Medicare still accepts modifier 59, but check with individual payers to see which modifiers they prefer for a distinct procedural service. WebHere are some examples provided by the American Academy of Ophthalmology demonstrating how to unbundle NCCI edits: A patient has pterygium surgery in the right For example, a home healthcare agency that reports more time-intensive services provided to a patient than were actually provided is a type of upcoding. History; physical examination; complexity of medical decision making; amount of time spent with the patient; nature of the patient's problem; need for coordination of care; need for counseling and/or teaching. The CO-SURG (Co-surgeons) column is related to modifier 62 Two surgeons. Omitting modifiers or using the wrong modifiers may cause claim denials that lead to rework, payment delays, and potential reimbursement loss.
Medical Coding Terms For DMEPOS claims, modifier KX indicates the supplier ensured coverage criteria was met and that there is documentation to support medical necessity. According to NCCI, this bundling edit is mutually exclusive. Call (404) 550-4615 Today Print. If more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported unless the evaluation and management services are for unrelated problems. In particular, Medicare and some other payers may accept KX for these types of claims: For instance, on physical therapy claims reported to Medicare, modifier KX may show that services are medically necessary and reasonable after the beneficiary has exceeded the defined threshold. Examples featuring indicator 1. Medicares Global Surgery Booklet states that using modifier 58 signifies that performing a procedure or service during the postoperative period was one of the following (the CPT code book uses similar language): You should append modifier 58 to the code for the staged or related procedure. CPT code 6703679LT (for the vitrectomy) and CPT code 669845979LT (for the cataract removal). Depending on payer rules, the number of modifiers required, and the space available, it may be appropriate to append modifier 99 Multiple modifiers to the code and then place additional modifiers in another section of the claim, such as CMS 1500 box 19. Upcoding is when the provider chooses a code for a more complex diagnosis or procedure, which is more expensive than the actual procedure. We can help you seek justice and protect your rights throughout the process. Keep in mind some ICD 10 codes must be accompanied by a code first or a second code. The ASST SURG (Assistant at Surgery) column provides information related to these modifiers: The ASST SURG indicator will let you know whether payment for the additional provider is permitted, not permitted, or possibly permitted if documentation supports medical necessity. When: From Sunday, Nov. 11, to Tuesday, Nov. 13. a separate injury or area of injury in extensive injuries. These modifiers belong after pricing modifiers on the claim. And to make matters worse, medical coding mistakes expose your practice to penalties ranging from thousands to millions of dollars. The codes were developed and are maintained by the American Medical Association In 2017, nearly $3.4 billion of the $3.7 billion recovered by the government under the FCA was the result of cases reported by whistleblowers. Healthcare providers and facilities that offer services to Medicare, Medicaid, and Tricare patients receive reimbursements from the government. If the AWV billed with ACP is denied for exceeding the once per year limit, the deductible and coinsurance will be applied to the ACP.. Web7. In addition to modifiers 26 and TC, the Medicare relative value files include modifier 53 Discontinued procedure. The DRG and severity level are determined by diagnosis codes (ICD codes). A: Only if one procedure was performed on the left eye and the other on the right. To indicate a procedure was bilateral, it may be appropriate to append modifier 50 Bilateral procedure. By miscoding the patients visit, the physician has committed Medicare fraud because, among other things, the physician charged for services which were not provided. Modifier 59 Distinct procedural service is a medical coding modifier that indicates documentation supports reporting non-E/M services or procedures together that you normally wouldnt report on the same date. Modifier JW Drug amount discarded/not administered to any patient is not limited to use for Medicare claims. Before appending modifier GV to a code, you should check these points: Medicare Claims Processing Manual, Chapter 11, Section 40.1.3, provides more information about attending physicians for hospice patients. In this case, it is appropriate to append modifier -59 to unbundle since it was known preoperatively that the patient needed both procedures. For codes that accept modifiers 26 and TC, the MPFS RVU spreadsheet provides RVUs and indicators specific to the global code and the individual components. Many coders find that determining whether an E/M service is significant and separately identifiable is the most problematic requirement for modifier 25 use. The American Medical Association (AMA) holds copyright in CPT. If the provider bills for each test separately rather than billing for the Below are some examples of HCPCS Level II modifiers: You can find HCPCS Level II modifier lists in HCPCS Level II code books and in online coding resources. Reporting the same code for the initial procedure and the unrelated procedure may be appropriate, as this example of proper modifier 79 use shows: Suppose a patient has a right-eye cataract extraction reported using 66984 Extracapsular cataract removal with insertion of intraocular lens prosthesis (1 stage procedure), manual or mechanical technique (eg, irrigation and aspiration or phacoemulsification); without endoscopic cyclophotocoagulation. 1. A modifier also may provide details not included in the code descriptor, such as the anatomic location of the procedure. Although you would not receive payment for the Column 2 code of the edit without modifier 59 on one of the codes from the edit pair, you may find modifier 59 classified as an informational modifier rather than a payment modifier. For each edit, see if unbundling is permitted by checking the numeric indicator in column 4. Specialized Medical Billing & Coding Resources, Medicare Alignment for SIM Models through Customized Statewide Models. Modifiers also play an important role in reporting procedures and services performed during a surgical codes global period, which is the timeframe when the global surgical package concept applies. Examples featuring indicator 0. Other payers may require you to use modifier 95 to indicate the performance of a telehealth service. That code is used when the insertion is not part of another medical procedure. This is a mutually exclusive edit. There are no circumstances in which both procedures of the code pair should be paid. Five Phillips & Cohen partners make 2022 Leading Lawyers list, SEC whistleblower award for $37M goes to Phillips & Cohens international clients, West Virginia hospital agrees to pay $50M to settle whistleblower case alleging Stark and Anti-kickback violations, Qui Tam Lawsuits Whistleblower Guide & Qui Tam FAQs, Medical equipment maker ResMed settles whistleblower lawsuits for $39.5 million, Whistleblower cases brought by Phillips & Cohen featured on CBS Whistleblower TV Series, Qui tam lawsuits whistleblower guide & FAQs, Anti-money laundering whistleblower program. Medical billing coders review medical records, determine the service or procedure that the patient received, identify the CPT code that describes that service or procedure, and add the CPT code to the billing. You should append modifier 79 to the code for the second procedure. For instance, WPS Government Health Administrators has a Modifier 76 Fact Sheet that clarifies you should use the modifier for repeat procedures performed on the same day. While it is not the norm by any means, upcoding can a different session or patient encounter. ABN claim reporting modifiers are listed in the MLN booklet Medicare Advance Written Notices of Noncoverage with the following explanations: Modifier GA Waiver of liability statement issued as required by payer policy, individual case, Modifier GX Notice of liability issued, voluntary under payer policy, Modifier 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, Modifier GZ Item or service expected to be denied as not reasonable and necessary. It could lead to unbundling, and such reporting falls under the purview of fraudulent medical billing. Access: Register in Hall A for $270. Where: Rooms S501-S504. While we will treat any information
Master Bundling Basics - AAPC Knowledge Center For instance, Medicare states you should use modifier JW only with drugs designated as single use or single dose on the FDA-approved label or package insert. and private insurers to restructure their reimbursement models that stress Automated claims processing systems can use the table of NCCI edits to review claims for irregularities. Append modifier GY when Medicare statutorily excludes the item or service, or the item or service does not meet the definition of any Medicare benefit. Most providers use the electronic equivalent of this form to bill Medicare for professional (pro-fee) services. Selecting the correct CPT code is vital to accurate billing. Medical billing experts One way to ensure that you dont inadvertently step onto an unbundling/ upcoding time bomb is to work with a professional medical coding and billing service with an established reputation in the industry. PC is an abbreviation for professional component, but medical coders must take care not to accidentally append modifier PC Wrong surgery or other invasive procedure on patient in place of modifier 26. Please call 888-720-8884. Unbundling occurs when multiple CPT codes are used to report component parts of the procedure, either unintentionally or in order to increase payment. During the 90-day global period, the patient is hit in the left eye with a bungee cord, causing a traumatic cataract and vitreous hemorrhage. For instance, you can bill twice for the same procedure within the 90 -days global period if the patient did not report the second issue when the first medical procedure was performed. Upcoding is when a healthcare service provider uses the billing code for a more expensive procedure when, in reality, a less expensive procedure was performed. When a screening colonoscopy becomes a diagnostic colonoscopy, moderate sedation services (G0500 or 99153) are reported with only the PT modifier [Colorectal cancer screening test; converted to diagnostic test or other procedure]; only the deductible is waived., Section 140.8 about advance care planning (ACP) as an element of an annual wellness visit (AWV) also references modifier 33: The deductible and coinsurance for ACP will only be waived when billed with modifier 33 on the same day and on the same claim as an AWV (code G0438 or G0439), and must also be furnished by the same provider. As every medical billing and coding company knows, it is important to distinguish when separate reporting of services is correct coding and when such reporting becomes fraudulent. 8596 E. 101st Street, Suite HTulsa, OK 74133, Medical BillingMedical CodingVerifications & AuthorizationsDental BillingAR Management, CPC: Director of Revenue Cycle Management, CPC: Senior Solutions Manager: Practice and RCM, Outsource Strategies International. Tenet settled the lawsuit for $900 million. In addition to separating modifiers based on whether theyre from the CPT or HCPCS Level II code set, modifiers are also categorized by type. You enter the pricing modifier directly to the right of the procedure code on the claim. Again, each surgeon reports the code with modifier 62 appended. Why Medical Practices Fail to Maximize their Revenue? Based on the descriptor, an E/M encounter must meet the criteria below to qualify for separate reporting using modifier 25. This means that when, for instance, you perform pterygium excision and cataract surgery together, youll get paid only for one of themif you submit codes for both, dont be surprised if you are reimbursed for the one with the lower allowable. downcoding. This means the edit was deleted on that date and both codes can be billed. Pairs of codes should not be billed together. More than one provider performed the service or procedure. An urgent care facility may engage in upcoding by billing for medical services that were more extended or complex than those provided. Some payer programs may have modifiers that apply only when youre reporting codes in connection with those programs, as well. The whistleblower was entitled to between 15 and 25%. During the 90-day global period, she is hit in the left eye with a bungee cord, causing a traumatic cataract and vitreous hemorrhage. Modifier KX Requirements specified in the medical policy have been met is appropriate in a variety of circumstances. Payment would be 100 percent of the ALT and 100 percent of the gonioscopy. Unbundling also occurs when a coder charges for two services when the code for the major service assumes that the minor service is also provided. Whether intentional or unintentional, unbundling and upcoding can expose your medical practice to investigation and significant financial penalties. According to Acting Assistant Attorney General Chad Readler, because those who defraud the government often hide their misconduct from public view, whistleblowers are often essential to uncovering the truth. The False Claims Act (FCA) allows whistleblowers to bring cases alleging fraud on behalf of the government and entitles whistleblowers to between 15 and 25% of the money collected from a favorable verdict or settlement. To return to our WPS GHA example, the payer lists modifier 59 as an informational modifier. A complete online CPT resource also should include CPT modifiers. What is Accounts Receivable Management in Medical Billing? Appending both CPT and HCPCS Level II modifiers to a single code may be appropriate. Medical billing experts also help lawyers by identifying unreasonable and fraudulent billings. The modifier provides additional information about the medical procedure, service, or supply involved without changing the meaning of the code. To NCCI is continually working towards to prevent wrong coding and fraudulent claims. When these healthcare providers and facilities improperly code the medical services theyve provided in order to receive higher reimbursements, they commit coding fraud. An urgent care facility may The HHS Office of Inspector General founds that from FY 2014 through FY 2019, the number of hospital stays billed at the highest severity level increased almost 20%. The goal of the NCCI is to prevent fraud and promote accurate coding.
What is Unbundling in Medical Billing? The CPT guidelines state that complications, exacerbations, recurrence, or the presence of other diseases or injuries requiring additional services should be separately reported. Because rules may differ, medical coders should check individual payer policies on reporting complications treated during the global period. She brings twenty five years of hands on management experience to the company. Compensation for any special damages including litigation costs and reasonable attorneys fees. The payer will apply the multiple-procedure fee reduction rules based on the codes reported and which of the nine possible MULT PROC indicators the fee schedule assigns to the code. Generally, upcoding and unbundling are difficult to detect without the help of whistleblower insiders. Access: Register in Hall A for $330. A high severity level requires that there be at least one secondary diagnosis that is considered a major complication or comorbidity, such as acute respiratory failure and sepsis. Have Knowledge That a Provider Is Unbundling? The False Claims Act gives employees and others who know about upcoding, unbundling and other healthcare fraud a way to report it safely. Table 1 shows the complete listing of NCCI PTP-associated modifiers. Individual modifiers may be appropriate only with certain codes, so be sure to check the rules specific to the case youre reporting. WebCMS categorizes fraud and program integrity issues into 4 categories: (1) mistakes resulting in administrative errors, such as incorrect billing; (2) inefficiencies causing waste, such as ordering excessive diagnostic tests; (3) bending and abuse of rules, such as upcoding claims; and (4) intentional, deceptive fraud, such as billing for services Explain the following coding errors and provide an example. WebExamples of Financial Abuse are: Billing for medical services that are unnecessary Upcoding and Unbundling Overcharging for supplies and services Common terms of Fraud and Abuse in the coding world are: Upcoding: Reporting a higher level of service than what is supported in the dictation Unbundling: Medicare Claims Processing Manual, Chapter 17, Section 40, provides the example of a single-use vial labeled to contain 100 units that has 95 units administered and 5 units discarded. You should not report an E/M code for that work, even with modifier 25 appended. Use of modifiers. Immediate surgery is scheduled. The Centers for Medicare & Medicaid Services (CMS) says that [m]isusing codes on a claim, such as upcoding or unbundling codes are unethical billing practices. Got a Coding Conundrum? If a code has both a technical and a professional component and you report the code without using modifier 26 or TC, youre claiming that youve earned reimbursement for both components. These are examples of some of the most commonly used CPT modifiers: 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 26 Professional component 59 Distinct procedural service A medical coding modifier is two characters (letters or numbers) appended to a CPT or HCPCS Level II code. A coder assigns Current Procedural Terminology (CPT) codes assigning 0 ir 9 as the 4th or 5th digit instead of reviewing the coding manual for the appropriate code. When a patient has a separate E/M service along with a procedure or other service on the same day by the same provider, you may report that E/M code separately for reimbursement by appending 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. Prior results do not guarantee a similar outcome. The goal of the NCCI is to prevent improper coding and fraudulent claims. Hospital inpatient costs are paid using pre-determined rates that vary according to the diagnosis-related group (DRG) assigned to the type of patient stay and the severity of the diagnosis. WebWhen unbundling is deemed appropriate, modifier 59 Distinct procedural service should be appended to the code in column 2. The deadline to file these cases varies, so whistleblowers should consult a medical billing attorney to ensure that theyre well-protected in the event their employer chooses to retaliate against them. Outsourcing medical billing and coding to an expert is the best way to report services correctly. Read theseexamples of upcoding and unbundling multi-million dollar penalties shared by Phillips and Cohen( an international law firm). However, misunderstanding medical coding and billing guidelines can impact the overall patient experience. Append modifier GX when you issue a voluntary ABN for a service Medicare never covers because the service is statutorily excluded or is not a Medicare benefit. Outsource Strategies International is one of the leading medical billing and coding companies in the medical outsourcing space focused on all aspects of revenue cycle management. Modifier GT is used on institutional claims for distant site services billed under Critical Access Hospital (CAH) method II. For instance, the Medicare Global Surgery Booklet clarifies that modifier 55 is appropriate only when there has been a transfer of care. The provider (physician or nonphysician practitioner) was identified as the patients attending physician when the patient enrolled in hospice. For example, if the percentage of cases assigned to a particular DRG is usually 10 to 15 percent, but in your facility, 60 percent of cases are assigned to that DRG, your facility could become a target of a fraud investigation. The MPFS splits the work required for a surgery into the PRE OP (Preoperative Percentage), INTRA OP (Intraoperative Percentage), and POST OP (Postoperative Percentage) columns, which show how much of the fee each portion of the surgical work earns in cases where the same provider is not responsible for every aspect of care. The manual goes on to explain that an OR for this purpose is defined as a place of service specifically equipped and staffed for the sole purpose of performing procedures. Bypassing or overriding an edit is also called unbundling. A: NCCI is updated quarterly. When services should not be bundled, however, a medical practice will lose revenue when a coder bundles them in error. By comparing medical records to medical billings, a medical billing expert can determine whether separately coded procedures were performed at the same time. Meghann joined MOS Revenue Cycle Management Division in February of 2013. The table also shows that CMS deleted the edit for CPT codes 66821 YAG and 66761 Iridotomy. If the government decides not to intervene in a qui tam case, whistleblowers and their counsel may then pursue the litigation on their own and recover funds on behalf of the government. However, misunderstanding medical coding and billing guidelines can impact the overall patient experience. With modifier 62, the Medicare fee for each co-surgeon is 62.5% of the global surgery fee schedule amount.
NCCI, Part Two: Examples of Unbundling Here is an example of when to use modifier 25 based on a scenario in Medicare Claims Processing Manual, Chapter 12, Section 40.1.C. The FCA protects and rewards whistleblowers who bring a claim against a provider or organization that is defrauding the government.