|
Common Surgical Modifiers
What Is a Modifier?
A modifier is a two-digit qualifier that is appended to a Current Procedural Terminology (CPT) code that provides additional information when submitting a claim to the carrier for reimbursement. A modifier may be used to indicate:
- A service or procedure has both a technical and professional component.
- An increase or reduction in a service or procedure.
- A service or procedure has been performed by more than one provider.
- The service or procedure was rendered in more than one location.
- Only part of a service was performed.
- A bilateral procedure was performed.
- A service or procedure was performed more than once.
- An unusual event occurred during a service or procedure.
- A more extensive procedure needs to be performed or a staged procedure.
The Modifier Reference Guide  lists Level I (CPT-4), and Level II (non-CPT-4 alpha numeric) modifiers. Level I and II modifier definitions are contained in the Healthcare Common Procedure Coding System (HCPCS).
Surgical-Related Modifiers 58, 78, 79
Several modifiers have been created to assist in billing for special situations that occur during surgical procedures.
Staged or Related Procedures:
Modifier 58 was established to facilitate billing of staged or related surgical procedures done during the postoperative period of the first procedure.
The physician may need to indicate that the performance of a procedure or service during the postoperative period was:
- Planned prospectively or at the time of the original procedure;
- More extensive than the original procedure; or
- For therapy following a diagnostic surgical procedure.
These circumstances may be reported by adding modifier 58 to the staged procedure. A new postoperative period begins when the next procedure in the series is billed.
Unrelated Procedures During the Postoperative Period
Modifier 79 was established to report an unrelated procedure by the same physician during a postoperative period. The physician may need to indicate that the performance of a procedure or service during a postoperative period was unrelated to the original procedure.
A new postoperative period begins when the unrelated procedure is billed.
Return Trips to the Operating Room During the Postoperative Period
When treatment for complications requires a return trip to the operating room, physicians must bill the CPT code that describes the procedure(s) performed during the return trip. The procedure code for the original surgery is not used except when the identical procedure is repeated.
In addition to the CPT code, physicians use modifier 78 for these return trips (return to the operating room for a related procedure during a postoperative period.)
The physician may also need to indicate that another procedure was performed during the postoperative period of the initial procedure. When this subsequent procedure is related to the first procedure and requires the use of the operating room, this circumstance may be reported by adding the modifier 78 to the related procedure.
Note: An operating room does not necessarily mean you must return to the hospital. An operating room can be in an office setting.
A new postoperative period does not begin with the subsequent surgery.
Claims for Multiple Surgeries - Modifier 51
Sometimes multiple procedures are performed during the same surgical session. Modifier 51 indicates the performance of additional procedure(s) and will affect the pricing allowance. All additional surgical procedures should be reported with modifier 51. Reimbursement for multiple surgical procedures is made at 100 percent allowance for the major procedure (no 51 modifier) and 50 percent of the allowance for each subsequent procedure (51 modifier appended).
The multiple surgery reduction does not apply to treatment for complications resulting from the initial surgery that require a return trip to the operating room, even when multiple procedures are required to treat the complication. However, the multiple surgery reduction does apply when modifier 78 indicates a related procedure only.
The following procedures apply when billing for multiple surgeries by the same physician on the same day.
- Report the more major surgical procedure without the multiple procedures modifier 51.
- Report additional surgical procedures performed by the surgeon on the same day with modifier 51.
There may be instances in which two or more physicians each perform distinctly different, unrelated surgeries on the same patient on the same day (e.g., in some multiple trauma cases). When this occurs, the payment adjustment rules for multiple surgeries may not be appropriate. In such cases, the physician does not use modifier 51 unless one of the surgeons individually performs multiple surgeries.
Assistant at Surgery
When a physician is acting as the assistant surgeon, one of the following modifiers must be billed to indicate assistant surgery:
80 - Assistant Surgeon: Surgical assistant services may be identified by adding the modifier 80 to the usual procedure number(s).
82 - Assistant Surgeon (when qualified resident surgeon is not available in a teaching facility): The unavailability of a qualified resident surgeon is a prerequisite for use of this modifier.
When a non-physician practitioner (physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS)) is acting as the assistant at surgery, the AS modifier must be appended to the service or procedure.
The Medicare allowance for an assistant at surgery claim for a physician is 16 percent of the Medicare Physician Fee Schedule amount. Since physician assistants (PAs) and nurse practitioners (NPs) are reimbursed at 85 percent of the Physician Fee Schedule amount, the PA and NP are reimbursed at 85 percent of the 16 percent when they are acting as an assistant at surgery. The AS modifier must be appended to claims submitted by a PA or NP for assistant at surgery claims.
You may also reference the Global Surgery Policy for advice regarding billing of surgical procedures.
References:
Pub. 100-04, Medicare Claims Processing Manual, Chapter 12, §40 (www.cms.hhs.gov/manuals)
Test Your Knowledge of Common Surgical Modifiers - Take the Common Surgical Modifiers Quiz
Please Note: This quiz utilizes Javascript. You must have Javascript enabled in order to use this quiz. If you do not have Javascript enabled, please consider searching our Bulletins for additional information on Common Surgical Modifiers.
|
 |
