes and modifiers, it is always a good idea to check the carrier policies and guidelines before submitting a claim. You can find a link to the NCCI guidelines in this week’s weblinks.
Four modifiers may be appended, or added, to each CPT or HCPCS code, but it is important to list the modifier that will affect reimbursement first.
Just as a reminder, remember that modifiers are found in Appendix A and inside the front cover of all CPT manuals. They are not found in the index.
The first modifiers we will discuss are commonly used with Evaluation and Management codes.
Modifier 22, Increased Procedural Service, indicates the service time is greater than that usually required for the service. The work and effort is substantially increased and documentation must support the substantial additional work and the reason for the additional work. Some reasons the service would be greater than usual include increased intensity of the medical condition, technical difficulty of procedure, severity of patient’s condition, and additional physical and mental effort required. It is important to point out that this modifier should not be appended to an Evaluation and Management code.
Modifier 24 Unrelated E&M service by the same physician during the postoperative period, which means an E&M service not related to an initial surgical procedure, was performed during the post operative period. For example, an orthopedic surgeon performs a hip replacement on a patient. During the normal, uncomplicated postoperative period the patient falls and sprains her wrist. A diagnosis code for a sprained wrist will be necessary to substantiate use of modifier 24.
Modifier 25 means Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service. This means, on the same day as another procedure or service was performed, the patient’s condition required E&M service beyond the usual pre- and postoperative care of the initial procedure. Symptom or condition related to initial procedure may prompt E&M services. For example, if a patient was seen for an annual preventive examination and the physician discovered the patient had an abnormal heart rhythm, two E/M codes would be reported. The first code would be for the preventive visit, and the second for the work involved in diagnosing the heart problem. The second code would be reported with modifier 25.
Modifier 26, Professional Component, is used if a procedure is comprised of both a technical and a professional component, and the procedure is performed with facility owned equipment. Physicians use modifier 26 to indicate that only the professional component is being billed. The professional component includes the physician’s work, associated overhead, and professional liability insurance for the physician. The kinds of services involved include diagnostic tests that involve a physician’s interpretation, such as EEGs, diagnostic & therapeutic radiology services, and physician pathology services.
Modifier 32, Mandated Services, is used when a basic procedure is required by a third party payer, or a governmental, legislative, or regulatory requirement. For example, Workers’ Compensation may require a second opinion consultation from a different surgeon for a patient who required surgery. The consultation would be reported with modifier 32.
Modifier 23 Unusual Anesthesia is used by anesthesiologists. This modifier is used with procedures that would usually require only local anesthesia, but because of unusual circumstances must be performed under general anesthesia. Examples include an individual with a developmental disability who is extremely apprehensive or has specific physical conditions such as tremors and spasticity, or a child that requires extensive stitches on his face. If the wounds are deep and jagged and the child is extremely agitated, the plastic surgeon may elect to use a general instead of a local anesthetic.
In some cases, a regional or general anesthesia is provided by the surgeon who performed the procedure instead of the anesthesiologist. The surgical procedure code is appended with Modifier 47, Anesthesia by Surgeon. The modifier does not include local anesthesia and would not be used as a modifier for procedures that already indicate the use of anesthesia.
Let’s move forward to discuss modifiers for procedures performed in ways that either reduce or increase reimbursement of a selected code.
Modifier 50, Bilateral Procedure, is used to report procedures performed on both sides of symmetrical body parts during the same operative session. The physician is paid 150% of the fee schedule allowed amount for the procedure. Note that if the terminology in the procedural code states “bilateral or “unilateral,” modifier 50 should not be used.
Modifier 51, Multiple Procedures, is used when multiple medical procedures are performed at the same session by the same provider. The primary procedure is reported and additional procedures or services are reported with the modifier 51. Reporting modifier 51 reduces the reimbursement rate for procedures. The physician is generally paid the full insurance allowed amount on the primary procedure. The second procedure would be paid at 50% of the allowed amount. Additional procedures are paid at 25% of the allowed amount. The rationale for the reduced payment is that the patient is already prepped for surgery and the same materials, facility, and supplies are used during the procedure. Appendix E in the CPT manual lists codes exempt from modifier 51. Modifier 51 also cannot be used with add-on codes.
Modifier 52, Reduced Services, is a procedure partially reduced or eliminated at the physician’s discretion. An example is an extremity arterial study performed on a patient who had above the knee amputation. Code 93923, a bilateral study code would be applied since the procedure could not be done bilaterally due to the patient’s missing lower leg. Modifier 52 would be appended.
You can think about modifier 52 as the opposite of modifier 51. Modifier 51 indicates that a procedure was performed bilaterally, whereas modifier 52 indicates that a procedure wasn’t performed bilaterally.
Modifier 53, Discontinued Procedure, is applied when a physician terminates a procedure due to a life threatening condition of patient, for example, arrhythmia, hypotensive or hypertensive crisis. The procedure was started, but stopped after induction of anesthesia and after surgical preparation in the operating suite. Modifier 53 is not used for elective cancellation of a surgical procedure, only necessary cancelations.
When a procedure is stopped, a report describing the extent of the procedure at the time it was stopped should be composed. Modifier 53 is used by physicians only.
Most surgeries are part of what is known as a Surgical Package which means all preoperative, postoperative, and the surgery itself are reported, or bundled, into one code. All normal surgical care is included in the code for the global period of the surgery. A global period is the average amount time a patient heals from a particular surgery. The global period can last anywhere from 10 to 90 days depending upon the type of surgery. There are times when a physician performs only one aspect of a surgical procedure. For example, a patient may have a surgery performed away from home. Once the patient is stabilized, they return to their regular provider for postoperative care. In this case, Modifier 55, Postoperative Management Only, is provided by the physician who saw the patient for the postoperative care. The Modifier 54, Surgical Care Only, would be reported by the physician who performed the surgical procedure.
Modifier 56, Preoperative Management Only, is used when one physician performs the preoperative care and evaluation and another physician performs the surgical procedure. The physician providing preoperative care and evaluation reports the code for the procedure with modifier 56. For example, a physician may have performed all of the preoperative care for a patient prior to a surgery, but was unavailable to perform the surgery itself.
Modifier 57, Decision for Surgery, is a frequently used modifier used modifier. It is appended to an Evaluation and Management service if the decision to perform major surgery was made either the day before or day of the surgery. Modifier 57 indicates that the consultation is not part of the surgery package or global surgical package. For example, a consultant sees a patient for abdominal pain and recommends surgery. The requesting doctor concurs and the cholecystectomy is done the same day. The Evaluation and Management code is appended with modifier 57. The cholecystectomy code is assigned with no modifier.
The consultation led to a decision for surgery and the surgery was not scheduled until after the consultation. If a patient was seen for a consultation to discuss an upcoming surgery, modifier 57 could not be reported. Are you following? I know, the use of modifiers can be confusing.
Modifier 58 is a Staged or Related Procedure or Service by the same physician during the Postoperative Period. The performance of the procedure was planned at the time of the original procedure or a more extensive procedure is required after the first procedure. Modifier 58 may also be used for therapy following a diagnostic surgical procedure. This modifier is most commonly used for surgical procedures that require healing time between procedures. For example, a colostomy is a procedure performed in which a tube is inserted into the intestine after a portion of the colon has been removed. The tube is attached to a colostomy bag which collects waste from the body that is no longer removed by the colon. After the portion of the colon has been removed, the surgeon may choose to allow the surgical area to heal or the swelling to reduce before inserting a permanent colostomy.
Modifier 59, Distinct Procedural Service, indicates that another procedural service was distinct or independent from a previous service that occurred on the same day. Documentation in the patient record must support a different session or encounter, different site or organ system, separate incision or excision, separate lesion, treatment of a different injury or area of injuries if the injuries are extensive. Modifier 59 should only be used if another more descriptive modifier is not available and should not be appended to an Evaluation and Management service. Modifier 59 is most often used with codes that are not normally reported together. For example, there are two ways to report a colonoscopy: either by snare technique which uses forceps to remove polyps, or hot biopsy which is a method of cauterization. These procedures are rarely performed at the same time. If they are performed together, modifier 59 would be appended to the code with the lesser cost to show it was a distinct service.
Modifier 63 is used for procedures performed on an infant or neonate weighing less than 4 kilograms in the 20000 to 69999 code range. Modifier 63 is not used on E&M, Anesthesia, Radiology, Pathology and Laboratory, and Medicine Sections. It is also not used with certain procedures performed on infants for correction of congenital abnormalities or for procedures where age and/or weight are already considered. Modifier 63 is used with procedures on neonates and infants involving significantly increased complexity and physician work. Procedures related to temperature control, obtaining IV access and an operation that is technically more difficult than it usually is, are all procedures that can be used with modifier 63.
Let’s discuss a few modifiers that are used when surgeons work together.
Modifier 62, Two Surgeons, is used when two surgeons of different specialties work together as primary surgeons on distinct parts of a single reportable procedure. Each surgeon’s portion of the procedure is considered equal and they are usually each paid 50 percent each of the allowed amount for the procedure. Each surgeon reports his or her distinct part by adding modifier 62.
Modifier 66, Surgical Team, is used when highly complex procedures require a surgical team, services of several physicians of different specialties, other highly skilled personnel, and complex equipment. An example is a heart transplant, CPT code 33945, modifier 66. Each physician involved in the transplant would report the same code plus modifier 66.
Modifier 80, Surgical Assistant, is used when one physician assists another physician. The assisting operating surgeon reports the same surgical procedure as the operating surgeon, but the assisting operating surgeon uses modifier 80. The operating surgeon would not append a modifier to the procedure he or she reports. The assistant surgeon is usually paid 20 percent of the allowed charge for the surgical procedure.
Modifier 81, Minimum Assistant Surgeon, is used when a procedure may require more than one assistant surgeon or when a primary operating physician plans to perform a surgical procedure alone but circumstances arise that require an assistant surgeon for a short period. The second surgeon provides minimal assistance and reports the surgical procedure code with modifier 81 appended. The minimal assistant usually receives only 10 percent of the surgical allowed charge.
Modifier 82, Assistant Surgeon, is used only when a qualified resident surgeon is not available. This modifier should not be confused with modifier 81. The unavailability of a qualified resident surgeon is a prerequisite for use of modifier 82 appended to the usual procedure code numbers. In teaching hospitals, the assistant surgeon is usually a qualified resident surgeon. There are times during rotational changes when a qualified resident surgeon is not available and another surgeon assists during the operation. When this happens, modifier 82 is used. This indicates that another surgeon is assisting at the operation instead of a qualified resident surgeon.
When a patient has surgery, extenuating circumstances can occur that cause the patient to be returned to the operating room either the same day or during the postoperative period. It is important to indicate to the insurance company why the same procedure is performed. In addition to the modifiers listed on this slide, it may also be necessary to submit operative reports along with the insurance claim to justify the need of the second surgical procedure.
It may be necessary to indicate that a procedure or service was repeated subsequent to the original procedure or service. This circumstance may be reported by adding the Modifier 76, Repeat Procedure or Service by the Same Physician. For example, the physician may have performed a test that was inconclusive and ran the test again to verify the results. Reporting modifier 76 on the second procedure indicates that the services are not duplicates.
If the same procedure is performed on a patient by a different physician than the one who originally performed to the surgery, Modifier 77, Repeat Procedure by Another Physician, must be used. For example, say Physician A performs bypass graft procedure in the morning and reports code 35556. The graft clots and physician B performs the same procedure that afternoon and reports 35556 with modifier 77.
There are times when a patient must be returned to the operating room as a result of complications from a surgery performed on the postoperative period day. In this event, modifier 78, Unplanned Return to the Operating or Procedure Room by the Same Physician Following Initial Procedure for a Related Procedure during the Postoperative Period, is appended to the code. Here is an example: A patient’s operative site bleeds after the initial surgery; the same surgery would not be repeated, instead CPT code 35860, exploration for postoperative hemorrhage, chest, is used with modifier 78 appended.
Modifier 79, Unrelated Procedure or Service by the Same Physician During the Postoperative Period, is required if the physician may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. This circumstance may be reported by using the modifier 79. For repeat procedures on the same day, modifier 76 would be used.
Let’s conclude our lecture by discussing the remaining modifiers used for laboratory services.
Modifier 90, Reference outside Laboratory, is used for laboratory procedures performed by a party other than the treating or reporting physician. The analysis of a test or specimen is done by an outside or reference lab instead of the physician’s office. For example, a physician takes a specimen sample and sends it to the lab, the lab sends results to the physician, and the physician bills for the service. The physician would bill for the procedure, but would use modifier 90 to indicate that the actual lab test was performed at a different facility. This is a common occurrence with procedures such as pap smears and biopsies.
Modifier 91, Repeat Clinical Diagnostic Laboratory Test, is used for lab tests repeated on the same day to obtain subsequent results. The modifier 91 is only used to produce multiple test results. For example, it may be required to perform a test at different times of the day such as morning and nighttime. This modifier cannot be used when tests are rerun to confirm initial results, due to testing problems with specimens or equipment, or for any other reason when a normal, one-time, reportable result is all that is required. Modifier 91 also cannot be used when codes describe a series of test results like glucose tolerance tests. This modifier can only be used for laboratory tests performed more than once on the same day on the same patient.
Modifier 92, Alternative Laboratory Platform Testing, is used when laboratory testing is being performed using a kit or transportable instrument that wholly or partially consists of a single-use, disposable analytical chamber, the service may be identified by adding modifier 92 to the usual laboratory procedure code. For example codes 86701-86703 are used to report a single use of a disposable HIV kit.
Our final modifier is used when reporting multiple modifiers on a claim form. As we discussed earlier, up to four modifiers can be used with each procedure on a claim form. When it is necessary to report more than one modifier, Modifier 99, Multiple Modifiers, is used to alert a third party payer that multiple modifiers are being used. It is important to check with the insurance carriers guidelines before submitting a claim with multiple modifiers. The guidelines may vary on where in the order of modifiers the 99 should be placed. This modifier is only used for submitting claims to carriers who do not routinely except multiple modifiers on the claim form.
Let’s get you off to a good start by reviewing the information we covered today. This lecture focused on the Current Procedural Terminology manual, or CPT. Remember, the CPT manual is considered Level I of the Health Care Common Procedural Coding System. The CPT manual uses symbols and other conventions to guide the user in selection of an appropriate code. For example, the bullet symbol represents a new code and a triangle means the code has been revised from a previous edition. While there are many codes listed in the CPT manual, it is possible that there is not a code available that completely defines the service provided. If this is the case, you will need to use an unlisted code.
Remember, to locate a code you should always begin by referencing the main term and subterms in the Index, then look for your code choices in the Tabular section. The index often lists ranges of codes which are separated by a hyphen. Make sure to check each code in the range.
The codes in the Tabular section are considered either stand alone codes or indented codes. Stand alone codes contain the full description of a service or procedure. Indented codes are considered space savers and are located beneath the stand alone code. The indented code includes all of the information before the semi-colon in the stand alone code.
Each section within the CPT manual contains its own set of guidelines. Within the section you will see additional notes and parenthetical instructions. Make sure you read the information carefully before selecting a code.
Much of our lecture focused on modifiers. Remember, modifiers are used to indicate that a service or procedure has been altered by some specific circumstance, but the definition of the service, supply, or procedure remains the same. Modifiers are found within both the HCPCS and CPT manuals and can be appended to either a HCPCS code or CPT code. Insurance carriers may have different rules on how modifiers and codes can be used. It is always a good idea to check the National Correct Coding Initiative, or NCCI, guidelines before submitting a claim to the carrier.
