Tips for Modifier Use in an Ambulatory Surgery Center

Modifiers have had reporting relevance since the implementation of the Centers for Medicare & Medicaid Services (CMS) payment methodology for procedures performed in ambulatory surgery centers (ASCs), and hospital-based ASCs. On the basis of approval by the National Uniform Billing Committee, CMS instructed its Medicare fiscal intermediaries to accept those approved CPT (HCPCS Level I) and HCPCS (HCPCS Level II) modifiers applicable to outpatient reporting.

A modifier provides the means by which a reporting facility can indicate that the service or procedure represented by a specific code does not exactly meet the standards for that code. A procedural circumstance requires an alteration of the code’s meaning. The individual circumstance depicted by each modifier has reimbursement or tracking relevance to the carrier, and for payment to the provider. The use of the modifier enables the insurance carriers to appropriately pay for the procedure and any associated postoperative services performed within or subsequent to the global period (same day for ASCs). In addition, it allows the carrier to differentiate instances in which duplicate billing or duplicate services may have been reported.

The facility should apply the CMS-endorsed coding policy/instructions when outpatient services are billed, and these should apply to all payers, unless other carrier-specific directives have been received. Some of the most common modifiers used in the ASC are: 

Modifier 50: Bilateral Procedure

Unless otherwise identified in the listings, bilateral procedures that are performed in the same operative session should be identified by adding modifier 50 to the appropriate five-digit CPT code. This modifier is reported for procedures/ services that are performed on both sides of the body at the same operative session (mirror image). The policies each payer has for the use of modifier 50 vary widely, so be sure and check with each carrier before use. The modifier is applied to the CPT code, which is billed once even though the procedure was performed on two sides. For example, a 22-year-old skier injures both right and left knees, with peripheral longitudinal tears of both medial and lateral menisci and underwent arthroscopic meniscus repair of both knees by a suture technique. Appropriate reporting would be 29883-50.

Do not use modifier 50 if the procedure is designated inherent bilateral, which means the code descriptor indicates bilateral in the description. (Example: 58600 ligation or transaction of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral). Determination of pricing for a bilateral procedure would be identical to the determination of pricing in multiple procedures for CMS: 100 percent for the first procedure and 50 percent for the second procedure.

Note that some carriers prefer the use of modifiers LT and RT instead of modifier 50. In this case, the CPT code would be reported twice, as in 29883-LT and 29883-RT. Check with each carrier to ensure you are billing appropriately.

HCPCS Level II Modifier LT and RT: Modifiers LT and RT apply to codes that identify procedures that can be performed on paired organs such as ears, eyes, nostrils, kidneys, lungs, and ovaries. Modifier LT (left) and RT (right) are usually applied when a procedure is performed on only one side. ASCs use the appropriate modifier to identify which one of the paired organs was operated on. CMS requires these modifiers whenever appropriate.

For example: 66984 RT cataract surgery on the right eye. If these modifiers are not used, the carrier may assume that the second procedure done on the opposite eye is a duplicate service and may deny payment. 

Modifier 59: Distinct Procedural Service

Under certain circumstances, the physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. This may represent 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 physician. Although the modifier has several different reporting uses, it should only be used if another more descriptive modifier is not available and its use best describes the circumstances.

Caution should be used with modifier 59, as this is one of the most misused modifiers. If this modifier is not used appropriately, the claim will be denied. The denial from the carrier states, “Medicare does not pay for this service because it is part of another service that was performed on the same day.”

For example: A patient presents with a 4.5 malignant lesion on the arm. He also has a sore on his leg. The physician excises the lesion on the arm and does a biopsy on the leg.

CPT codes:
11606 excised lesion over 4 cm on leg 
11000-59 biopsy of skin 

As coding guidelines state, if a biopsy is performed with an excision on the same site, then you would code the excision only. But in the above example, the excision and biopsy were performed on different sites. Modifier 59 lets the payer know that this service should not be bundled into the excision code because it was performed on a distinctly different site. Normally, a biopsy is considered inherent to an excision procedure.

The best way to know if modifier 59 is the correct modifier is to see if the CMS National Correct Coding Initiative (NCCI) contains an edit that prohibits the two procedure codes from being billed together. If NCCI unbundles the codes, but your services were provided on distinctly different sites, then modifier 59 is appropriate. In the event that a more descriptive modifier is available, it should be used in preference to modifier 59.

Modifier 73: Discontinued Outpatient Hospital/ASC Procedure Prior to the Administration of Anesthesia

Due to extenuating circumstances or those that threaten the well being of the patient, the physician may cancel a surgical or diagnostic procedure subsequent to the patient’s surgical preparation (including sedation when provided, and being taken to the room where the procedure is to be performed, but prior to the administration of anesthesia (local, regional block(s) or general). The elective cancellation of a service prior to the administration of anesthesia and/ or surgical preparation of the patient should not be reported. Physicians can report this using modifier 53. The facility cannot.

For CMS, if modifier 73 is reported and the procedure is an approved ASC service, payment will be 50 percent of the facility rate, subject to the ASC payment calculation. When one or more of the procedures planned is completed, the completed procedures are reported as usual. When none of the planned procedures is completed, then the first planned procedure is reported with modifier 73. The others are not reported.

A lot of revenue is lost because physicians do not want to bill for this or they do not understand the cost involved in this situation. This modifier should be used to cover the expenses involved for the use of the facility. This modifier is for use of facilities only.

For example: A 65-year-old man was brought to the operating room for repair of a recurrent inguinal hernia. The patient was prepped and positioning was carried out. Before the administration of anesthesia, the patient complained of chest pain, with cardiac monitor revealing ST segment changes. The procedure was cancelled. CPT codes: 49520-73 Repair recurrent inguinal hernia, any age, reducible.

Modifier 74: Discontinued Outpatient Hospital/ASC Procedure After Administration of Anesthesia

Due to extenuating circumstances or those that threaten the well being of the patient, the physician may terminate a surgical or diagnostic procedure after the administration of anesthesia (local, regional block(s), general) or after the procedure as started (incision made, intubation started, scope inserted, etc.). This procedure would be reported by its usual CPT code and the addition of modifier 74.

For CMS, when the procedure is reported with modifier 74, there is no payment reduction. This is because the resources of the facility are consumed in essentially the same manner to the same extent as they would have been had the procedure been completed. If this modifier is not used and the patient has to come back for the same procedure, then the subsequent procedure will be denied. You would only get paid for one, whereas the use of the modifier 74 would allow you to be paid for both. The same applies to the modifier 73.

For example: A 65-year-old man was taken to the operating room for a laparoscopic cholecystectomy. After making the portal entry incision, the anesthesiologist noticed the patient having ventricular fibrillation on the cardiac monitor. Defibrillation effort was tried two times, finally the arrhythmia abated. The procedure was cancelled pending further cardiac consultation. CPT code: 47562-74 laparoscopy, surgical: cholecystectomy.

Modifiers 73 and 74 should be used when possible to help streamline revenue. As discussed earlier, modifiers explain to the insurance carrier that the description of the code is the same, but something about the procedure or service was changed.

Some modifiers impact reimbursement, while others are only informational and help get the claim paid without costly delays.

Using a modifier does not guarantee reimbursement, however, if the medical record does not support the modifier billed by the provider, the provider risks denial of the claim and possible penalties for submitting an incorrect claim. The important issue is to understand how to use the modifiers appropriately and which modifier should be appended to the claim appropriately.

Reference:

1. Grider, Deborah. AMA CPT 2007 Professional Edition; AMA Coding With Modifiers.