Modifier Billing Guide0611 - CallidusCloud

1 REF-EDO-0058 Version RT B Modifier Billing Guide June 2011 NHIC, PART BMEDICARE PART BPART BModifier Billing Guide _____ NHIC, Corp. 2 June 2011 REF-EDO-0058 Version The controlled version of this document resides on the NHIC Quality Portal (SharePoint). Any other version or copy, either electronic or paper, is uncontrolled and must be destroyed when it has served its purpose. Modifier Billing Guide _____ NHIC, Corp. 3 June 2011 REF-EDO-0058 Version The controlled version of this document resides on the NHIC Quality Portal (SharePoint). Any other version or copy, either electronic or paper, is uncontrolled and must be destroyed when it has served its purpose. Table of Contents Introduction .. 6 General information .. 7 WHAT ARE modifiers ?

2 7 AMBULANCE .. 8 AMBULATORY SURG ical CENTER (ASC) .. 11 ANESTHESIA .. 12 ASSISTANT SURGEON .. 12 Reimbursement .. 13 BILATERAL SERVICES .. 13 Bilateral Procedures Billed Correctly .. 14 14 CLINICAL PSYCHOLOGIST & CLINICAL SOCIAL WORKER .. 14 Clinical Research Studies .. 15 Coronary Artery .. 15 Drugs and Biologicals .. 15 ERYTHROPOIESIS STIMULATING AGENTS (ESA) .. 16 EVALUATION AND MANAGEMENT (E/M) .. 17 EYE .. 20 FOOT CARE .. 21 Digit modifiers for the Foot .. 21 HEALTH PROFESSIONAL SHORTAGE AREA (HPSA) .. 21 HOSPICE .. 22 LABORATORY SERVICES .. 23 Billing Tips .. 23 NATIONAL CORRECT CODING INITIATIVE (NCCI) .. 24 OUTPATIENT THERAPY SERVICES .. 27 PHYSICIAN QUALITY REPORTING System (PQRS) .. 27 Billing Tips: .. 28 PORTABLE X-RAY .. 28 RECIPROCAL AND LOCUM TENENS ARRANGEMENTS .. 29 SURGERY .. 30 Global Surgical Split Billing (Transfer of Care between Providers).

3 30 Staged Procedures .. 31 Co-Surgery and Surgical Teams .. 31 Repeat Procedures .. 32 Unrelated Surgical Service .. 33 Unusual Circumstances .. 34 Digit modifiers for the Hand .. 35 Modifier Billing Guide _____ NHIC, Corp. 4 June 2011 REF-EDO-0058 Version The controlled version of this document resides on the NHIC Quality Portal (SharePoint). Any other version or copy, either electronic or paper, is uncontrolled and must be destroyed when it has served its purpose. Surgical Errors .. 35 Colorectal Cancer Screening .. 36 TEACHING PHYSICIAN .. 36 TECHNICAL & PROFESSIONAL COMPONENTS .. 37 MISCELLANEOUS modifiers .. 38 National Correct Coding Initiative .. 40 Medically Unlikely Edits .. 40 Limitation of Liability (Advance Beneficiary Notice) .. 41 ABN modifiers .. 41 Local Coverage Determination (LCD) .. 41 National Coverage Determination (NCD).

4 42 medicare Fraud and Abuse .. 42 Recovery Audit Contractor .. 43 Comprehensive Error Rate Testing .. 43 Provider Interactive Voice Response (IVR) Directory .. 44 Provider Customer Service Directory .. 44 PROVIDER ENROLLMENT HELP LINE .. 45 PROVIDER ENROLLMENT STATUS INQUIRY TOOL .. 45 Mailing Address Directory .. 46 PROVIDER SERVICES PORTAL (PSP) .. 47 Durable Medical Equipment (DME) .. 47 Reconsideration (Second Level of Appeal) .. 47 Internet Resources .. 48 NHIC, Corp.. 48 Provider Page Menus/Links .. 48 medicare Coverage Database .. 48 medicare Learning Network .. 49 Open Door Forums .. 49 Publications and Forms .. 49 Revision History: .. 51 Modifier Billing Guide _____ NHIC, Corp. 5 June 2011 REF-EDO-0058 Version The controlled version of this document resides on the NHIC Quality Portal (SharePoint).

5 Any other version or copy, either electronic or paper, is uncontrolled and must be destroyed when it has served its purpose. Modifier Billing Guide _____ NHIC, Corp. 6 June 2011 REF-EDO-0058 Version The controlled version of this document resides on the NHIC Quality Portal (SharePoint). Any other version or copy, either electronic or paper, is uncontrolled and must be destroyed when it has served its purpose. INTRODUCTION The Provider Outreach and Education Team at NHIC, Corp. developed this guide to provide you with medicare Part B Modifier Billing information. It is intended to serve as a useful supplement to other manuals published by NHIC, and not as a replacement. The information provided in no way represents a guarantee of payment. Benefits for all claims will be based on the patient s eligibility, provisions of the Law, and regulations and instructions from the Centers for medicare & Medicaid Services (CMS).

6 It is the responsibility of each provider or practitioner submitting claims to become familiar with medicare coverage and requirements. All information is subject to change as federal regulations and medicare Part B policy guidelines, mandated by the CMS, are revised or implemented. This information guide, in conjunction with the NHIC website ( ), J14 A/B MAC Resource (monthly provider newsletter), and special program mailings, provide qualified reference resources. We advise you to check our website for updates to this guide. To receive program updates, you may join our mailing list by clicking on Join Our Mailing List on our website. Most of the information in this guide is based on Publication 100-04, Chapter 12; and Publication 100-4, Chapter 23 of the CMS Internet Only Manual (IOM). The CMS IOM provides detailed regulations and coverage guidelines of the medicare program.

7 To access the manual, visit the CMS website at If you have questions or comments regarding this material, please call the Customer Service Center at 866-801-5304. DISCLAIMER: This information release is the property of NHIC, Corp. It may be freely distributed in its entirety but may not be modified, sold for profit or used in commercial documents. The information is provided as is without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice. All models, methodologies and guidelines are undergoing continuous improvement and modification by NHIC, Corp. and the CMS. The most current edition of the information contained in this release can be found on the NHIC, Corp. web site at and the CMS web site at The identification of an organization or product in this information does not imply any form of endorsement.

8 The CPT codes, descriptors, and other data only are copyright 2010 by the American Medical Association. All rights reserved. Applicable FARS/DFARS apply. The ICD-9-CM codes and their descriptors used in this publication are copyright 2010 under the Uniform Copyright Convention. All rights reserved. Current Dental Terminology (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. 2010 American Dental Association. All rights reserved. Applicable FARS/DFARS apply. Modifier Billing Guide _____ NHIC, Corp. 7 June 2011 REF-EDO-0058 Version The controlled version of this document resides on the NHIC Quality Portal (SharePoint). Any other version or copy, either electronic or paper, is uncontrolled and must be destroyed when it has served its purpose.

9 GENERAL INFORMATION The use of modifiers is an important part of coding and Billing for health care services. Modifier use has increased as various commercial payers, who in the past did not incorporate modifiers into their reimbursement protocol, recognize and accept CPT/ HCPCS codes appended with these specialized Billing flags. Correct Modifier use is also an important part of avoiding fraud and abuse or noncompliance issues, especially in coding and Billing processes involving the federal and state governments. Several of the top Billing errors involve the incorrect use of modifiers . WHAT ARE modifiers ? A Modifier is a two-digit numeric or alpha numeric character reported with a CPT/HCPCS code, when appropriate. modifiers are designed to give medicare and commercial payers additional information needed to process a claim. A Modifier provides the means by which a physician can report or indicate that a service or procedure that has been performed has been altered by some special circumstances(s), but has not changed in its definition or code.

10 modifiers also enable health care professionals to effectively respond to payment policy requirements established by other entities. These codes should be entered in item 24D on the Form CMS-1500 or electronic equivalent. Some examples of when a Modifier may be appropriate include: A service or procedure has both a professional and technical component, but both components are not applicable A service or procedure was performed by more than one physician and/or in more than one location A service or procedure has been increased or decreased in complexity or performance An adjunctive service was performed A bilateral procedure was performed Unusual events occurred during a procedure or service Placement of a Modifier after a CPT or HCPCS code does not insure reimbursement. A special report may be necessary if the service is rarely provided, unusual, variable or new.