​Access is a significant concern in the United States and all over the world when it comes to patient care. We all know that the patients have to wait for months to get the physician they want, and a good doctor has more patients than they can manage. The patients waiting for months to get the physician surely lead to delayed treatment and also can jeopardize their health and their life. On the other hand, it will certainly reduce the patient satisfaction scores for the doctors and the medical service providers.

As these scores have to be shared with third parties such as pharmaceuticals and drug companies as well as the insurance companies, managing the scores is extremely significant for the doctors.

So here are a few ways that you can make sure your patients are not sitting and waiting for you to give them an appointment for half a year. 

Step 1:  Learn how to Measure
The first appointment available is a valuable commodity. So make sure that you have a good system to call people who are on the waiting list. Not just the first appointment available, but the second and third appointments available can also be prescheduled. You should inform the patients that are on the waiting list that they can be called in for a consult at short notice. When a person is coming up for the next available appointment, you can inform them that they are next on the list. That will allow individuals to prepare for showing up without feeling like it was impractical to ask on such short notice. 

Call people up or have a reminder system in place that will inform people on the list when they are next on the list of first appointment available. There are many openings happening every day, and placing then effectively can reduce overextended waiting lists considerably.

Step 2: Denied Appointment Requests
The patients who were denied an appointment is also a crucial list that needs to be monitored closely. There are many reasons that a patient is denied care, and those reasons should be listed clearly. If there is no appointment available or the appointment is not given for another reason, the reasons should be listed. That process will allow the nurses and administration to solve the problem and will allow them to develop a system that reduces denied appointments. 

Step 3: Implementation of the Data
The main focus of all of the points mentioned above is to have a system that focuses on developing data sheets on appointment schedules so that you can decide how to have a more productive appointment culture.

Billing for the Genicular Nerve Branches RFA have been a struggle since it was not too clear to us on how we should be billing for this service. The good news is, we have a new code for this effective January 1, 2020. New CPT 2020 Changes. New Pain Management 2020 Codes.

When your physician is performing an RFA on Genicular nerves, use code 64624 (Destruction by neurolytic agent of genicular nerve branches). Take note of the word "branches".

These changes are explained as follows:
Destruction by Neurolytic Agent (eg, Chemical, Thermal, Electrical or Radiofrequency), Chemodenervation on the Somatic Nerves

CPT CODE 64624 Destruction by neurolytic agent, genicular nerve branches including imaging guidance, when performed

(Do not report 64624 in conjunction with 64454 - Injection(s), anesthetic agent(s) and/or steroid; genicular nerve branches, including imaging guidance, when performed

Pay attention to this, the CPT 64624 requires the destruction of each of the following genicular nerve branches: (make sure your Provider had documented this!)

• superolateral
• superomedial
• inferomedial

If a neurolytic agent for the purposes of destruction is not applied to all of these nerve branches, you can report CPT 64624 but you MUST append the MODIFIER 52:

64624-52

What is Modifier 52?

Modifier 52 is usually used for reduced services. It may occur under certain circumstances that a service or procedure is partially reduced or eliminated at the physician’s discretion. There can be several reasons behind the physician’s decision. In this situation, service provided can be identified by its usual procedure number and the addition of the modifier 52, which indicates that the service was reduced.

Here's the good news! Effective January 1, 2020, we now have a more specific code instead of using the "other peripheral" nerve block. 

Our 2020 Pain Management New Code is:

64451, Injection(s), anesthetic agent(s) and/or steroid; nerves innervating the sacroiliac joint, with image guidance (ie, fluoroscopy or CT computed tomography), should be reported once for this procedure. The fluoroscopic guidance should not be separately reported as it is included in the work described with code 64451.

Here are the 7 Common Reasons that I know make sense why many physicians cannot make more money!

1. Reimbursements are NOT being Maximized due to Poor Medical Coding Knowledge, Skill and Analysis
Let me show you some example:
a. Bilateral Procedure billed anatomically at only "one side"
b. Surgery Converted to Open Procedure (the OP report documents from "Lap" to "Open" was performed) - how will you bill and code for this encounter? You may not know this, you cannot bill for both lap and open (check your CCI Edits!) together. And the guideline says, you have to report "Open" on your claim upon submission.
c. Unbundling/bundling services that are billable based on the "Edits" and medical necessity
d. No knowledge on how to utilize and use Modifiers
e. Too naive that payments processed at 100% of the charged amount ("allowed amount") is NOT GOOD! - it would've allowed more!

2. Out of Network Physician Services Payments can be a Big Challenge! Non-contracted physicians can be very challenging. Especially when they send the payments directly to their member / the patient! Any one experienced this? That's why it is very important that you "Accept Assignment" and make your patient sign a re-assignment of benefits so you get paid directly by the insurance company!

3. Lack of Effective Collection Techniques and Staff Traininga. Copay is always due at the time of service - do many physicians do collect copay upfront?
b. How often are patient statements being sent out?
c. ... there's a lot more to site! 

4. Now, isn't it Time to Negotiate Fees and Update the Fee Schedule?When was the last time or have you ever thought of renegotiating your contracted fees? Wouldn't it be time to analyze and review your contracts? Maybe its time to renegotiate your fees.

5. Missing "Revenue-Making" Opportunity for Additional Services in the PracticeOne good example, they know they can make big profit-margin on medically coded LSO Back Braces. And yet, they hesitate to even look at it. The truth is, it is always based on Medical Necessity! and Real-Time-Accurate Documentation, Period. You have to know your guidelines, policies and limitations. They are all out there, well documented.

For instance, as a Physician, you are exempted to the Accreditation Process and Surety Bond - as long as you ONLY provide the LSO braces to your own patients as part of your services. 

6. Low Productivity is also one of the Reasons!
a. Physician Services
b. Accounts Receivables Collection

7. Too Much Cost Running the Practice
a. Staffing
b. Technology
c. Supplies
d. Lease

There you go the 7 reasons I think why Physicians can not make more money! And there is only one recommendation I can give to every physician out there - become a Leader. Build a team within your practice rather than employee and managers. Provide training and education to everyone including your self.
Here are my 3 Useful Tips (and so easy to implement in your office):
1. Always check and verify patient's insurance benefits and eligibility (imperative!)
2. Always know your payers' clinical and reimbursement guidelines, policies and limitations (do your best!)
3. Hire the most qualified and experienced billing and coding staff or choose the right billing service company that are experienced based on your specialty. (very important to consider!)
​
Be open to every possibility and strategic planning that you can definitely run a profitable practice while focusing on delivering high quality patient care.I hope you found value in this article. Your comment will be highly appreciated.

There are guidelines we need to follow and the ABN can only be used when (any of the following applies);

1. If you think Medicare will likely deny payments for an item or service; 
2. Medicare may cover the service but not likely medically necessary for the particular patient;
   
3. Medicare consider the service as "not a Medicare benefit";

​Do not use an advance written notice of noncoverage for items and services you furnish under Medicare Advantage (Part C) or the Medicare Prescription Drug Benefit (Part D).
​
You are not required to notify the beneficiary before you furnish items or services that are not a Medicare benefit or that Medicare never covers, such as:

1. Services when there is no legal obligation to pay
2. Services authorized or paid by a government entity other than Medicare (this exclusion does not include services paid by Medicaid on behalf of dual eligibles)
3. Services required because of war
4. Personal comfort items such as radios and televisions
5. Eye examinations for prescribing, fitting, or changing eyeglasses
6. Hearing aids

CMS - The Centers for Medicare & Medicaid Services (CMS) published the 2019 Medicare Physician Fee Schedule Final Rule, which includes a significant expansion of Medicare reimbursement for virtual (non-face-to-face) services furnished by physician practices in November 2018.

In the Final Rule, CMS noted “[i]n recent years, we have sought to recognize significant changes in healthcare practice, especially innovations in the active management and ongoing care of chronically ill patients. . . .”  However, CMS’ efforts to promote these innovations have been limited by its interpretation of the statutory restrictions on Medicare reimbursement for telehealth services.

While CMS previously interpreted the geographic and site-of-service restrictions found in Section 1834(m) of the Social Security Act as applying to any virtual service, CMS now recognizes that these rules apply only “to a discrete set of physicians’ services that ordinarily involve, and are defined, coded, and paid for as if they were furnished during an in-person encounter between a patient and a healthcare professional.”  By contrast, “services that are defined by, and inherently involve the use of, communication technology” are not subject to the Section 1834(m) restrictions.  In making this distinction, CMS opened the door to new payment for remote patient monitoring (RPM), virtual check-ins, and interprofessional internet consultations.

This is what we know, in 2018, Medicare began reimbursing for Remote Patient Monitoring using the CPT® code 99091. Then, this year 2019, CMS will now reimburse for Remote Patient Monitoring using the new codes (see below) and in addition to the earlier CPT® code 99091

Let's look at our codes here:
CPT® Code 99453: Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment. Approximate Allowable/Reimbursement Fee Schedule: $21.00
CPT® Code 99454: Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days. Approximate Allowable/Reimbursement Fee Schedule: $69.00
CPT® Code 99457: Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified healthcare professional time in a calendar month requiring interactive communication with the patient/caregiver during the month.
Approximate Allowable/Reimbursement Fee Schedule: $54.00

Keypoints:
1. The first two codes are reimbursement for the practice expense associated with rendering the Remote Patient Monitoring RPM services; no physician work is required to bill for either of this code.  
2. Remember that the Remote Patient Monitoring Services may be billed for the same patient, on the same month as chronic care management (CCM) services, provided that the time spent for CPT® code 99457 is in addition to (and not the same as) the time spent for CPT® 99490, 99487, or 99489.
In the Final Rule, CMS summarized the numerous comments it received regarding the new Remote Patient Monitoring Services codes, especially that pertaining to what types of technology that meet the requirements/guidelines for Remote Patient Monitoring. CMS thus stated “to issue guidance to help inform practitioners and stakeholders on these issues.”  CMS offered no timeframe for the publication of such guidance.  Without this guidance, providers likely will be unwilling to make investments in Remote Patient Monitoring  programs.

n the past years, its been hard to get paid for separate payment for patient telephone calls that determines if an office visit or other service is justified.  If the physician should want to see the patient, CMS considers the check-in as bundled into the service for the encounter.  

Earlier this year, CMS acknowledged the problems this reimbursement model creates:
To the extent that these kinds of check-ins become more effective at addressing patient concerns and needs using evolving technology, we believe that the overall payment implications of considering the services to be broadly bundled becomes more problematic.  Effectively, the better practitioners are in leveraging technology to furnish effective check-ins that mitigate the need for potentially unnecessary office visits, the fewer billable services they furnish.  Given the evolving technological landscape, we believe this creates incentives that are inconsistent with current trends in medical practice and potentially undermines payment accuracy.

In an effort to address these misaligned incentives, CMS now will pay for virtual check-ins using HCPCS G2012 (approximate allowable amount: $13).  The reimbursable service is narrowly defined:

Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified healthcare professional who can report evaluation and management [E/M] services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion.

CMS set the reimbursement for this service at approximately $15, citing “low work time and intensity.”  For now, there are no frequency limits on this service, although CMS noted it may impose such limits if it detects over-utilization.

In the Final Rule, CMS clarified “that telephone calls that involve only clinical staff (cannot) be billed using HCPCS G2012, since the code explicitly describes (and requires) direct interaction between the patient and the billing practitioner.”  Also, CMS elected to require “verbal consent that is noted in the medical record for each billed service” and to limit eligibility to established patients.  In addition to reimbursement for synchronous communication, CMS will also pay for—under another new code, HCPCS G2010—remote evaluation of patient-submitted recorded video and/or images.  This reimbursable service also is narrowly defined:

Remote evaluation of recorded video and/or images submitted by the patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment.

CMS clarified that patient follow-up may take place “via any mode of communication, including secure text messaging, phone call, or live/asynchronous video chat, so as not to restrict a clinician’s interaction with patients.”

Again, the provider must document the beneficiary’s consent in the record (regardless of whether such consent is provided verbally, in writing, or by electronic confirmation) and eligibility is limited to established patients.

CMS also created a new HCPCS G0071 for virtual communication services furnished by a rural health clinic (RHC) or federally qualified health center (FQHC).  Specifically, an RHC or FQHC may receive reimbursement for “at least 5 minutes of communication technology-based or remote evaluation services” furnished for a patient who has had an RHC or FQHC billable visit within the last year.  This service is subject to the same limitations as HCPCS G2012 and G2010 with regard to prior and subsequent in-person visits.  Payment for HCPCS G0071 is set at the average of the national non-facility payment rates for HCPCS G2010 and G2012.

CMS expects usage of virtual check-ins will be limited at first, “result[ing] in fewer than 1 million visits in the first year. . . .”  However, CMS predicts usage of these services “will eventually result in more than 19 million visits per year. . . .”

Interprofessional Internet Consultation
Because specialists receive no reimbursement for time spent consulting with treating practitioners regarding specific patients, specialist input often requires scheduling a separate patient visit when telephonic or internet-based interaction between the specialist and the treating practitioner would suffice.  

Remote Patient Monitoring Services

This is what we know. In 2018, Medicare began reimbursing for Remote Patient Monitoring using the CPT® code 99091. Then, this year 2019, CMS will now reimburse for Remote Patient Monitoring using the new codes (see below) and in addition to the earlier CPT® code 99091

Let's look at our codes here:

CPT® Code 99453: Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; set-up and patient education on use of equipment. Approximate Allowable/Reimbursement Fee Schedule: $21.00

CPT® Code 99454: Remote monitoring of physiologic parameter(s) (e.g., weight, blood pressure, pulse oximetry, respiratory flow rate), initial; device(s) supply with daily recording(s) or programmed alert(s) transmission, each 30 days. Approximate Allowable/Reimbursement Fee Schedule: $69.00

CPT® Code 99457: Remote physiologic monitoring treatment management services, 20 minutes or more of clinical staff/physician/other qualified healthcare professional time in a calendar month requiring interactive communication with the patient/caregiver during the month.
Approximate Allowable/Reimbursement Fee Schedule: $54.00

Keypoints:
1. The first two codes are reimbursement for the practice expense associated with rendering the Remote Patient Monitoring RPM services; no physician work is required to bill for either of this code.  
2. Remember that the Remote Patient Monitoring Services may be billed for the same patient, on the same month as chronic care management (CCM) services, provided that the time spent for CPT® code 99457 is in addition to (and not the same as) the time spent for CPT® 99490, 99487, or 99489.

In the Final Rule, CMS summarized the numerous comments it received regarding the new Remote Patient Monitoring Services codes, especially that pertaining to what types of technology that meet the requirements/guidelines for Remote Patient Monitoring.  CMS thus stated “to issue guidance to help inform practitioners and stakeholders on these issues.”  CMS offered no time frame for the publication of such guidance.  Without this guidance, providers likely will be unwilling to make investments in Remote Patient Monitoring  programs.

Here comes the Virtual Check-Ins: Introducing HCPCS G2012

In the past years, its been hard to get paid for separate payment for patient telephone calls that determines if an office visit or other service is justified.  If the physician should want to see the patient, CMS considers the check-in as bundled into the service for the encounter.  

Earlier this year, CMS acknowledged the problems this reimbursement model creates:

To the extent that these kinds of check-ins become more effective at addressing patient concerns and needs using evolving technology, we believe that the overall payment implications of considering the services to be broadly bundled becomes more problematic.  Effectively, the better practitioners are in leveraging technology to furnish effective check-ins that mitigate the need for potentially unnecessary office visits, the fewer billable services they furnish.  Given the evolving technological landscape, we believe this creates incentives that are inconsistent with current trends in medical practice and potentially undermines payment accuracy.

In an effort to address these misaligned incentives, CMS now will pay for virtual check-ins using HCPCS G2012 (approximate allowable amount: $13).  The reimbursable service is narrowly defined:

Brief communication technology-based service, e.g. virtual check-in, by a physician or other qualified healthcare professional who can report evaluation and management [E/M] services, provided to an established patient, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment; 5-10 minutes of medical discussion.

CMS set the reimbursement for this service at approximately $15, citing “low work time and intensity.”  For now, there are no frequency limits on this service, although CMS noted it may impose such limits if it detects overutilization.

In the Final Rule, CMS clarified “that telephone calls that involve only clinical staff (cannot) be billed using HCPCS G2012, since the code explicitly describes (and requires) direct interaction between the patient and the billing practitioner.”  Also, CMS elected to require “verbal consent that is noted in the medical record for each billed service” and to limit eligibility to established patients.  In addition to reimbursement for synchronous communication, CMS will also pay for—under another new code, HCPCS G2010—remote evaluation of patient-submitted recorded video and/or images.  This reimbursable service also is narrowly defined:

Remote evaluation of recorded video and/or images submitted by the patient (e.g., store and forward), including interpretation with follow-up with the patient within 24 business hours, not originating from a related E/M service provided within the previous 7 days nor leading to an E/M service or procedure within the next 24 hours or soonest available appointment.

CMS clarified that patient follow-up may take place “via any mode of communication, including secure text messaging, phone call, or live/asynchronous video chat, so as not to restrict a clinician’s interaction with patients.”

Again, the provider must document the beneficiary’s consent in the record (regardless of whether such consent is provided verbally, in writing, or by electronic confirmation) and eligibility is limited to established patients.

CMS also created a new HCPCS G0071 for virtual communication services furnished by a rural health clinic (RHC) or federally qualified health center (FQHC).  Specifically, an RHC or FQHC may receive reimbursement for “at least 5 minutes of communication technology-based or remote evaluation services” furnished for a patient who has had an RHC or FQHC billable visit within the last year.  This service is subject to the same limitations as HCPCS G2012 and G2010 with regard to prior and subsequent in-person visits.  Payment for HCPCS G0071 is set at the average of the national non-facility payment rates for HCPCS G2010 and G2012.

CMS expects usage of virtual check-ins will be limited at first, “result[ing] in fewer than 1 million visits in the first year. . . .”  However, CMS predicts usage of these services “will eventually result in more than 19 million visits per year. . . .”

Interprofessional Internet Consultation

Because specialists receive no reimbursement for time spent consulting with treating practitioners regarding specific patients, specialist input often requires scheduling a separate patient visit when telephonic or internet-based interaction between the specialist and the treating practitioner would suffice.  

CMS Introduced the InterProfessional Consultations usingn Six New Codes (see below)

CPT® Code 99451: Interprofessional telephone/internet/electronic health record assessment and management service provided by a consultative physician including a written report to the patient’s treating/requesting physician or other qualified healthcare professional, 5 or more minutes of medical consultative time (reimbursement approximately $34).

CPT® Code 99452: Interprofessional telephone/internet/electronic health record referral service(s) provided by a treating/requesting physician or qualified healthcare professional, 30 minutes (reimbursement approximately $34).
CPT® Code 99446: Interprofessional telephone/internet assessment and management service provided by a consultative physician, including a verbal and written report to the patient’s treating/requesting physician or other qualified healthcare professional; 5-10 minutes of medical consultative discussion and review (reimbursement approximately $18).

CPT® 99447:  Crossover to CPT® 99446, except 11-20 minutes (reimbursement approximately $36).
CPT® 99448:  Crossover to CPT® 99446, except 21–30 minutes (reimbursement approximately $54).
CPT® 99449:  Crossover to CPT® 99446, except 31 or more minutes (reimbursement approximately $73).

Because these codes concern services furnished without the beneficiary present, CMS requires the treating practitioner to obtain and document verbal consent in the medical record.  CMS notes such consent “includes ensuring that the patient is aware of applicable cost sharing.”  Although it did not directly address the matter, it appears CMS expects the consultant to confirm such consent with the treating practitioner and make note of it in the consultant’s record.

Although the reimbursement for these virtual medical services are so little, but almost all providers are already been rendering these services (for free) so why not get paid and reimbursed in 2019? 

The biggest challenge is how do you implement this in your practice? One biggest element is Compliance in terms of meeting the proper/accurate documentation process and the integration with technology.

This may impact your reimbursement in the coming New Year 2015! Make sure you and your staff knows about these new changes.
Let's welcome the new year 2015 with more easy to use Modifier 59 and say hello to its the new 4 X's HCPCS modifers added by CMS.





2015 Medicare Modifier 59 Changes

If you are familiar with the CCI Edits or the Correct Coding Initiative Edits? isn't it that Modifier 59 has always been the modifier that comes to our mind to bypass edits with column 2 "1"?

We use modifier 59 for the purpose of telling the payers that the procedure(s) was performed as "DISTINCT PROCEDURAL SERVICE"
A little background - why are we using Modifier -59.
The Procedural Service can be "Distinct" due to the fact that it was a same-day procedure performed on:

• a different body site or organ system.
• a different or separate lesion.
• a different area of injury
• a different procedure
• a separate incision or excision
• a different day of encounter
• a different practitioner
• a different session
• a distinct and independent procedure/surgery/encounter from other services performed.

The CPT Manual clearly defines Modifier -59 as follows:
"Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system. separate incision/excision, separate lesion, or separate injury not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate, it should be used rather than Modifier 59. Only if no more descriptive modifier is available, and the use of Modifier 59 best explains the circumstances, should Modifier 59 be used. NOTE: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see Modifier 25

Modifier 59 and other NCCI-associated modifiers should NOT be used to bypass a PTP edit unless the proper criteria for use of the modifier are met. Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier that is used. If you are audited for misuse of Modifier 59, your documentation will be checked so it must clearly state that the criteria was met
CMS introduced the 4 New Modifiers for 2015 (not to replace Modifier 59 - just not yet!).

These 4 new modifiers were developed for more specificity when the procedure is truly a DISTINCT procedure! These are Specific Modifiers for Distinct Procedural Services or subsets of Modifier -59.

2015 Medicare Modifier 59 Changes and the 4 New Modifiers
1. XE "Separate encounter, a service that is distinct because it occurred during a separate encounter".
2. XS "Separate structure, a service that is distinct because it was performed on a separate organ/structure".
3. XP "Separate practitioner, a service that is distinct because it was performed by a different practitioner".
4. XU "Unusual non-overlapping service, the use of a service that is distinct because it does not overlap usual components of the main service"
CMS will continue to recognize Modifier -59 but you have to make sure you will only utilize this modifier when there is no other specific modifier that may describe your "distinct" procedure service.
When using this modifier, Medical Documentation is vital and essential to support medical necessity. This must be well-documented on the patient's medical record.
References:

• 2015 CMS Modifier 15 Changes Transmittal 1422 CR 8863
• modifier59-per NCCI (Modifier -59 Per NCCI Edits and the 4  subsets New Modifiers X(ESPU)
• CPT Code Books

​Guideline:
The same physician planned, at time of original surgery/procedure, a return trip to operating or procedure room within 10 or 90 day post op days



​

WHEN IT IS APPROPRIATE:

• Treatment of problem requiring a return to operating/procedure room
• More extensive than original procedure
• Unanticipated clinical condition
• Therapy following a diagnostic, surgical procedure                                
• Each case requires surgical documentation and evaluation

Modifier 58 appropriate for example; hardware removal was planned as part of therapeutic approach involving multiple, staged procedures to the surgical intervention

Physicians in same specialty, same group are to bill and are reimbursed as a single physician

Key to Remember!  Use modifier 78 (not 58!) for treatment problems unplanned requiring return trip to operating room

If hardware removed in unplanned surgery return for a complication, (e.g. infection of the wound site or rejection of the hardware itself), modifier 78 appropriate

It is NOT APPROPRIATE WHEN:

• Not appropriate for E/M - Evaluation and Management! or assistant surgery services

References:
CMS Medicare Website
Coding Books
​Payers Websites

​ Per the Current Procedure Terminology® (CPT®) manual, the descriptor of modifier 79 is:
• "Unrelated procedure or service by the same physician during the postoperative period."
As indicated, this modifier is used to bill an unrelated procedure or service performed by the same physician during the postoperative period of a previous surgical procedure.
When a patient has surgery performed, there is a postoperative period -- a period after the surgery has been performed when additional surgical care related to the initial surgery is considered already covered (and paid for) by the allowance provided for the initial surgery. The postoperative period can be zero or 10 days (minor surgical procedure) or 90 days (major surgical procedure). (Note that some surgeries are considered so minor that they have a zero day postoperative period, usually a very quick outpatient procedure.)

Modifier 79 should be used when a surgical procedure is:

• Performed during the postoperative period, where the original surgery had a global period of 10 or 90 days.
• Performed by the same physician or physician of the same specialty within the same group, and
• Unrelated to the original surgical procedure

REMEMBER! 
When the 79 modifier is used, a new postoperative period for the second surgical procedure begins. Additionally, the remainder of the postoperative period of the original surgery is still applicable.

References:
Medicare CMS Website
American Medical Association CPT
Coding Books
Payers Websites

Coding Billing for Medial and Lateral Nerve Blocks.

According to the AMA, the code series for medial branch blocks and the facet joint injections are the same (i.e., CPT series 64490-64495), with reporting based on the number of facet joints injected, not the number of nerves injected. 

For example: If three (3) medial branch nerves are injected only two (2) facet joint injection codes would be reported despite the fact that three nerves were injected, since each facet joint is connected to two medial nerves.

The lateral branch nerve is a peripheral nerve and would be reported with CPT code 64450, Injection, anesthetic agent; other peripheral nerve or branch, when a lateral branch nerve block is performed.

Please note: CPT code 64450 should only be reported per nerve or branch and not per injection.

CPT code 76942, Ultrasonic guidance for needle placement (e.g., biopsy, aspiration, injection, localization device), imaging supervision and interpretation, would be additionally reported when utilizing ultrasound guidance for certain nerve block procedures when it is not inherent in the primary procedure code.

The Different kinds or types of NERVE BLOCKS and what are they targeting:
   
NERVE BLOCKS: Brachial plexus block, elbow block, wrist block BODY AREAS: Shoulder, arm, hand, elbow, wrist)
NERVE BLOCKS: Cervical epidural, thoracic epidural, lumbar epidural block BODY AREAS: Neck, back
NERVE BLOCKS: Cervical plexus block, cervical paravertebral block BODY AREAS: Shoulder, upper neck   
NERVE BLOCKS: Maxillary nerve block BODY AREAS: Upper jaw  
NERVE BLOCKS: Ophthalmic nerve block BODY AREAS: Eyelids, scalp   
NERVE BLOCKS: Sphenopalatine nerve block BODY AREAS: Nose, palate   
NERVE BLOCKS: Subarachnoid block, Celiac plexus block BODY AREAS: Abdomen, pelvis   
NERVE BLOCKS: Supraorbital nerve block BODY AREAS: Forehead   
NERVE BLOCKS: Trigeminal nerve block BODY AREAS: Face

CPT 64490, 64493, 64495, 64633 - Billing and Coding for Facet Nerve Block and Nerve Ablation RFA

CPT CODE 64490 PARAVERTEBRAL FACET JOINT BILLING AND CODING WITH IMAGING GUIDANCEInjection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level
64491 ----------- second level
64492 ----------- third and any additional level(s) level
CPT CODE 64493Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; single level
64494 ----------- second level
64495 ----------- third and any additional level(s) level
​
FACET JOINT BILLING AND CODING WITH ULTRA-SOUND
0213T
Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, cervical or thoracic; single level
....................................................................+ 0214T second level
....................................................................+ 0215T third and any additional level(s)
0216TInjection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with ultrasound guidance, lumbar or sacral; single level
..................................................................+ 0217T second level
..................................................................+ 0218T third and any additional level(s)
Billing and Coding for Radiofrequency Facet denervationCPT

CODE 64633
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); cervical or thoracic, single facet joint'

+64634 cervical or thoracic, each additional facet joint (List separately in addition to code for primary procedure)

CPT CODE 64635
Destruction by neurolytic agent, paravertebral facet joint nerve(s), with imaging guidance (fluoroscopy or CT); lumbar or sacral, single facet joint;

+64636 lumbar or sacral, each additional facet joint (List separately in addition to code for primary procedure)
​
Other Searched Keywords:
Billing and Coding for RFA of Facet Joint Nerves
Billing and Coding for Facet Joint AblationKey Points for CPT 64490, 64493, 64495, 64633 - Billing and Coding for Facet Nerve Block and Nerve Ablation RFA

These codes are unilateral

• Append Modifier 50 when its bilateral
• CPT 64490, 64493, 64495, 64633 are performed with Imaging Guidance; it's inappropriate to report these codes if its not with imaging guidance
• If its under ultra-sound, use the Category 3 Codes shown above
• You don't need Modifier 51 for the add-on codes +64491, +64496, +64634, +64636
• Place of Service applicable to POS 11, 24, 22

Let's look at these questions and answers:
#1 Question
"What are the appropriate code assignments when a patient receives 3 separate nerve blocks into the same lateral branch nerve? Would it be appropriate to report 3 units of this service?"
The right CPT code 64450, Injection, anesthetic agent; other peripheral nerve or branch, would be appropriately reported only once in this case since all 3 nerve blocks were administered to the same nerve or branch.

#2 Question
"We are getting conflicting information regarding coding medial and lateral branch blocks S1, S2, and S3, Medial 64493, 64494, Lateral 64493, and 64494. Our Pain Center wants to use facet injection for the medial branch block and other peripheral nerve for the lateral branch block. Are we correct in reporting lateral branch nerve block(s) to the peripheral nerve CPT code?" Yes, you are correct. The lateral branches of the dorsal sacral nerve plexus are considered peripheral nerves. Therefore, for the four lateral branch block injections at S1, S2, S3, and S4, report 4 units of CPT code 64450, Injection, anesthetic agent; other peripheral nerve or branch. Report multiple units of the injection for the four lateral branch block injections performed, modifier 59 would not be appended in this case.

# 3 Question
"A patient was seen at our facility and underwent a left-sided L5 and S1, S2, S3, and S4 lateral branch nerve block for diagnostic purpose with C-arm fluoroscopy. What are the correct codes for a lateral nerve block?"

So OK, ... based on the operative report a medial branch nerve block was performed at the L5 and a lateral branch nerve block was performed at the S1, S2, S3 and S4

Therefore, it would be appropriate to report CPT code 64493, Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapohphyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral, single level, for the L5 medial branch block.

For the 4 lateral branch block injections at S1, S2, S3, and S4, report 4 units of CPT code 64450, Injection, anesthetic agent; other peripheral nerve or branch.

References:
2017 / 2018 Coding Books (CPT is a Trademark and Owned by the American Medical Association)
AMA's CPT Assistant Archives
CMS Medicare Website (LMN, NCD/LCD, Manuals)
Commercial Payers Guidelines

​Chronic Care Management Services and the New Changes for 2017
CMS Medicare recognizes the Chronic Care Management (CCM) as a critical component of primary care services that contributes to better health and care for individuals.
So in 2015, Medicare began paying separately under the Medicare Physician Fee Schedule for CCM services furnished to Medicare patients with multiple chronic conditions.

Beginning January 1, 2017, the CCM codes are:

Code 99490 Chronic care management services, at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month, with the following required elements:

• Multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient
• Chronic conditions place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline
• Comprehensive care plan established, implemented, revised, or monitored
• Assumes 15 minutes of work by the billing practitioner per month

Keys to Remember:
Let’s try to describe what CCM is or Chronic Care Management Services. These are services rendered by a Physician or Non-Physician Practitioners such as Nurse Practitioners, Physician Assistants, Clinical Nurse Specialist, Certified Nurse-Midwife and the CLINICAL Staff ---  per month, for patients with two or more chronic medical conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.
Take note that ONLY (1) One Practitioner can report and bill for Chronic Care Management per month.
The included services are:
○ Access and use of a Certified Electronic Health Record (EHR)
○ Continuity of Care with Designated Care Team Member
○ Comprehensive Care Management and Care Planning
○ Transitional Care Management
○ Coordination with Home and Community-Based Clinical Service Providers
○ 24/7 Access to Address Urgent Needs
○ Enhanced Communication (email, and telephone for example)
○ Advance Consent CCM Changes in 2017 are the following:

• Increased payment and additional codes the single CCM code paid approximately $42.
• Now there are 3 codes and payment can range from approximately $43 to over $141, depending on how complex a patient’s needs are;
• A given patient can receive either regular (often referred to as “non-complex”) CCM or complex CCM during a service period if applicable (not both)

The difference between complex and non-complex CCM is the amount of clinical staff time, the extent of care planning, and the complexity of the problems addressed by the billing practitioner during the month;
There is a more complex care and we describe it as Complex Chronic Care Management services;

Here are your two new codes for the Complex CCM - Complex Chronic Care Management services:
CPT 99487
Complex chronic care management services, with the following required elements:
● Multiple (two or more) chronic conditions expected to last at least 12 months, or until the
death of the patient;
● Chronic conditions place the patient at significant risk of death, acute exacerbation/
decompensation, or functional decline;
● Establishment or substantial revision of a comprehensive care plan
● Moderate or high complexity medical decision making
● 60 minutes of clinical staff time directed by a physician or other qualified health care
professional, per calendar month
(Novitas Part B NJ North $102.36)

CPT +99489     --- (this is an add-code and cannot be billed by itself!)    
Each additional 30 minutes of clinical staff time directed by a physician or other qualified    health care professional, per calendar month (List separately in addition to code for primary procedure)
Complex CCM services of less than 60 minutes in duration, in a calendar month, are not reported separately(Novitas Part B NJ North $50.98)
Supervision
The CCM codes (CPT 99487, 99489, and 99490) are assigned general supervision under the Medicare PFS. General supervision means when the service is not personally performed by the billing practitioner, it is performed under his or her overall direction and control although his or her physical presence is not required.
Patient Eligibility
Patients with multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at signifcant risk of death, acute exacerbation/decompensation, or functional decline are eligible for CCM services.
● Billing practitioners may consider identifying patients who require CCM services using criteria suggested in CPT guidance (such as number of illnesses, number of medications or repeat admissions or emergency department visits) or the profile of typical patients in the CPT prefatory language.
● There is a need to reduce geographic and racial/ethnic disparities in health through provision of CCM services. Table 2 provides a number of resources for identifying and engaging subpopulations to help reduce these disparities.
The billing practitioner cannot report both complex and regular (non-complex) CCM for a given patient for a given calendar month. In other words, a given patient receives either complex or non-complex CCM during a given service period, not both.
Examples of chronic conditions include, but are not limited to, the following:
● Alzheimer’s disease and related dementia
● Arthritis (osteoarthritis and rheumatoid)
● Asthma
● Atrial fbrillation
● Autism spectrum disorders
● Cancer
● Cardiovascular Disease
● Chronic Obstructive Pulmonary Disease
● Depression
● Diabetes
● Hypertension
● Infectious diseases such as HIV/AIDS
Initiating Visit
For new patients or patients not seen within one year prior to the commencement of CCM, Medicare requires initiation of CCM services during a face-to-face visit with the billing practitioner (an Annual Wellness Visit [AWV] or Initial Preventive Physical Exam [IPPE], or other face-to-face visit with the billing practitioner).  

This initiating visit is not part of the CCM service and is separately billed.
Practitioners who furnish a CCM initiating visit and personally perform extensive assessment and CCM care planning outside of the usual effort described by the initiating visit code may also bill HCPCS code G0506 (Comprehensive assessment of and care planning by the physician or other qualifed health care professional for patients requiring chronic care management services [billed separately from monthly care management services] [Add-on code, list separately in addition to primary service]).
G0506 is reportable once per CCM billing practitioner, in conjunction with CCM initiation.
Patient Consent Obtaining advance consent for CCM services ensures the patient is engaged and aware of applicable cost sharing. It may also help prevent duplicative practitioner billing. A practitioner must obtain patient consent before furnishing or billing CCM. Consent may be verbal or written but must be documented in the medical record, and includes informing them about:
● The availability of CCM services and applicable cost-sharing
● That only one practitioner can furnish and be paid for CCM services during a calendar month
● The right to stop CCM services at any time (effective at the end of the calendar month)

Definition: Indicates an Evaluation and Management (E/M) service resulted in the initial decision to perform surgery either the day before a major surgery (90 day global) or the day of a major surgery. You can access this information on the Medicare Physicians Fee Schedule Data Base.

APPROPRIATE:

• Append where the decision to perform surgery is made the day of or day before a major surgery during an E/M service
• Append only to the E/M procedure code

INAPPROPRIATE:

• Appending to a surgical procedure code
• Appending to an E/M procedure code performed the same day as a minor surgery. When the decision to perform a minor procedure is done immediately before the service, it is considered a routine preoperative service and not billable in addition to the procedure.
• Do not report on the day of surgery for a preplanned or prescheduled surgery.
• Do not report on the day of surgery if the surgical procedure indicates performance in multiple sessions or stages.

Below are information that you need to understand and remember; many are still confused with this:
Global period is the day before surgery, the day of the surgery and the number of days following the surgery as indicated on the MPFSDB. Often, a major surgery has a 90 day post operative period and a minor surgery has either a zero or a 10 day post operative period.

A preoperative period is the day before the surgery or the day of surgery.

When an E/M service resulting in the initial decision to perform major surgery is furnished during the post-operative period of another, unrelated procedure, then the E/M service must be billed with both the 24 and 57 modifiers.

See Codes:
92002-92014    E/M Ophthalmology Services
99201-99499    E/M all locations

Definition: Bilateral Procedure; procedures/services that occur on identical, opposing structures (such as for example - "LEFT" and "RIGHT" Side)
Many Billers are still really confused on how Modifier 50 really works. 

APPROPRIATE:

• When performing a procedure bilaterally during one session and the Medicare Physician Fee Schedule BILAT SURG indicator is 1: 
• Report codes with a BILAT SURG indicator of 1 on one line, appending modifier 50 and submit one unit of service. 

For example: 64490 Injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), cervical or thoracic; single level 

Billed as 64490 -50  1 unit

• When performing a procedure bilaterally during one session and the Medicare Physician Fee Schedule (MPFS) BILAT SURG indicator is 3: 
• Submit codes with a BILAT SURG 3 on one line appending either modifier 50 using one unit of service (UOS); or 
• Submit codes on one line with two UOS (the use of the RT/LT modifiers would be optional); or 
• Submit on two lines of service using RT on one line and LT on the other with one UOS each.

INAPPROPRIATE:

• Reporting this modifier when performing the service on different areas of the same side of the body. 
• The BILAT SURG indicator is 0, 2, or 9. 
• When removing a lesion on the right arm and one on the left arm - use the RT and LT modifiers. 
• Do not use modifier 50 for multiple procedures on one organ, such as the skin. 
• On a procedure code that is described as bilateral or unilateral or bilateral in its CPT description. 
• Do not report a bilateral procedure on two lines of service appending modifier 50 to the second line of service.

Coding Tip:
Generally speaking, the above information applies when two of the same procedure codes are performed on the same day for the same patient by the same provider. However, there could be instances where two separate procedure codes are used. If so, Medicare's payment or denial would depend on any other type of rules or regulations concerning the individual services in question. This could include the National Correct Coding Initiative (NCCI) that could necessitate additional modifiers, duplicate edits, and global surgery edits.

Remember, the Modifier 50 is used as a payment, rather than informational, modifier. The addition of this modifier could affect payment depending on the procedure code and the BILAT SURG indicator. The BILAT SURG indicator for each procedure code can be found on the Medicare Physician Fee Schedule Relative Value File. Following are the indicators and their descriptions.

BILAT SURG indicator "0" =150% payment adjustment for bilateral procedures does not apply. If procedure is reported with modifier -50 or with modifiers RT and LT, base the payment for the two sides on the lower of: (a) the total actual charge for both sides and (b) 100% of the fee schedule amount for a single code. Example: The fee schedule amount for code XXXXX is $125. The physician reports code XXXXX-LT with an actual charge of $100 and XXXXX-RT with an actual charge of $100. Payment should be based on the fee schedule amount ($125) since it is lower than the total actual charges for the left and right sides ($200). The bilateral adjustment is inappropriate for codes in this category (a) because of physiology or anatomy, or (b) because the code description specifically states that it is a unilateral procedure and there is an existing code for the bilateral procedure.

BILAT SURG Indicator "1" =150% payment adjustment for bilateral procedures applies. If the code is billed with the bilateral modifier or is reported twice on the same day by any other means (e.g., with RT and LT modifiers, or with a 2 in the units field), base the payment for these codes when reported as bilateral procedures on the lower of: (a) the total actual charge for both sides or (b) 150% of the fee schedule amount for a single code. If the code is reported as a bilateral procedure and is reported with other procedure codes on the same day, apply the bilateral adjustment before applying any multiple procedure rules.

Reference Manual:
The CMS Internet-Only Manual, Publication 100-04, Chapter 12 , Section 40.7.B, indicates "If a procedure is not identified by its terminology as a bilateral procedure (or unilateral or bilateral), physician must report the procedure with modifier "-50". They report such procedure as a single line item."

BILAT SURG Indicator "2" =150% payment adjustment does not apply. Relative Value Units (RVUs) are already based on the procedure being performed as a bilateral procedure. If the procedure is reported with modifier -50 or is reported twice on the same day by any other means (e.g., with RT and LT modifiers or with a 2 in the units field), base the payment for both sides on the lower of (a) the total actual charge by the physician for both sides, or (b) 100% of the fee schedule for a single code. Example: The fee schedule amount for code YYYYY is $125. The physician reports code YYYYY-LT with an actual charge of $100 and YYYYY-RT with an actual charge of $100. Payment should be based on the fee schedule amount ($125) since it is lower than the total actual charges for the left and right sides ($200).

The RVUs are based on a bilateral procedure because (a) the code descriptor specifically states that the procedure is bilateral, (b) the code descriptor states that the procedure may be performed either unilaterally or bilaterally, or (c) the procedure is usually performed as a bilateral procedure.

BILAT SURG Indicator "3" = the usual payment adjustment for bilateral procedures does not apply. If the procedure is reported with modifier -50 or is reported for both sides on the same day by any other means (e.g., with RT and LT modifiers or with a 2 in the units field), base the payment for each side or organ or site of a paired organ on the lower of (a) the actual charge for each side or (b) 100% of the fee schedule amount for each side. If the procedure is reported as a bilateral procedure and with other procedure codes on the same day, determine the fee schedule amount for a bilateral procedure before applying any multiple procedure rules. Services in this category are generally radiology procedures or other diagnostic tests which are not subject to the special payment rules for other bilateral surgeries.

BILAT SURG Indicator "9" = The bilateral payment adjustment concept does not apply.

Ambulatory Surgical Centers (ASCs) and Modifier 50

Bilateral surgical procedures furnished by certified ASCs may be covered under Part B. While use of the 50 modifier is not prohibited according to Medicare billing instructions, the modifier is not recognized for payment purposes and if used, may result in incorrect payment to ASCs.

Bilateral procedures should be reported as a single unit on two separate lines or a single unit with "2" in the unit field on one line, in order for both procedures to be paid correctly. The multiple procedure reduction of 50 percent will apply to all bilateral procedures subject to multiple procedure discounting.

Read more examples for appropriate billing procedures in the MLN Matters article,

"Revised Payment System for Ambulatory Surgical Centers (ASC) in Calendar Year (CY) 2008"  (Revised SE 0742).

References:
CMS: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c12.pdf
Noridian: https://med.noridianmedicare.com/web/jeb/specialties/surgery/bilateral-surgery
American Medical Association Coding Guidelines

​Definition: Unrelated evaluation and management (E/M) service by the same physician* during a postoperative period 

APPROPRIATE:

• Append modifier 24 to the E/M procedure code (Not Procedure Codes!)
• Use on an unrelated E/M service beginning the day after a procedure, when the E/M is performed by the same physician* during the 10 or 90 day post-operative period. 
• Use modifier 24 on the E/M if documentation indicates the service was exclusively for treatment of the underlying condition and not for post-operative care. 
• Use modifier 24 on the E/M code when the same physician* is managing immunosuppressant therapy during the post-operative period of a transplant. 
• Use modifier 24 on the E/M code when the same physician* is managing chemotherapy during the post-operative period of a procedure. 
• When the same physician* provides unrelated critical care during the post-operative period. 

INAPPROPRIATE:

• Do not use when the E/M is for a surgical complication or infection. This treatment is part of the surgery package. 
• Do not use when the service is removal of sutures or other wound treatment. This treatment is part of the surgery package. 
• Do not use when the surgeon admits a patient to a skilled nursing facility for a condition related to the surgery. 
• Do not use unless the medical record documentation clearly indicates the E/M was unrelated to the surgery. 
• Do not use outside of the post-op period of a procedure. 
• Do not use on the same day as a procedure. 

*Same physician - Medicare regulation states: "Physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician."

Reporting Multiple Surgery Modifiers on the Same Claim Line
The following is an example of appropriate reporting of both modifiers 24 (Unrelated E/M by the same physician during a postoperative period), and 25 (Significant, separately identifiable E/M by the same physician on the same day of the procedure or other service), on the same E/M code.

Many are still confused on this. But here... 
"A physician performs a major surgery and within the global period sees the patient for an unrelated E/M visit. During this unrelated E/M visit, the physician determines the necessity of a minor surgery or other procedure. This minor surgery/other procedure is significant and separately identifiable from the E/M and unrelated to the original major surgery. Both the 24 and 25 modifiers are appropriate to add to the E/M code. The 24 modifier is appropriate because the E/M service is unrelated and during the postoperative period of the major surgery. The 25 modifier is necessary to identify that the minor surgery/procedure performed on the same day is separately identifiable from the E/M service. In addition, the minor surgery procedure code may need a 79 modifier to indicate the procedure is not related to the major surgery."

Definition: Increased Procedural Service requiring work substantially greater than typically required.

The RIGHT WAY:

• Surgeries where services performed are significantly greater than usual. 
• Anatomical variants could be an appropriate use of the modifier. 
• Assistant at surgery claims where a procedure is significantly greater than usual. 
• Procedures having a global surgery indicator of 000, 010, or 090 on the Medicare Physician Fee Schedule Database (MPFSDB). 
• Procedures having a global period but not surgical services (i.e. 77761, 77777, 77782).

Inappropriate:

• Additional time alone does not justify the use of this modifier (very important to KNOW!)
• Do not use when there is an existing code to describe the service. 
• We may deny the claim when the documentation supports another existing code. 
• Do not use to indicate a specialist performed the service. 
• Not appropriate for an Evaluation and Management (E/M) service.
• Documentation

Indicate "additional information available upon request" in field 19 of the 1500 Claim Form.

When the modifier 22 is used, two separate documents will be required to support the claim: 

• An operative report; and 
• A separate statement indicating how the service differs from the usual

Important Information for Billing and Documentation

Based on Medicare's Guideline of which most payers does follow Medicare's Guideline. So pay attention on this:

If you append a 22 modifier to a procedure you will receive an Additional Documentation Request (ADR) letter requesting medical records to support the use of the 22 Modifier. It is important that both the operative report and a separate concise statement on why it was beyond the normal difficulty be returned with a copy of the ADR letter. Failure to submit the statement and documentation in a timely fashion will result in processing of the claim with the fee schedule rate for the same surgery submitted without the 22 modifier.

Documentation Tips:
When developing a separate statement avoid using a generalized statement. Comments like "patient was obese" or "surgery took longer than usual" or "multiple adhesions" lack specific details which identify why the procedure was beyond the normal difficulties that could be encountered with the procedure. Further, it is important that your operative note supports the statement on why the surgical procedure was beyond the ordinary range of difficulty.

Unassigned Claim
For unassigned claims, an increase in the limiting charge is allowed only when a charge above the fee schedule amount is justified.

Reference CMS Manual Instruction:
The CMS Internet-Only Manual (IOM) Publication 100-04, Chapter 12 , Section 20.4.6 shows the requirements for using this modifier.

How to use MODIFIERS for MEDICAL AND GLOBAL SURGERY Encounters - GoHealthcare is a Leader in Revenue Cycle Management.

I have shared a lot of guidelines on each of this modifier. But today, this blog post will cover from Modifier 22 to Modifier 99. So are you ready? Make sure to click on "DIG DEEPER" for learn more and read more on clinical scenario samples.

All of these guidelines are based on Medicare's Guidelines. References are attached on each guideline. I strongly believe 98% of all the commercial payers does follow Medicare's Guidelines. Period.

​Modifier 22
Increased Procedural Services (Dig Deeper to learn more ... CLICK HERE)

Modifier 23
Unusual Anesthesia

Modifier 24
Unrelated Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional During a Postoperative Period (Dig Deeper to learn more ... CLICK HERE)

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

Modifier 26
Professional Component

Modifier 27
Multiple Outpatient Hospital E/M Encounters on the Same Date

Modifier 32
Mandated Services

Modifier 33
Preventive Services

Modifier 47
Anesthesia by Surgeon

Modifier 50
Bilateral Procedure (Dig Deeper to learn more ... CLICK HERE)

Modifier 51
Multiple Procedures

Modifier 52
Reduced Services

Modifier 53
Discontinued Procedure

Modifier 54
Surgical Care Only

Modifier 55
Postoperative Management Only

Modifier 56
Preoperative Management Only

Modifier 57
Decision for Surgery (Dig Deeper to learn more ... CLICK HERE)

Modifier 58 
Staged or Related Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period (Dig Deeper to learn more ... CLICK HERE)

Modifier 59
Distinct Procedural Service (Dig Deeper to learn more ... CLICK HERE)

Modifier 62
Two Surgeons

Modifier 63
Procedure Performed on Infants less than 4 kg
 
Modifier 66
Surgical Team
 
Modifier 73
Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC) Procedure Prior to the Administration of Anesthesia
 
Modifier 74
Discontinued Out-Patient Hospital/Ambulatory Surgery Center (ASC) Procedure After Administration of Anesthesia
 
Modifier 76
Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional
 
Modifier 77
Repeat Procedure by Another Physician or Other Qualified Health Care Professional
 
Modifier 78
Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period
 
Modifier 79
Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period (Dig Deeper to learn more ... CLICK HERE)
 
Modifier 80
Assistant Surgeon
 
Modifier 81
Minimum Assistant Surgeon

Modifier 82
Assistant Surgeon (when qualified resident surgeon not available)
 
Modifier 90
Reference (Outside) Laboratory
 
Modifier 91
Repeat Clinical Diagnostic Laboratory Test
 
Modifier 92
Alternative Laboratory Platform Testing
 
Modifier 95
Synchronous Telemedicine Service Rendered Via a Real-Time Interactive Audio and Video Telecommunications System
 
Modifier 96
Habilitative Services
 
Modifier 97
Rehabilitative Services
 
Modifier 99
Multiple Modifiers

Techniques:

• Posterior Lumbar Interbody Fusion (PLIF) * Incision is performed through a midline incision in the back

Image Source: https://www.slideshare.net/drpraveenktripathi/lumbar-interbody-fusion-indications-techniques-and-complications

• Transforaminal Lumbar Interbody Fusion (TLIF) * Incision is also performed through a midline incision in the back, only on the side of the spine, to access the vertebral body at an angle

​​Both Procedures (PLIF and TLIF) allows for an Anterior Interbody Fusion through a Posterior Approach. The Interbody space is part of the anterior column of the spine.

22630
Arthrodesis, posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression), single interspace; lumbar
+22632
Each Additional interspace (list separately in addition to code for primary procedure code)
​
Here's what occurs when 22630 is performed:
The provider performs an arthrodesis, also known as spinal fusion, in the lumbar spine, or lower back, to permanently join two vertebrae, the interlocking bones of the spine. He excises the lamina and disk material and applies bone graft between the disks to fuse them. The procedure helps to alleviate persistent pain caused by various spinal conditions, including herniated intervertebral disks, stenosis, or spinal injuries.

Then, in 2012 
Code  22633 was introduced to to represent the combination of 22630 and 22612 Arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed) at the same level.

22558
Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar 
Remember: (For arthrodesis using pre-sacral interbody technique, see 22586, 0195T)
+22585
Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); each additional interspace (List separately in addition to code for primary procedure) 
Remember: (Use 22585 in conjunction with 22554, 22556, 22558) 
(Do not report 22585 in conjunction with 63075, even if performed by a separate individual. To report anterior cervical discectomy and interbody fusion at the same level during the same session, use 22552)

Here's what occurs when 22558 is being performed:
The provider performs arthrodesis, also known as spinal fusion, in the lower back, to permanently join two vertebrae, the interlocking bones of the spine, to alleviate persistent pain caused by a herniated, or bulging, disk, or other spinal condition. He makes an incision in the abdomen to access the spine and remove disk material.

POSTERIOR INSTRUMENTATION:

Add-Code +22840 Posterior non-segmental instrumentation (eg, Harrington rod technique, pedicle fixation across 1 interspace, atlantoaxial transarticular screw fixation, sublaminar wiring at C1, facet screw fixation) (List separately in addition to code for primary procedure)
(Use 22840 in conjunction with 22100-22102, 22110-22114, 22206, 22207, 22210-22214, 22220-22224, 22310-22327, 22532, 22533, 22548-22558, 22590-22612, 22630, 22633, 22634, 22800-22812, 63001-63030, 63040-63042, 63045-63047, 63050-63056, 63064, 63075, 63077, 63081, 63085, 63087, 63090, 63101, 63102, 63170-63290, 63300-63307)

Add-On Code +22841 Internal spinal fixation by wiring of spinous processes (List separately in addition to code for primary procedure)

Add-On Code +22842 Posterior segmental instrumentation (eg, pedicle fixation, dual rods with multiple hooks and sublaminar wires); 3 to 6 vertebral segments (List separately in addition to code for primary procedure)
Use 22842 in conjunction with 22100- 22102, 22110- 22114, 22206, 22207, 22210- 22214, 22220-22224, 22305-22327, 22532, 22533, 22548-22558, 22590-22612, 22630, 22633, 22634, 22800-22812, 63001-63030, 63040-63042, 63045-63047, 63050-63056, 63064, 63075, 63077, 63081, 63085, 63087, 63090, 63101, 63102, 63170-63290, 63300- 63307)Text has been updated

Add-On Code +22843 7 to 12 vertebral segments (List separately in addition to code for primary procedure)
(Use 22843 in conjunction with 22100- 22102, 22110-22114, 22206, 22207, 22210- 22214, 22220-22224, 22305-22327, 22532, 22533, 22548-22558, 22590-22612, 22630, 22633, 22634, 22800-22812, 63001-63030, 63040-63042, 63045-63047, 63050-63056, 63064, 63075, 63077, 63081,63085, 63087, 63090, 63101, 63102, 63170-63290,63300- 63307)Text has been updated

Add-On Code +22844 13 or more vertebral segments (List separately in addition to code for primary procedure)
(Use 22844 in conjunction with 22100- 22102, 22110-22114, 22206, 22207, 22210- 22214, 22220-22224, 22305-22327, 22532, 22533, 22548-22558, 22590-22612, 22630, 22633, 22634, 22800-22812, 63001-63030, 63040-63042, 63045-63047, 63050-63056, 63064, 63075, 63077, 63081, 63085, 63087, 63090, 63101, 63102, 63170-63290, 63300- 63307)

ANTERIOR INSTRUMENTATION
Add-On Code +22845 Anterior instrumentation; 2 to 3 vertebral segments (List separately in addition to code for primary procedure)
(Use 22845 in conjunction with 22100- 22102, 22110-22114, 22206, 22207, 22210- 22214, 22220-22224, 22305-22327, 22532, 22533, 22548-22558, 22590-22612, 22630, 22633, 22634, 22800-22812, 63001-63030, 63040-63042, 63045-63047, 63050-63056, 63064, 63075, 63077, 63081,63085, 63087, 63090, 63101, 63102, 63170-63290,63300- 63307)Text has been updated

Add-On Code +22846 4 to 7 vertebral segments (List separately in addition to code for primary procedure)
Use 22846 in conjunction with 22100- 22102, 22110-22114, 22206, 22207, 22210- 22214, 22220-22224, 22305-22327, 22532, 22533, 22548-22558, 22590-22612, 22630, 22633, 22634, 22800-22812, 63001-63030, 63040-63042, 63045-63047, 63050-63056, 63064, 63075, 63077, 63081, 63085, 63087, 63090, 63101, 63102, 63170-63290, 63300- 63307)Text has been updated

Add-On Code +22847 8 or more vertebral segments (List separately in addition to code for primary procedure)
(Use 22847 in conjunction with 22100-22102, 22110-22114, 22206, 22207, 22210-22214, 22220-22224, 22305-22327, 22532, 22533, 22548-22558, 22590-22612, 22630, 22633, 22634, 22800-22812, 63001-63030, 63040- 63042, 63045-63047, 63050-63056, 63064, 63075, 63077, 63081, 63085, 63087, 63090, 63101, 63102, 63170-63290,63300-63307)Text has been updated

Add-On Code +22848 Pelvic fixation (attachment of caudal end of instrumentation to pelvic bony structures) other than sacrum (List separately in addition to code for primary procedure)
(Use 22848 in conjunction with 22100- 22102, 22110-22114, 22206, 22207, 22210- 22214, 22220-22224, 22305-22327, 22532, 22533, 22548-22558, 22590-22612, 22630, 22633, 22634, 22800-22812, 63001-63030, 63040-63042, 63045-63047, 63050-63056, 63064, 63075, 63077, 63081, 63085, 63087, 63090, 63101, 63102, 63170-63290, 63300- 63307)​

22853
Insertion of interbody biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to intervertebral disc space in conjunction with interbody arthrodesis, each interspace (List separately in addition to code for primary procedure) 
Notes:
(Use 22853 in conjunction with 22100-22102, 22110-22114, 22206, 22207, 22210-22214, 22220-22224, 22310-22327, 22532, 22533, 22548-22558, 22590-22612, 22630, 22633, 22634, 22800-22812, 63001-63030, 63040-63042, 63045-63047, 63050-63056, 63064, 63075, 63077, 63081, 63085, 63087, 63090, 63101, 63102, 63170-63290, 63300-63307) 
(Report 22853 for each treated intervertebral disc space)

Code +22853 is one of several new codes within the spine section for the insertion of biomechanical devices that replace deleted code +22851 (Application of intervertebral biomechanical device[s] ...). The new add-on codes are more specific regarding the type and location of the biomechanical devices.

CPT® guidelines direct you to report +22853 for each treated intervertebral disc space.
Report +22853 in addition to the definitive procedure(s) since it is an add-on code.

Do not append modifier 62 (Two surgeons) to 22853.

The provider inserts a metallic cage or mesh device between two vertebrae and may use screws or flanges to attach it to the front part of the vertebrae; the device maintains the disc space, provides spinal stability, and yet preserves some range of motion, which helps relieve persistent pain caused by a herniated, or bulging, disk or other spinal condition. The provider performs this procedure during a spinal interbody arthrodesis procedure, which is fusion, or permanent joining, of vertebrae over the joint space.

Remember!
Code +22853 is an add–on code and must be reported with an appropriate primary procedure, such as 22548–22586 (Anterior or anterolateral approach technique arthrodesis procedures on the spine [vertebral column]), but there are many other codes that can be reported as a primary code.

Report one unit of this code for each interspace treated, not for the number of devices inserted. For example, if the provider inserts two cages into a single interspace, you report this code only once. If the provider inserts a device at two separate interspaces, e.g., between C3–4 and C5–6, then you would report this code twice.

This code is for the application of a device to expand or maintain an intervertebral disc space.

For a similar procedure to cover a defect created by removal of a vertebral body,
report 22854 (Insertion of intervertebral biomechanical device(s) [e.g., synthetic cage, mesh] with integral anterior instrumentation for device anchoring [e.g., screws, flanges], when performed, to vertebral corpectomy[ies] [vertebral body resection, partial or complete] defect, in conjunction with interbody arthrodesis, each contiguous defect [List separately in addition to code for primary procedure]).

For insertion of a similar device to treat an intervertebral disc space or vertebral body removal defect but without interbody fusion (arthrodesis), report 22859 (Insertion of intervertebral biomechanical device[s] [e.g., synthetic cage, mesh, methylmethacrylate] to intervertebral disc space or vertebral body defect without interbody arthrodesis, each contiguous defect [List separately in addition to code for primary procedure]).

20930
Allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in addition to code for primary procedure) 
Notes:
(Use 20930 in conjunction with 22319, 22532, 22533, 22548-22558, 22590-22612, 22630, 22633, 22634, 22800-22812)

Here's what occurs when 20930 is being performed;
The provider applies small pieces of donor or synthetic bone graft material during a spinal surgery to encourage bone growth during the healing period. 

Coding Tip!
Code 20930 is an add on code and used for specified spinal procedures only.

Check with your payer to determine if 20930 can be billed separately or if the application of the bone graft material is included in the code for the primary surgical procedure. 

Do not append modifier 62 to bone graft codes 20900-20938. 

(For spinal surgery bone graft[s] see codes 20930-20938)

Check with your payer if you can separately report this code;

+20931
Allograft, structural, for spine surgery only (List separately in addition to code for primary procedure) 
Notes:
(Use 20931 in conjunction with 22319, 22532-22533, 22548-22558, 22590-22612, 22630, 22633, 22634, 22800-22812)
A provider uses a structural allograft, a type of donor bone, to fill in bony defects as she performs a spinal surgery procedure.

Coding Tips:
Code 20931 is an add on code describing application of structural allograft to spinal defects and must be reported with an allowable primary spinal procedure code.

Report 20930, Allograft, morselized, or placement of osteopromotive material, for spine surgery only, together with 20931 only in the case of a human donor who is a different person from the recipient.

You should never append modifier 50, Bilateral procedure, to 20931. The CMS Physician Fee Schedule Database includes a 9 indictor in the BILAT SURG column for this code. According to further CMS instructions, a 9 indicator in this column means that the concept of a bilateral surgery with spinal grafting does not apply.

+20936
Autograft for spine surgery only (includes harvesting the graft); local (eg, ribs, spinous process, or laminar fragments) obtained from same incision (List separately in addition to code for primary procedure) 
Notes:
(Use 20936 in conjunction with 22319, 22532, 22533, 22548-22558, 22590-22612, 22630, 22633, 22634, 22800-22812)

A provider uses an autograft, a type of donor bone, to fill in bony defects as she performs a spinal surgery procedure. She extracts the autograft from the patient’s own bone, taken from the same surgical incision.

Coding Tips:
Code 20936 is an add on code describing grafting from a donor area using the same incision during a major operative procedure and must be reported with an allowable primary spinal procedure code.

You should never append modifier 50, Bilateral procedure, to 20936. The CMS Physician Fee Schedule Database includes a 9 indictor in the BILAT SURG column for this code. According to further CMS instructions, a 9 indicator in this column means that the concept of a bilateral surgery with spinal grafting does not apply.

+20937
Autograft for spine surgery only (includes harvesting the graft); morselized (through separate skin or fascial incision) (List separately in addition to code for primary procedure) 
Notes:
(Use 20937 in conjunction with 22319, 22532, 22533, 22548-22558, 22590-22612, 22630, 22633, 22634, 22800-22812)

The provider uses an autograft, a type of donor bone, to fill in bony defects as she performs a spinal surgery procedure. She extracts the autograft from the patient’s own body during the surgical procedure, through a separate incision.

Coding Tips:
Code 20937 is an add on code describing preparation and application of a morselized autograft through a separate skin incision and must be reported with an allowable primary spinal procedure code.


*** A vertebral segment describes the basic constituent part into which the spine may be divided. It represents a single complete vertebral bone with its associated articular processes and laminae. A vertebral interspace is the non-bony compartment between two adjacent vertebral bodies which contains the intervertebral disc, and includes the nucleus pulposus, annulus fibrosus, and two cartilaginous endplates. 

Autograft for spine surgery only (includes harvesting the graft); structural, bicortical or tricortical (through separate skin or fascial incision) (List separately in addition to code for primary procedure) 
Notes:
(Use 20938 in conjunction with 22319, 22532, 22533, 22548-22558, 22590-22612, 22630, 22633, 22634, 22800-22812) 

(For aspiration of bone marrow for bone grafting, spine surgery only, use 20939)

The provider uses an autograft, a type of donor bone, to fill in bony defects as she performs a spinal surgery procedure. She extracts the autograft from the patient's own body during the surgical procedure, through a separate incision.

Source: CPT®  Assistant July 1996 page 7
Coding Tip
Reporting Cosurgeries
"We receive many questions concerning how to report surgeries performed by more than one physician. To help you understand the proper coding we present the following information."
The General Question
"I am a general surgeon who sometimes performs surgeries with other surgeons (cosurgeries), such as orthopedic or neurosurgeons. I open the surgical site, the other surgeon does the definitive portion of the procedure, and then I close. What CPT codes should I report for my services? I have heard from some sources that I should bill for a thoracotomy and wound repair. But other sources have told me to report the same CPT codes as the other surgeon. Which is correct?

CPT® ​ASSISTANT'S REPLY:
Here's How to Code:
"For situations in which one surgeon performs the opening and closing of a surgery and another physician performs the definitive portion of the procedure, both physicians should report the same CPT codes, and appropriately append either modifier -62 or modifier -66."

Illustration
A patient's surgery includes arthrodesis of two interspaces of the thoracic spine by anterior interbody technique, with anterior instrumentation of three vertebral segments. Physician "A" performs a thoracotomy at the start of the surgical session, and Physician "B" performs the arthrodesis and spinal instrumentation. Upon completion of the arthrodesis and spinal instrumentation, Physician A closes the operative site. 
Coding the Illustration
(The physicians in the illustration would report the codes indicated below.)
Physician A       22556-62
Physician B       22556-62
22558-62
22558-62

22845-62
22845-62
When performing these cosurgeries, it is important to communicate with the other surgeon's office to be certain that you submit the claims properly

CPT®  Guideline September 1997 page 8
Coding Communication
How to Code Prosthetic Devices
It is not often that we devote an entire article to a single code, but sometimes this is the only way to fully explain the use of certain codes-22851, application of prosthetic device (eg, metal cages, methylmethacrylate) to vertebral defect or interspace, is such a code. But before we review how to report this code, it is probably a good idea to first do a brief anatomical review of the vertebral column.

The vertebral column (spine) consists of a series of bones known as vertebrae.


An adult human possesses 33 vertebrae divided into the following five types:

    7 cervical vertebrae;

    12 thoracic vertebrae;

    5 lumbar vertebrae;

    5 sacral vertebrae; and

    4 coccygeal vertebrae. 

The sacral vertebrae are typically fused into a single bone known as the sacrum. The coccygeal vertebrae are sometimes fused into a single bone known as the coccyx.

Therefore, the actual number of bones in the vertebral column may be 26-29, depending on if the coccygeal vertebrae are fused. Vertebrae are commonly named by a letter that corresponds to the region of the vertebral column to which the vertebrae belongs, followed by a number that indicates where in the region the vertebrae is located. For example, the most superior cervical vertebra is called C1, with the next cervical vertebrae down designated C2. The most superior thoracic vertebrae is T1, with the next one down designated T2.

Fig. 1 - Spinal Prosthetic Devices
Between each pair of vertebrae is a disc that cushions the spinal column. If one of the discs degenerates or if one of the 26-29 vertebrae are injured (as in the case of a fracture, degenerative disease, or secondary to tumor destruction) the physician may need to place a prosthetic device (eg, metal cages or methyl-methacrylate) in the vertebral defect or interspace. (Fig. 1) In these instances, a segment of vertebral level may be drilled and metal cages packed with porous implants of bone graft may be inserted or methylmethacrylate may be placed between the affected vertebrae.

Proper Reporting of code 22851
It is important to note that CPT®  code 22851 is not intended to be reported per cage.

CPT®  code 22851 should only be reported one time, regardless if one or more metal cages are placed in the intervertebral space at the same level. However, if metal cages are placed at two different levels, (eg, metal cage placed at L3-4 interspace and L5-S1 interspace), then 22851 may be reported more than once to indicate that one or more cages were placed at two or more different levels. It is important to note that a single cage or methylmethacrylate can cover a defect of several vertebral segments (eg, a single cage may replace three entire vertebrae), wherein code 22851 would still only be reported one time.

Within the spine section, instrumentation procedure codes (22840-22855) are reported in addition to the definitive procedure(s) without appending the modifier -51. Therefore, if arthrodesis is performed in addition to the placement of the metal cages, then it would be appropriate to report code 22851 in addition to the appropriate arthrodesis code, 22548-22632. In this instance, the modifier -51 would not be appended to code 22851. 

If metal cages are placed through an anterior approach and pedicle screws are placed through a posterior approach, it would be appropriate to report both code 22851 and one of the codes from the posterior instrumentation series, 22840, 22842-22844. However, if different instrumentation is used in addition to the metal cages or methylmethacrylate through the same approach (eg, an anterior plating system) or pedicle screws and posterior lumbar interbody fusion utilizing cages), then the appropriate instrumentation code would be reported in addition to code 22851. However, 22851 and 22845 should not both be reported if only the metal cage is inserted.
If fracture treatment, dislocation, or arthrodesis is performed in addition to spinal instrumentation, then the appropriate fracture treatment, dislocation or arthrodesis code (22325, 22326, 22327, 22548-22812) would be reported separately in addition to code 22851. In this instance, CPT®  code 22851 would be reported in addition to the definitive procedure(s) without the modifier -51 appended.
If bone grafting is performed in addition to code 22851, then the appropriate bone grafting code, 20930-20938, would be reported additionally.
Clinical Sample:
CPT® Code 22851
A 50-year-old man undergoes an anterior fusion of L5-S1 for degenerative disease. A retroperitoneal incision is made and an arthrodesis performed using a BAK cage. A distracter is placed in the interspace, a hole is drilled in the interspace, and the BAK cage is placed in the hole. The spacer is removed and replaced with another BAK cage. Both cages are filled with bone graft. (Report arthrodesis and/or bone grafting separately using the appropriate CPT code[s]).

The exposed disk space and adjacent vertebrae are prepared with bone-cutting instruments for acceptance of the prosthetic device. Preparation of the recipient site is made according to the protocol of the particular device. If methylmethacrylate is to be used, a screw or pin may be inserted into the adjacent vertebral surfaces to anchor the methylmethacrylate. Provision is made for cooling of adjacent tissues and protection of heat sensitive tissue from the exothermic reaction of the curing of the methylmethacrylate. For cages, the recipient site is prepared by bone dissection, a trial fit with the device or a spacer or template as indicated by the protocol is inserted and removed for any final modifications of the recipient site. The prosthetic device is then screwed, impacted, or injected into place according to protocol for this particular device. (Additional fixation, other provision for arthrodesis, or bone grafting are coordinated with the placement of the prosthetic device and are coded separately.) For devices that incorporate graft material, that material is appropriately placed into the device prior to its final insertion.

CPT®  ASSISTANT September 2000 page 10
Coding Consultation
Musculoskeletal System, Surgery, 22548-22585, 22899 (Q&A)

Question
"Should I use the anterior or anterolateral approach technique arthrodesis series of codes (22548-22585) to report intra-abdominal laparoscopic, video assisted anterior interbody fusion?"

AMA CPT®  Comment
"The anterior or anterolateral approach technique arthrodesis series of codes (22548-22585) are intended to describe arthrodesis performed via an open surgical approach. There is not a specific CPT code that accurately describes laparoscopic anterior interbody fusion. Therefore, code 22899, Unlisted procedure, spine should be reported. When reporting an unlisted code to describe a procedure or service, it will be necessary to submit supporting documentation (eg, procedure report) along with the claim to provide an adequate description of the nature, extent, need for the procedure, and the time limit, effort, and equipment necessary to provide the service."

CPT®  ASSISTANT March 2015 page 9
Frequently Asked Questions:Surgery: Musculoskeletal System

Question: "Are CPT codes 22851 and 22845 appropriate to report when modular implants, such as the RSB (RSB LLC; Cleveland, OH) InterPlate® (a modular interbody platform technology), are implanted for spinal fusion procedures?"

Answer:
"No. The RSB InterPlate® describes a stand-alone interbody fusion device that consists of an interbody spacer with screw fixation or other mechanisms, which engage adjacent vertebrae. Such devices should be reported with code 22558, Arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar, and 22851, Application of intervertebral biomechanical device(s) (eg, synthetic cage(s), methylmethacrylate) to vertebral defect or interspace (List separately in addition to code for primary procedure). An additional anterior instrumentation code (22845) is not applicable because there is no separate construct placed across the vertebral segment."

Question: "Would it be appropriate to separately report any of the following with the hammertoe correction code 28285 (2nd digit), if adequately documented? (1) Resection of hypertrophied base of proximal phalanx (28126), if performed through a separate incision at the metatarsophalangeal (MTP joint); (2) flexor tenotomy (28232) performed through a separate incision at the distal interphalangeal (DIP) joint; (3) an additional unit of 28285 if K-wire is inserted through the DIP, MTP, or proximal interphalangeal (PIP) joint."

Answer:
"No. Code 28126, Resection, partial or complete, phalangeal base, each toe; code 28232, Tenotomy, open, tendon flexor; toe, single tendon (separate procedure); and the insertion of K-wire through DIP, PIP, and MTP joints are all inclusive components of the procedure described by code 28285, Correction, hammertoe (eg, interphalangeal fusion, partial or total phalangectomy), and should not be reported separately."

References:
2018 AMA's CPT®  Guidelines
2017 AMA's CPT®  Guidelines
CPT® Assistant Archives

​Websites:
NASS
​Spine-Health
Medtronic
Ahima
AAPC
CMS
​

Trigger Point  Injections  Coding and  Billing (How to Bill CPT 20553 and 20552). Is this unilateral procedures?Are you Properly Coding  and Billing for  your Services?

Coding for Trigger Point Injections (which include how to bill cpt 20553)“Trigger points are described as hyper irritable spots in skeletal muscle that are associated with palpable nodules in taut bands of muscle fibers. Trigger point researchers believe that palpable nodules are small contraction knots and a common cause of pain.”keyword tags: how to bill cpt 20553, billing trigger point injection

What Causes Trigger Points? It could be due to or but not limited to:
Injuries (e.g. whiplash)
Daily activities (especially of that are work-related) of repetitive
movements (e.g. typing, data entry)
Lack of exercise, stress and poor posture
Lack of activity
Poor back support
Poor sleeping positionThe trigger point codes are very specific and here our two codes (see how to bill cpt 20553)20552 – Injection(s); single or multiple trigger point(s), one or two muscles
20553 – Single or multiple trigger points(s), three or more muscles (AMA Guidelines: If imaging guidance is performed, see 76942, 77002, 77021)
Global Days: 0

*** Imaging/Radiology Crosscodes:
76942 Ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation
77002 Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device)

Trigger point injections must be billed one line regardless how many injections.
For instance, if your pain doc performed trigger points on 2 muscles, report 20552 x 1 unit… (not 2 units for 2 muscles!)
CPT 20553 is NOT an add-on code!
Modifier -59 should not be used with these codes.
NO Anatomical Modifier because this service is NOT billable as Unilateral/Bilateral

Modifier –25 can be appended for E/M office visit if done on the same day and such is separate and identifiable medically necessary. Above and Beyond.Documentation in the patient’s medical record should include proper evaluation leading to the diagnosis of the trigger points, specific identification of the affected muscle(s). It must also be properly documented the reason why injections are the chosen as a treatment option.

Is the Code for Trigger Points / Muscles Group Injections Billable for Bilateral?
“Is the Code for Trigger Points / Muscles Group Injections 20552 – 20553 Billable as Bilateral?”
Another interesting question on Trigger Points Injection codes 20552-20553!
The answer is NO, it is not billable as bilateral. Because you are billing on the number of muscles or trigger points. There is no left and right on this procedure. You bill and code on the number of muscles or trigger points. Be careful! you do not bill for number of injections too! Again, identify the number of muscle(s) or trigger point(s).

A needle placement guidance is rarely used for trigger points injection procedure, but if the medical record shows that the physician used needle placement guidance, look at 77002 for the needle placement guidance code.

Here’s a part of AMA’s Question and Answer Per CPT Assistant May 2003
Question: “My physician performed two trigger point injections in two different muscles. Would it be appropriate to report code 20552 twice for the two injections?”

AMA Comment: “Code 20552-20553 are reported one time per session, regardless of the number of injections or muscles injected. Therefore, it would not be appropriate to report code 20552, Injection(s); single or multiple trigger point(s), one or two muscle(s) twice for the two injections administered.”
**** CPT is owned by the American Medical Association (AMA)
**** For more references: Consult your CPT code books. The National Correct Coding Initiative (NCCI) and third pary payer payment policies and guidelines
**** CPT Assistant September 2003
**** Always refer to your local carrier’s LCDs
keyword tags: how to bill cpt 20553, billing trigger point injection

22 Increased Procedural Services
50 Bilateral Procedure
51 Multiple Procedures
52 Reduced Services
58 Staged or Related Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period
59 Distinct Procedural Service
63 Procedure Performed on Infants less than 4 kg
76 Repeat Procedure or Service by Same Physician or Other Qualified Health Care Professional
77 Repeat Procedure by Another Physician or Other Qualified Health Care Professional
78 Unplanned Return to the Operating/Procedure Room by the Same Physician or Other Qualified Health Care Professional Following Initial Procedure for a Related Procedure During the Postoperative Period
79 Unrelated Procedure or Service by the Same Physician or Other Qualified Health Care Professional During the Postoperative Period
99 Multiple Modifiers
AQ Physician providing a service in an unlisted health professional shortage area (hpsa)
AR Physician provider services in a physician scarcity area
CR Catastrophe/disaster related
CS Item or service related, in whole or in part, to an illness, injury, or condition that was caused by or exacerbated by the effects, direct or indirect, of the 2010 oil spill in the gulf of mexico, including but not limited to subsequent clean-up activities
ET Emergency services
F1 Left hand, second digit
F2 Left hand, third digit
F3 Left hand, fourth digit
F4 Left hand, fifth digit
F5 Right hand, thumb
F6 Right hand, second digit
F7 Right hand, third digit
F8 Right hand, fourth digit
F9 Right hand, fifth digit
FA Left hand, thumb
GA Waiver of liability statement issued as required by payer policy, individual case
GC This service has been performed in part by a resident under the direction of a teaching physician
GJ "opt out" physician or practitioner emergency or urgent service
GR This service was performed in whole or in part by a resident in a department of veterans affairs medical center or clinic, supervised in accordance with va policy
KX Requirements specified in the medical policy have been met
LT Left side (used to identify procedures performed on the left side of the body)
PD Diagnostic or related non diagnostic item or service provided in a wholly owned or operated entity to a patient who is admitted as an inpatient within 3 days
Q5 Service furnished under a reciprocal billing arrangement by a substitute physician; or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
Q6 Service furnished under a fee-for-time compensation arrangement by a substitute physician; or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
QJ Services/items provided to a prisoner or patient in state or local custody, however the state or local government, as applicable, meets the requirements in 42 cfr 411.4 (b)
RT Right side (used to identify procedures performed on the right side of the body)
T1 Left foot, second digit
T2 Left foot, third digit
T3 Left foot, fourth digit
T4 Left foot, fifth digit
T5 Right foot, great toe
T6 Right foot, second digit
T7 Right foot, third digit
T8 Right foot, fourth digit
T9 Right foot, fifth digit
TA Left foot, great toe
XE Separate encounter
XP Separate practitioner
XS Separate structure
XU Unusual non-overlapping service​

Trigger point codes are grouped to reflect the total number of muscles treated, not how many injections the provider performs. When the provider treats one or two muscles with injections, regardless of the number of injections, report 20552, Injections, single or multiple trigger points, one or two muscles. When the provider performs trigger points on three or more muscles, report 20553, Injections, single or multiple trigger points, three or more muscles.
Coding examples include:
A patient with a history of back problems reports to the emergency department complaining of sharp lower back pain and aching legs. The provider discovers three trigger points in the patient's longissimus muscle, which is one of the deep muscles in the back, and performs therapeutic injections at each trigger point. Do not report 20553, Injections, single or multiple trigger points, three or more muscles, because the provider treated only one muscle. For this encounter, report 20552, Injections, single or multiple trigger points, one or two muscles.

Do you know that you can bill for a Smoking Cessation Face-to-face encounter? But the question that you may have is how do you bill for Smoking Cessation Counseling?

Here are your codes:
99406 Intermediate Smoking and tobacco use cessation counseling visit is greater than three minutes, but not more than 10 minutes

99407 Intensive Smoking and tobacco use cessation counseling visit is greater than 10 minutes

Diagnosis that Meets Medical Necessity (always refer to your payer's guidelines too!)
F17.200 Nicotine dependence, unspecified, uncomplicated
F17.201 Nicotine dependence, unspecified, in remission
F17.210 Nicotine dependence, cigarettes, uncomplicated
F17.211 Nicotine dependence, cigarettes, in remission
F17.220 Nicotine dependence, chewing tobacco, uncomplicated
F17.221 Nicotine dependence, chewing tobacco, in remission
F17.290 Nicotine dependence, other tobacco product, uncomplicated
F17.291 Nicotine dependence, other tobacco product, in remission
Z87.891 Personal history of nicotine dependence

How do you bill Smoking Cessation code with the EM  or Evaluation and Management codes?

Append your Modifier 25 to the E/M Code and not on the Smoking Counselling Code!

Make sure you know the guideline of Modifier 25 and always know how to identify necessity.

Modifier -25, Significant, separately identifiable evaluation and management
service by the same physician on the same day of the procedure or other
service:

This modifier must be appended with an E/M service. This is the modifier you will need to use 
with the evaluation and management service done on the same day with other procedure done 
by the same physician. It has to be above and beyond the usual preoperative and postoperative 
encounter with the procedure. In fact, by using this modifier, it doesn't have to have a different 
diagnosis reported. The most important thing is that, the E/M level should meet its key 
components or if it is selected based on time with the patient (counseling and coordination). You 
have to be careful in using this modifier. It must meet medical necessity. As you know, there are 
procedures that already includes all other care and management.

Let's describe this modifier 25:

A patient came in for her monthly follow up for her chronic back pain. At the same time, patient 
was complaining with severe headache. The pain doctor performed bilateral occipital block on 
the patient at the time of service. You will append modifier 25 for the E/M code to indicate that both 
services were rendered on the same day.

You don't use modifier 25 with E/M encounter that resulted to Decision for Surgery (we have 
another modifier for this!)

So, meaning, when you bill for $2000.00 and the insurance made their determination at 100% of your charges… you bill $2,000, they allowed $2,000 – would you be happy?
Honestly, if I see EOB like this, I will be very very nervous! Your provider could have been paid more than the practice submitted charges, isn’t it?

Interestingly, most of my readers said they’ll be happy if they were paid at 100% of their charges… now, would you?

What if the allowed amount could have been $2,500? – how much is the difference? Yep, $500! How can the payer allow $2,500 if you have only submitted a charged amount of $2,000?!
Make sense?

Ok, now, here’s the deal! — if you got paid at 100% based on your charged amount you should find out about your fee schedule or contracted rate or what is usual and customary if you are out of network provider. Make sure you know you are not under-charging the insurance payer.
But what if you have realized that you did under-charge the insurance payer? what will you do? can you recover the money that you could have been paid for? The answer is YES! you can recover that money!
Now, don’t wait too long! Take action immediately!

Based on my experience, you can go back as far as 3 years from the date the claims were paid. I haven’t tried more than 3 years of claim to recover due to undercharges! After all, just like the insurance payer, they can always go back as far as more than 3 years I think to recover overpayments. Or depending on where state you are located.
Pay attention on your EOBs! I think that’s the key. As soon as you discover there is an undercharging and you were paid 100% on your charged amount. Pick up the phone and call that insurance payer immediately.
Connect with us today, we will show you better strategies on how to run an effective revenue cycle management!

​Here are our Unlisted Service or Procedure Codes
A service encounter or surgical procedure may be provided that is not listed in this edition of the CPT code book. When reporting such a encounter or service, the appropriate “Unlisted Procedure” code may be used to indicate the service, identifying it by “Special Report” as discussed in the section below.

The “Unlisted Procedures” and accompanying codes for Surgery are as follows:
15999 Unlisted procedure, excision pressure ulcer
17999 Unlisted procedure, skin, mucous membrane and subcutaneous tissue
19499 Unlisted procedure, breast
20999 Unlisted procedure, musculoskeletal system, general
21089 Unlisted maxillofacial prosthetic procedure
21299 Unlisted craniofacial and maxillofacial procedure
21499 Unlisted musculoskeletal procedure, head
21899 Unlisted procedure, neck or thorax
22899 Unlisted procedure, spine
22999 Unlisted procedure, abdomen, musculoskeletal system
23929 Unlisted procedure, shoulder
24999 Unlisted procedure, humerus or elbow
25999 Unlisted procedure, forearm or wrist
26989 Unlisted procedure, hands or fingers
27299 Unlisted procedure, pelvis or hip joint
27599 Unlisted procedure, femur or knee
27899 Unlisted procedure, leg or ankle
28899 Unlisted procedure, foot or toes
29799 Unlisted procedure, casting or strapping
29999 Unlisted procedure, arthroscopy
30999 Unlisted procedure, nose
31299 Unlisted procedure, accessory sinuses
31599 Unlisted procedure, larynx
31899 Unlisted procedure, trachea, bronchi
32999 Unlisted procedure, lungs and pleura
33999 Unlisted procedure, cardiac surgery
36299 Unlisted procedure, vascular injection
37501 Unlisted vascular endoscopy procedure
37799 Unlisted procedure, vascular surgery
38129 Unlisted laparoscopy procedure, spleen
38589 Unlisted laparoscopy procedure, lymphatic system
38999 Unlisted procedure, hemic or lymphatic system
39499 Unlisted procedure, mediastinum
39599 Unlisted procedure, diaphragm
40799 Unlisted procedure, lips
40899 Unlisted procedure, vestibule of mouth
41599 Unlisted procedure, tongue, floor of mouth
41899 Unlisted procedure, dentoalveolar structures
42299 Unlisted procedure, palate, uvula
42699 Unlisted procedure, salivary glands or ducts
42999 Unlisted procedure, pharynx, adenoids, or tonsils
43289 Unlisted laparoscopy procedure, esophagus
43499 Unlisted procedure, esophagus
43659 Unlisted laparoscopy procedure, stomach
43999 Unlisted procedure, stomach

44238 Unlisted laparoscopy procedure, intestine (except rectum)
44799 Unlisted procedure, intestine
44899 Unlisted procedure, Meckel’s diverticulum and the mesentery
44979 Unlisted laparoscopy procedure, appendix
45399 Unlisted procedure, colon
45499 Unlisted laparoscopy procedure, rectum
45999 Unlisted procedure, rectum
46999 Unlisted procedure, anus
47379 Unlisted laparoscopic procedure, liver
47399 Unlisted procedure, liver
47579 Unlisted laparoscopy procedure, biliary tract
47999 Unlisted procedure, biliary tract
48999 Unlisted procedure, pancreas
49329 Unlisted laparoscopy procedure, abdomen, peritoneum and omentum
49659 Unlisted laparoscopy procedure, hernioplasty, herniorrhaphy, herniotomy
49999 Unlisted procedure, abdomen, peritoneum and omentum
50549 Unlisted laparoscopy procedure, renal
50949 Unlisted laparoscopy procedure, ureter
51999 Unlisted laparoscopy procedure, bladder
53899 Unlisted procedure, urinary system
54699 Unlisted laparoscopy procedure, testis
55559 Unlisted laparoscopy procedure, spermatic cord
55899 Unlisted procedure, male genital system
58578 Unlisted laparoscopy procedure, uterus
58579 Unlisted hysteroscopy procedure, uterus
58679 Unlisted laparoscopy procedure, oviduct, ovary

​Can you bill a Medicare Patient for Missed Appointment or No-Show?

When patients missed their appointments, it does cost you your time and your staff. In this article, you are wondering if you can bill Medicare when their beneficiaries missed and appointment or has no-show. Below you will find clarifications.

​According to Chapter 1, section 30.3.13 of the Medicare Claims Processing Manual, which is attached to CR5613, CMS policy allows physicians, providers, and suppliers to charge Medicare beneficiaries for missed appointments, provided that they do not discriminate against Medicare beneficiaries but also charge nonMedicare patients for missed appointments and the charges for Medicare and non-Medicare patient are the same. The charge for a missed appointment is not a charge for a service itself (to which the assignment and limiting charge provisions apply), but rather is a charge for a missed business opportunity. Therefore, if a physician's or supplier's missed appointment policy applies equally to all patients (Medicare and non-Medicare), then the Medicare law and regulations do not preclude the physician or supplier from charging the Medicare patient directly.
The other key points of CR5613 are:

• The provider may bill the Medicare beneficiary directly. • Medicare does not make any payments for missed appointment fees/charges that are imposed by providers, physicians, or other suppliers.
• Claims for missed appointments sent to Medicare will be denied with the reason code 204 (This service/equipment/drug is not covered under the patient’s current benefit plan.).
• In most instances, a hospital outpatient department can charge a beneficiary a missed appointment charge.
• In the event, however, that a hospital inpatient misses an appointment in the hospital outpatient department, it would violate 42 CFR 489.22 for the outpatient department to charge the beneficiary a missed appointment fee. 

According to Medicare guideline; "make certain that your billing staff is aware that you may bill the beneficiary directly, that Medicare itself does not make any payments for missed appointments, and that Medicare should not be billed for these charges".
"The Centers for Medicare & Medicaid Services (CMS) policy is to allow physicians and suppliers to charge Medicare beneficiaries for missed appointments. However, Medicare itself does not pay for missed appointments, so such charges should not be billed to Medicare."
"Providers may not charge ONLY Medicare beneficiaries for missed appointments; they must also charge non-Medicare patients. The amount the physician/supplier charges Medicare beneficiaries for missed appointments must be the same as the amount that they charge non-Medicare patients.​"

Source: MLN: MM5613 Related Change Request Number: 5613

CMS Require Global Surgery Reporting for Post-Op Visits Effective July 01, 2017 from 9 States CMS now require providers who are part of a group practice with 10 or more providers; and are practicing in the State of Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon and Rhode Island to report CPT Code 99024 to indicate a post-operative visit during a 10-days or 90-days global surgical periods. This is required for surgeries performed on and after July 1st 2017.
Reporting Process for Post-Operative Visits CPT Code 99024

• Reporting is only required for post-operative encounters during the global surgical periods with the dates of service on or after July 1st 2017;
• Report the post operative encounters through the usual submission of your claims;
• Modifiers and Time Units are NOT required;
• You can add the CPT Code 99024 several times on the claim if the services rendered are within the applicable range of dates;
• Reporting is ONLY required if Medicare is Primary Payer and is traditional fee for service Medicare patients.

Qualifying Post-Surgical Visits and Place of Service:

• All Follow-up visits during the global surgical period (10-days or 90-days); post-operative services provided must be related with the original surgery;
• Place of service: (Hospitals, SNF, Physician Offices and Outpatient Clinics);
• If patients are at an eligible originating site, Telehealth encounters must also be reported.

 The CPT Codes for Required Global Surgery Reporting for CY 2017 can be found from CMS Website as a Downloadable File.

​Reference:
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched/Global-Surgery-Data-Collection-.html

​Keypoints:

• Make sure you have identified medical necessity for a DME Durable Equipment Item
• Make sure you have documented the necessity
• Make sure you have a delivery receipt that the patient had received the DME Item
• Make sure you are reporting the right DME Item
• Make sure you are reporting the right place of service
• Make sure you have checked with your payer how they want you to report the DME Item on your Claims

RR — RENTAL. (USE THIS 'R' MODIFIER WHEN DME IS TO BE RENTED)
This modifier is used for DME items that are rented, and will be used for equipment in the following categories:

• Inexpensive or other Routinely purchased DME (IRP)
• Frequent or Substantial Servicing (FS)
• Certain customized items:
  • Other Prosthetic and Orthotic Devices (P & O)
  • Capped Rental Items (CR)
  • Oxygen and Oxygen Equipment

KH — DMEPOS ITEM, INITIAL CLAIM, PURCHASE OR FIRST MONTH RENTAL
This modifier is used for a capped rental DME item. When using the KH modifier, you are indicating you are billing for the first month of the capped rental period.
KJ — DMEPOS ITEM, PARENTERAL ENTERAL NUTRITION (PEN) PUMP OR CAPPED RENTAL, Month four to fifteen. This modifier is used for capped rental DME items. When using the KJ modifier, you are indicating you are billing for months four through thirteen/fifteen of the capped rental period.
KI — DMEPOS ITEM, SECOND OR THIRD MONTH RENTAL
This modifier is used for capped rental DME items. When using the KI modifier, you are indicating you are billing for the second and/or third month of the capped rental period
A8 — DRESSING FOR EIGHT WOUNDS. (EFFECTIVE DATE 1/1/2003)
Surgical dressing codes billed without modifiers A1-A9 (see Coding Guidelines) are noncovered under the Surgical Dressings benefit. Certain dressings may be covered under other benefits.
A5 — DRESSING FOR FIVE WOUNDS. (EFFECTIVE DATE 1/1/2003)
Surgical dressing codes billed without modifiers A1-A9 (see Coding Guidelines) are noncovered under the Surgical Dressings benefit. Certain dressings may be covered under other benefits.
A4 — DRESSING FOR FOUR WOUNDS. (EFFECTIVE DATE 1/1/2003)
Surgical dressing codes billed without modifiers A1-A9 (see Coding Guidelines) are noncovered under the Surgical Dressings benefit. Certain dressings may be covered under other benefits.
A9 — DRESSING FOR NINE OR MORE WOUNDS. (EFFECTIVE DATE 1/1/2003)
Surgical dressing codes billed without modifiers A1-A9 (see Coding Guidelines) are noncovered under the Surgical Dressings benefit. Certain dressings may be covered under other benefits.
A1 — DRESSING FOR ONE WOUND. (EFFECTIVE DATE 1/1/2003)
Surgical dressing codes billed without modifiers A1-A9 (see Coding Guidelines) are noncovered under the Surgical Dressings benefit. Certain dressings may be covered under other benefits.
A7 — DRESSING FOR SEVEN WOUNDS. (EFFECTIVE DATE 1/1/2003)
Surgical dressing codes billed without modifiers A1-A9 (see Coding Guidelines) are noncovered under the Surgical Dressings benefit. Certain dressings may be covered under other benefits.
A6 — DRESSING FOR SIX WOUNDS. (EFFECTIVE DATE 1/1/2003)
Surgical dressing codes billed without modifiers A1-A9 (see Coding Guidelines) are noncovered under the Surgical Dressings benefit. Certain dressings may be covered under other benefits.
A3 — DRESSING FOR THREE WOUNDS. (EFFECTIVE DATE 1/1/2003)
Surgical dressing codes billed without modifiers A1-A9 (see Coding Guidelines) are noncovered under the Surgical Dressings benefit. Certain dressings may be covered under other benefits.
A2 — DRESSING FOR TWO WOUNDS. (EFFECTIVE DATE 1/1/2003)
Surgical dressing codes billed without modifiers A1-A9 (see Coding Guidelines) are noncovered under the Surgical Dressings benefit. Certain dressings may be covered under other benefits.
KA — ADD ON OPTION/ACCESSORY FOR WHEELCHAIR (EFFECTIVE DATE 01/01/1994)
JA — ADMINISTERED INTRAVENOUSLY (EFFECTIVE DATE 01/01/2007)
N/A
JB — ADMINISTERED SUBCUTANEOUSLY (EFFECTIVE DATE 01/01/2007)
For all immune globulin (J1559, J1561, J1562, J1569) and associated infusion pump (E0779) claims where the route of administration is subcutaneous, a JB modifier must be added to each HCPCS code.
VP — APHAKIC PATIENT (EFFECTIVE DATE 01/01/1984)
N/A
TW — BACK-UP EQUIPMENT (EFFECTIVE DATE 01/01/2003)
N/A
KB — BENEFICIARY REQUESTED UPGRADE FOR ABN, MORE THAN 4 MODIFIERS IDENTIFIED ON CLAIM. (EFFECTIVE DATE 1/1/2003)
N/A
KT — BENEFICIARY RESIDES IN A COMPETITIVE BIDDING AREA AND TRAVELS OUTSIDE THAT COMPETITIVE BIDDING AREA AND RECEIVES A COMPETITIVE BID ITEM (UPDATED DATE 04/01/2008
N/A
KE — BID UNDER ROUND ONE OF THE DMEPOS COMPETITIVE BIDDING PROGRAM FOR USE WITH NON-COMPETITIVE BID BASE EQUIPMENT (EFFECTIVE 01/01/2009)
This is a pricing modifier and it used with certain items that may be used with competitive or non-competitive bid items. Use of the KE indicates the 9.5% reduction should not affect your reimbursement.
CR — CATASTROPHE/DISASTER RELATED
For use by providers that have been granted a formal waiver under §1135 of the Social Security Act and then only for services affected by the emergency and while the waiver remains in effect.
QQ — CLAIM SUBMITTED WITH A WRITTEN STATEMENT OF INTENT
CT — COMPUTED TOMOGRAPHY SERVICES FURNISHED USING EQUIPMENT THAT DOES NOT MEET EACH OF THE ATTRIBUTES OF THE NATIONAL ELECTRICAL MANUFACTURERS ASSOCIATIONS (NEMA) XR-29-2013 STANDARD
N/A
PD — DIAGNOSTIC OR RELATED NON DIAGNOSTIC ITEM OR SERVICE PROVIDED IN A WHOLLY OWNED OR OPERATED ENITY TO A PATIENT WHO IS ADMITTED AS AN INPATIENT WITHIN 3 DAYS (EFFECTIVE DATE 01/01/2012)
KL — DMEPOS ITEM DELIVERED VIA MAIL (EFFECTIVE DATE 07/01/2007)
When using this modifier, you are indicating you have delivered your supplies via mail. This modifier must only be used with diabetic supplies.
KG — DMEPOS ITEM SUBJECT TO DMEPOS COMPETITIVE BIDDING PROGRAM NUMBER 1 (EFFECTIVE DATE 07/01/2007)
KK — DMEPOS ITEM SUBJECT TO DMEPOS COMPETITIVE BIDDING PROGRAM NUMBER 2 (EFFECTIVE DATE 07/01/2007)
KU — DMEPOS ITEM SUBJECT TO DMEPOS COMPETITIVE BIDDING PROGRAM NUMBER 3 (EFFECTIVE DATE 07/01/2007)
N/A
KW — DMEPOS ITEM SUBJECT TO DMEPOS COMPETITIVE BIDDING PROGRAM NUMBER 4 (EFFECTIVE DATE 1/1/2008)
N/A
KY — DMEPOS ITEM SUBJECT TO DMEPOS COMPETITIVE BIDDING PROGRAM NUMBER 5 (EFFECTIVE DATE 1/1/2008)
N/A
KV — DMEPOS ITEM SUBJECT TO DMEPOS COMPETITIVE BIDDING PROGRAM THAT IS FURNISHED AS PART OF A PROFESSIONAL SERVICE (EFFECTIVE DATE 1/1/2008)
N/A
J4 — DMEPOS ITEM SUBJECT TO DMEPOS COMPETITIVE BIDDING PROGRAM THAT IS FURNISHED BY A HOSPITAL UPON DISCHARGE (EFFECTIVE 01/01/2010)


JW — DRUG AMOUNT DISCARDED/NOT ADMINISTERED TO ANY PATIENT (EFFECTIVE 01/01/2003)
For CGS DMEMAC claims, the JW modifier is not required for discarded drugs and biologicals.
KD — DRUG OR BIOLOGICAL INFUSED THOUGH DME. (EFFECTIVE DATE 01/01/04)
RD — DRUG PROVIDED TO BENEFICIARY, BUT NOT ADMINISTERED 
EM — EMERGENCY RESERVE SUPPLY (FOR ESRD BENEFIT ONLY).
ET — EMERGENCY SERVICES
EA — ERYTHROPOETIC STIMULATING AGENT (ESA) ADMINISTERED TO TREAT ANEMIA DUE TO ANTI-CANCER CHEMOTHERAPY (EFFECTIVE DATE 1/1/2008)
EB — ERYTHROPOETIC STIMULATING AGENT (ESA) ADMINISTERED TO TREAT ANEMIA DUE TO ANTI-CANCER RADIOTHERAPY (EFFECTIVE DATE 1/1/2008)
EC — ERYTHROPOETIC STIMULATING AGENT (ESA) ADMINISTERED TO TREAT ANEMIA NOT DUE TO ANTI-CANCER RADIOTHERAPY OR ANTI-CANCER CHEMOTHERAPY (EFFECTIVE DATE 1/1/2008)
EX — EXPATRIATE BENEFICIARY
Effective July 1, 2016, use this modifier to bill Medicare for purchased only DMEPOS items that are furnished to expatriate beneficiaries. By attaching the EX modifier, the supplier is attesting that the benefidicary is an expatriate beneficiary, and that the item was delivered/furnished while the beneficiary is present in the U.S., and all other billing criteria has been met.
QA — FDA INVESTIGATIONAL DEVICE EXEMPTION (ENDS 12/31/2007)
KP — FIRST DRUG OF A MULTIPLE DRUG UNIT DOSE FORMULATION
When there is a single drug in a unit dose container, the KO modifier is added to the unit dose form code. (Exception: The KO modifier is not used with code J2545 or Q4080.) Except for code J7620, when two or more drugs are combined and dispensed to the patient in the same unit dose container, each of the drugs is billed using its unit dose form code. The KP modifier is added to only one of the unit dose form codes and the KQ modifier is added to the other unit dose code(s). Whenever a unit dose form code is billed, it must have a KO, KP or KQ modifier. (Exception: The KO, KP and KQ modifiers should not be used with code J7620.) If a unit dose code does not have one of these modifiers, it will be denied as an invalid code. The KO, KP, and KQ modifiers are not used with the concentrated form codes. The only FDA-approved unit dose preparation containing more than one drug is J7620, the combination of albuterol and ipratropium. Therefore, if the following FDA-approved unit dose codes are billed with a KP or KQ modifier, they will be rejected as invalid for claim submission: J2545, J7608, J7613, J7614, J7626, J7631, J7639, J7644, J7649, J7659, J7669, J7682, Q4080, and Q4080.
RE — FURNISHED IN FULL COMPLIANCE WITH FDA-MANDATED RISK EVALUATION AND MITIGATION STRATEGY (REMS) (EFFECTIVE 01/01/2009)
KS — GLUCOSE MONITOR SUPPLY FOR DIABETIC BENEFICIARY NOT TREATED WITH INSULIN
If the patient is not being treated with insulin injections, the KS modifier must be added to the code for the monitor and each related supply on every claim submitted.
ED — HEMATOCRIT LEVEL HAS EXCEEDED 39% (OR HEMOGLOBIN LEVEL HAS EXCEEDED 13.0 G/DL) FOR 3 OR MORE CONSECUTIVE BILLING CYCLES IMMEDIATELY PRIOR TO AND INCLUDING THE CURRENT CYCLE (EFFECTIVE DATE 1/1/2008)
EE — HEMATOCRIT LEVEL HAS NOT EXCEEDED 39% (OR HEMOGLOBIN LEVEL HAS NOT EXCEEDED 13.0 G/DL) FOR 3 OR MORE CONSECUTIVE BILLING CYCLES IMMEDIATELY PRIOR TO AND INCLUDING THE CURRENT CYCLE (EFFECTIVE DATE 1/1/2008)
Q0 — INVESTIGATIONAL CLINICAL SERVICE PROVIDED IN A CLINICAL RESEARCH STUDY THAT IS IN AN APPROVED CLINICAL RESEARCH STUDY (EFFECTIVE DATE 1/1/2008)
KF — ITEM DESIGNATED BY FDA AS CLASS III DEVICES. (EFFECTIVE DATE 04/01/04)
AV — ITEM FURNISHED IN CONJUNCTION WITH A PROSTHETIC DEVICE, PROSTHETIC OR ORTHOTIC. (EFFECTIVE DATE 1/1/2003)
AW — ITEM FURNISHED IN CONJUNCTION WITH A SURGICAL DRESSING. (EFFECTIVE DATE 1/1/2003)
AU — ITEM FURNISHED IN CONJUNCTION WITH A UROLOGICAL, OSTOMY, OR TRACHEOSTOMY SUPPLY. (EFFECTIVE DATE 1/1/2003)
This modifier is used specifically with codes A4450, A4452, and A5120.
AX — ITEM FURNISHED IN CONJUNCTION WITH DIALYSIS SERVICES. (EFFECTIVE DATE 1/1/2003)
BA — ITEM FURNISHED IN CONJUNCTION WITH PARENTERAL ENTERAL NUTRITION (PEN) SERVICES. (EFFECTIVE DATE 1/1/2003)
When an IV pole (E0776) is used in conjunction with parenteral nutrition, the BA modifier should be added to the code. Code E0776 is the only code with which the BA modifier may be used.
GZ — ITEM OR SERVICE EXPECTED TO BE DENIED AS NOT REASONABLE OR NECESSARY. (EFFECTIVE 1/1/2002)
AY — ITEM OR SERVICE FURNISHED TO AN ESRD PATIENT THAT IS NOT FOR THE TREATMENT OF ESRD (EFFECTIVE 01/01/2011)
QV — ITEM OR SERVICE PROVIDED AS ROUTINE CARE IN A MEDICARE QUALIFYING CLINICAL TRAIL (ENDS 12/31/2007)
GY — ITEM OR SERVICE STATUTORILY EXCLUDED, DOES NOT MEET THE DEFINITION OF ANY MEDICARE BENEFIT OR, FOR NON-MEDICARE INSURERS, IS NOT A CONTRACT BENEFIT (UPDATED 1/1/2008)
FB — ITEM PROVIDED W/O COST TO PROVIDER, SUPPLIER OR PRACTITIONER, OR FULL CREDIT RECEIVED FOR REPLACED DEVICE (UPDATED 1/1/2008)
QR — ITEM/SERVICE IN MEDICARE STUDY - OXYGEN (ENDS 12/31/2007)
T4 — LEFT FOOT, FIFTH DIGIT (EFFECTIVE DATE 01/01/1995)
Effective for dates of service on or after January 1, 2015, use with devices coded with HCPCS code E1830 or E1831. Failure to append the modifier will result in a rejection for incorrect coding.
T3 — LEFT FOOT, FOURTH DIGIT (EFFECTIVE DATE 01/01/1995)
Effective for dates of service on or after January 1, 2015, use with devices coded with HCPCS code E1830 or E1831. Failure to append the modifier will result in a rejection for incorrect coding.
TA — LEFT FOOT, GREAT TOE (EFFECTIVE DATE 01/01/1995)
Effective for dates of service on or after January 1, 2015, use with devices coded with HCPCS code E1830 or E1831. Failure to append the modifier will result in a rejection for incorrect coding.
T1 — LEFT FOOT, SECOND DIGIT (EFFECTIVE DATE 01/01/1995)
Effective for dates of service on or after January 1, 2015, use with devices coded with HCPCS code E1830 or E1831. Failure to append the modifier will result in a rejection for incorrect coding.
T2 — LEFT FOOT, THIRD DIGIT (EFFECTIVE DATE 01/01/1995)
Effective for dates of service on or after January 1, 2015, use with devices coded with HCPCS code E1830 or E1831. Failure to append the modifier will result in a rejection for incorrect coding.
F3 — LEFT HAND, FOURTH DIGIT (EFFECTIVE DATE 01/01/1995)
Effective for dates of service on or after January 1, 2015, use with devices coded with HCPCS code E1825. Failure to append the modifier will result in a rejection for incorrect coding.
F1 — LEFT HAND, SECOND DIGIT (EFFECTIVE DATE 01/01/1995)
Effective for dates of service on or after January 1, 2015, use with devices coded with HCPCS code E1825. Failure to append the modifier will result in a rejection for incorrect coding.
F2 — LEFT HAND, THIRD DIGIT (EFFECTIVE DATE 01/01/1995)
Effective for dates of service on or after January 1, 2015, use with devices coded with HCPCS code E1825. Failure to append the modifier will result in a rejection for incorrect coding.
FA — LEFT HAND, THUMB (EFFECTIVE DATE 01/01/1995)
Effective for dates of service on or after January 1, 2015, use with devices coded with HCPCS code E1825. Failure to append the modifier will result in a rejection for incorrect coding.
LT — LEFT SIDE. (USED TO IDENTIFY ITEM PROVIDED FOR THE LEFT SIDE OF THE BODY.)
N/A
K0 — LOWER EXTREMITY PROSTHESIS FUNCTIONAL LEVEL 0
DOES NOT HAVE THE ABILITY OR POTENTIAL TO AMBULATE OR TRANSFER SAFELY WITH OR WITHOUT ASSISTANCE AND A PROSTHESIS DOES NOT ENHANCE THEIR QUALITY OF LIFE OR MOBILITY.
K1 — LOWER EXTREMITY PROSTHESIS FUNCTIONAL LEVEL 1
HAS THE ABILITY OR POTENTIAL TO USE A PROSTHESIS FOR TRANSFERS OR AMBULATION ON LEVEL SURFACES AT FIXED CADENCE. TYPICAL OF THE LIMITED AND UNLIMITED HOUSEHOLD AMBULATOR.
K2 — LOWER EXTREMITY PROSTHESIS FUNCTIONAL LEVEL 2
HAS THE ABILITY OR POTENTIAL FOR AMBULATION WITH THE ABILITY TO TRAVERSE LOW LEVEL ENVIRONMENTAL BARRIERS SUCH AS CURBS, STAIRS OR UNEVEN SURFACES. TYPICAL OF THE LIMITED COMMUNITY AMBULATOR.
K3 — LOWER EXTREMITY PROSTHESIS FUNCTIONAL LEVEL 3
HAS THE ABILITY OR POTENTIAL FOR AMBULATION WITH VARIABLE CADENCE. TYPICAL OF THE COMMUNITY AMBULATOR WHO HAS THE ABILITY TO TRANSVERSE MOST ENVIRONMENTAL BARRIERS AND MAY HAVE VOCATIONAL, THERAPEUTIC OR EXERCISE ACTIVITY THAT DEMANDS PROSTHETIC UTILIZATION BEYOND SIMPLE LOCOMOTION.
K4 — LOWER PROSTHESIS FUNCTIONAL LEVEL 4
HAS THE ABILITY OR POTENTIAL FOR PROSTHETIC AMBULATION THAT EXCEEDS THE BASIC AMBULATION SKILLS, EXHIBITING HIGH IMPACT, STRESS, OR ENERGY LEVELS, TYPICAL OF THE PROSTHETIC DEMANDS OF THE CHILD, ACTIVE ADULT, OR ATHLETE.
SC — MEDICALLY NECESSARY SERVICE OR SUPPLY (EFFECTIVE DATE 01/01/2001)
GL — MEDICALLY UNNECESSARY UPGRADE PROVIDED INSTEAD OF NON-UPGRADED ITEM, NO CHARGE, NO ADVANCE BENEFICIARY NOTICE (ABN) (UPDATED 1/1/2008)
M2 — MEDICARE SECONDARY PAYER (MSP) (EFFECTIVE DATE 01/01/2007)
99 — MODIFIER OVERFLOW. (EFFECTIVE DATE 7/1/2003)
This modifier is used when you have exhausted the modifier field on the claim form. If you need additional room to add modifiers, append the 99 modifier to the last available field and include a narrative of other modifiers needed on the claim.
NB — NEBULIZER SYSTEM, ANY TYPE, FDA-CLEARED FOR USE WITH SPECIFIC DRUG (EFFECTIVE 01/01/2011)
NU — NEW DURABLE MEDICAL EQUIPMENT PURCHASE.
This modifier is used for new DME items that are purchased. When using the NU modifier, you are indicating you have furnished the beneficiary with a new (never used) piece of equipment.
NR — NEW WHEN RENTED
EY — NO PHYSICIAN OR OTHER LICENSED HEALTH CARE PROVIDER ORDER FOR THIS ITEM OR SERVICE. (EFFECTIVE DATE 1/1/2003)
If you do not have a prescription from the physician prior to billing Medicare, you must append the EY modifier to your claim
GX — NOTICE OF LIABILITY ISSUED, VOLUNTARY UNDER PAYER POLICY (EFFECTIVE 04/01/2010)
ZA — NOVARTIS/SANDOZ
BO — ORALLY ADMINISTERED NUTRITION, NOT BY FEEDING TUBE. (EFFECTIVE DATE 1/1/2003)
When enteral nutrients (B4149-B4162) are administered by mouth, the BO modifier must be added to the code.
QH — OXYGEN CONSERVING DEVICE IS BEING USED WITH AN OXYGEN DELIVERY SYSTEM.
FC — PARTIAL CREDIT RECEIVED FOR REPLACED DEVICE (EFFECTIVE DATE 1/1/2008)
CG — POLICY CRITERIA APPLIED (EFFECTIVE DATE 07/01/2008)
Effective for claims with dates of service on or after July 1, 2010, if an L3923 orthosis has a rigid plastic or metal component, the supplier must add the CG modifier (policy criteria applied) to the code. Claims for L3923 billed without a CG modifier will be rejected as incorrect coding. The CG modifier must be added to code L0450, L0454, L0455, L0621, L0625, or L0628 only if it is one made primarily of nonelastic material (e.g., canvas, cotton or nylon) or having a rigid posterior panel.
QF — PRESCRIBED AMOUNT OF OXYGEN EXCEEDS 4 LPM AND PORTABLE OXYGEN IS PRESCRIBED.
These modifiers may only be used with stationary gaseous (E0424) or liquid (E0439) systems or with an oxygen concentrator (E1390, E1391). They must not be used with codes for portable systems or oxygen contents.
QG — PRESCRIBED AMOUNT OF OXYGEN IS GREATER THAN 4 LITERS PER MINUTE (LPM).
These modifiers may only be used with stationary gaseous (E0424) or liquid (E0439) systems or with an oxygen concentrator (E1390, E1391). They must not be used with codes for portable systems or oxygen contents.
QE — PRESCRIBED AMOUNT OF OXYGEN IS LESS THAN 1 LITER PER MINUTE (LPM).
This modifier may only be used with stationary gaseous (E0424) or liquid (E0439) systems or with an oxygen concentrator (E1390, E1391). They must not be used with codes for portable systems or oxygen contents
CC — PROCEDURE CODE CHANGE (USE 'CC' WHEN THE PROCEDURE CODE SUBMITTED WAS CHANGED EITHER FOR ADMINISTRATIVE REASONS OR BECAUSE AN INCORRECT CODE WAS FILED). (SUPPLIERS SHOULD NOT SUBMIT MODIFIER CC.)
PL — PROGRESSIVE ADDITION LENSES (EFFECTIVE DATE 01/01/89)
GK — REASONABLE AND NECESSARY ITEM/SERVICE ASSOCIATED WITH A GA OR GZ MODIFIER (UPDATED 1/1/2008)
KR — RENTAL ITEM, BILLING FOR PARTIAL MONTH.
RP — REPLACEMENT AND REPAIR. (DELETED EFFECTIVE 12/31/2008)
RP MAY BE USED TO INDICATE REPLACEMENT OF DME, ORTHOTIC AND PROSTHETIC DEVICES, WHICH HAVE BEEN IN USE FOR SOMETIME.
RA — REPLACEMENT OF A DME ITEM (EFFECTIVE 01/01/2009)
Claims for replacement of DME items should include the RA modifer for dates of service on or after January 1, 2009.
RB — REPLACEMENT OF A PART OF DME FURNISHED AS PART OF A REPAIR (EFFECTIVE 01/01/2009)
KM — REPLACEMENT OF FACIAL PROSTHESIS INCLUDING NEW IMPRESSION/MOULAGE
KN — REPLACEMENT OF FACIAL PROSTHESIS USING PREVIOUS MASTER MODEL
KC — REPLACEMENT OF SPECIAL POWER WHEELCHAIR INTERFACE. (EFFECTIVE DATE 01/01/05)
T9 — RIGHT FOOT, FIFTH DIGIT (EFFECTIVE DATE 01/01/1995)
Effective for dates of service on or after January 1, 2015, use with devices coded with HCPCS code E1830 or E1831. Failure to append the modifier will result in a rejection for incorrect coding.
T8 — RIGHT FOOT, FOURTH DIGIT (EFFECTIVE DATE 01/01/1995)
Effective for dates of service on or after January 1, 2015, use with devices coded with HCPCS code E1830 or E1831. Failure to append the modifier will result in a rejection for incorrect coding.
T5 — RIGHT FOOT, GREAT TOE (EFFECTIVE DATE 01/01/1995)
Effective for dates of service on or after January 1, 2015, use with devices coded with HCPCS code E1830 or E1831. Failure to append the modifier will result in a rejection for incorrect coding.
T6 — RIGHT FOOT, SECOND DIGIT (EFFECTIVE DATE 01/01/1995)
Effective for dates of service on or after January 1, 2015, use with devices coded with HCPCS code E1830 or E1831. Failure to append the modifier will result in a rejection for incorrect coding.
T7 — RIGHT FOOT, THIRD DIGIT (EFFECTIVE DATE 01/01/1995)
Effective for dates of service on or after January 1, 2015, use with devices coded with HCPCS code E1830 or E1831. Failure to append the modifier will result in a rejection for incorrect coding.
F9 — RIGHT HAND, FIFTH DIGIT (EFFECTIVE DATE 01/01/1995)
Effective for dates of service on or after January 1, 2015, use with devices coded with HCPCS code E1825. Failure to append the modifier will result in a rejection for incorrect coding.
F8 — RIGHT HAND, FOURTH DIGIT (EFFECTIVE DATE 01/01/1995)
Effective for dates of service on or after January 1, 2015, use with devices coded with HCPCS code E1825. Failure to append the modifier will result in a rejection for incorrect coding.
F6 — RIGHT HAND, SECOND DIGIT (EFFECTIVE DATE 01/01/1995)
Effective for dates of service on or after January 1, 2015, use with devices coded with HCPCS code E1825. Failure to append the modifier will result in a rejection for incorrect coding.
F7 — RIGHT HAND, THIRD DIGIT (EFFECTIVE DATE 01/01/1995)
Effective for dates of service on or after January 1, 2015, use with devices coded with HCPCS code E1825. Failure to append the modifier will result in a rejection for incorrect coding.
F5 — RIGHT HAND, THUMB (EFFECTIVE DATE 01/01/1995)
Effective for dates of service on or after January 1, 2015, use with devices coded with HCPCS code E1825. Failure to append the modifier will result in a rejection for incorrect coding.
RT — RIGHT SIDE (USED TO IDENTIFY PROCEDURES PERFORMED ON THE RIGHT SIDE OF THE BODY).
Q1 — ROUTINE CLINICAL SERVICE PROVIDED IN A CLINICAL RESEARCH STUDY THAT IS IN AN APPROVED CLINICAL RESEARCH STUDY (EFFECTIVE DATE 1/1/2008)
KQ — SECOND OR SUBSEQUENT DRUG OF A MULTIPLE DRUG UNIT DOSE FORMULATION
When there is a single drug in a unit dose container, the KO modifier is added to the unit dose form code. (Exception: The KO modifier is not used with code J2545 or Q4080.) Except for code J7620, when two or more drugs are combined and dispensed to the patient in the same unit dose container, each of the drugs is billed using its unit dose form code. The KP modifier is added to only one of the unit dose form codes and the KQ modifier is added to the other unit dose code(s). Whenever a unit dose form code is billed, it must have a KO, KP or KQ modifier. (Exception: The KO, KP and KQ modifiers should not be used with code J7620.) If a unit dose code does not have one of these modifiers, it will be denied as an invalid code. The KO, KP, and KQ modifiers are not used with the concentrated form codes. The only FDA-approved unit dose preparation containing more than one drug is J7620, the combination of albuterol and ipratropium. Therefore, if the following FDA-approved unit dose codes are billed with a KP or KQ modifier, they will be rejected as invalid for claim submission: J2545, J7608, J7613, J7614, J7626, J7631, J7639, J7644, J7649, J7659, J7669, J7682, Q4080, and Q4080.
GW — SERVICE NOT RELATED TO THE HOSPICE PATIENT'S TERMINAL CONDITION. (USED FOR MEDICARE ADVANTAGE PLANS CLAIMS)
QJ — SERVICE/ITEMS PROVIDED TO A PRISONER OR PATIENT IN STATE OR LOCAL CUSTODY, HOWEVER THE STATE OR LOCAL GOVERNMENT, AS APPLICABLE, MEETS THE REQUIREMENT IN 42 CFR 411.1(B). (EFFECTIVE DATE 1/1/2003)

According to the Centers for Disease Control and Prevention
“Obesity, a common and costly health issue, affects more than one-third of adults and 17 percent of youth in the United States. “
By the numbers, 78 million adults and 12 million children are obese—figures many regard as an epidemic.

​Being obese increases the risk for heart disease, stroke and type 2 diabetes—the first, fourth and seventh leading causes of death, respectively—and contributes to more than one in five cancer-related deaths. Obesity-related health care spending continues to grow, with researchers estimating medical costs at $147 billion annually, including $7 billion for Medicare prescription drugs.

The American Medical Association recognized obesity as a disease in 2013 and the American Academy of Pediatrics recommended obesity prevention, assessment and patient counseling in 2007.

Medicare first recognized obesity as a medical condition in 2004 and began covering interventions when scientific evidence demonstrated their effectiveness.
In 2011, Medicare issued a Coverage Decision memorandum outlining requirements for intensive behavioral counseling and therapy for beneficiaries affected by obesity.

As of January 2012, Medicare and most private insurers cover obesity screening and behavioral counseling. In addition, as of Jan.1, 2014, the ACA requires: No consumer cost- sharing. Most insurance plans in all 50 states are required to cover certain services with no cost-sharing, including obesity screening and counseling for all adults and children. This includes no annual deductible amount, no enrollee copayments or coinsurance. Premium surcharges for being obese are prohibited in most insurance policies in all 50 states, including those sold through exchanges.
Source: http://www.ncsl.org/research/health/aca-and-health-mandates-for-obesity.aspx
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