New modifiers? Stay alert!

Modifiers play a key role in your day to day coding life. As such, you stand a better chance of getting the payments if you are well-versed with everything relating to modifiers. As an orthopedic coder, you need to stay on top of all modifier changes which in turn will have an impact on your orthopedic coding practice.

In 2011, it's important that you are aware of a few just-in modifiers as well as some changes to the present CPT modifiers.

This year add several just-in modifiers to your coding armory and update the descriptors for various others you might use regularly. Say for instance, you can use modifier GU (Waiver of liability statement issued as required by payer policy, routine notice) for dates of service (DOS) January 1, 2011 and after that.

There may be times when it's proper to report modifier GU in place of the revised stamdby modifier GA (Waiver of liability statement on file; individual).

In addition, three existing CPT modifiers (Source CPT http://www.supercoder.com/cpt-codes) now cover non-physician providers in the descriptors, as follows:

Modifier 76 -- Repeat procedure or service by same physician or non-physician provider

Modifier 77 -- Repeat procedure or service by another physician or NPP

Modifier 78 -- Unplanned return to the operating/procedure room by the same doctor or NPP following initial procedure for a related procedure during the postoperative period).

Modifier 78 -- Unplanned return to the operating/procedure room by the same physician or NPP following initial procedure for a related procedure during the postoperative period).

In earlier years, some payers did not allow non-physician providers to report their services with these modifiers as they purposely addressed “physician" care. If you update the descriptors, it should be much easier for you to report situations represented by modifiers 76, 77, or 78 to your payers.

Report Appendectomy Separately Depending On What The Situation Demands

So you think appendectomy always comes bundled with other procedures. If so, you need to think again. You can report appendectomy separately depending on what the situation demands. If you miss your appendectomy codes, you could be losing your deserved payments.


Many people are of the false notion that skipping appendectomy codes has no bearing. Whereas the fact is if you fail to report 44955 when the situation demands, you would be costing your practice $83.58 (2.46 relative value unit times the 2011 conversion factor of $33.9764).


Familiarize yourself with these two requirements for separate appendectomy:


a) Your surgeon clearly documented a problem with the appendix


b) Other procedures during the same session do not relate directly to the right colon. When your gastroenterologist carries out a medically necessary appendectomy at the same time as another procedure, you would use +44955 (reported in addition to the primary procedure performed).



Using 44955 follows that you code a diagnosis to prove that the procedure was medically necessary.


Clue: If you cannot find an appropriate diagnosis code to support 44955, there are chances that the removal wasn't required because of immediate health concerns, and you shouldn't be separately reporting the appendectomy after all. Your answer to supplying a separate ICD-9 for 44955 lies in the CPT's descriptor, which includes the phrase “indicated purpose. This means that there must be a separate, medically necessary diagnosis or signs and symptoms to justify the appendectomy.


Here's an example: The patient has a gallbladder problem, and while carrying out the gallbladder removal, the surgeon finds acute appendicitis as well; as such he carries out an appendectomy. In this instance, you should use 44955 as well as the cholecystectomy. (for instance 47562, Laparoscopy, surgical; cholecystectomy). Also, you should bill 540.9 (Acute appendicitis without mention of peritonitis) to support your claim.


Physician's notes suggest you should scoop up info from path report


Also, you can take a look at the applicable signs and symptoms or the pathology report to verify your diagnosis code(s). See to it that your codes are supported by both your physician's documentation and your path report.


Even if the pathology report turns out to be negative for appendicitis, you can still report 44955 as long as the physician's documentation clearly states the reason he is removing the appendix.

93970: Global Period A Factor for Evaluation & Management Coding

The question here is whether you can bill a bilateral scan (93970) along with an office visit and get paid for both. Also, would you need to use modifier 25 on the office visit?

Well, you may report an evaluation & management service and 93970 (Duplex scan of extremity veins together with responses to compression and other maneuvers; entire bilateral study) on the same claim. Whether you need to add modifier 25 (Significant, separately identifiable evaluation & management service by the same doctor on the same day of the procedure or other service) may depend on your payer.

Details: As per the Medicare physician fee schedule, the global period for 93970 is XXX. According to Medicare's Correct Coding Initiative (CCI) manual, chapter 1, section D, if you have a truly separate evaluation & management, you may report it on the same day as a XXX procedure. The manual further says that you should add modifier 25 to the evaluation & management code. (As we said above, different payers may have different requirements for use of modifier 25, more so since you won't find evaluation & management codes bundled with 93970 in the listed CCI edit pairs.)

Note of caution: The CCI manual sets out the following rules:

You shouldn't report a separate evaluation & management code for the usual pre-, intra-, and post-procedure work expected from a physician for the given XXX procedure.

You shouldn't report a separate evaluation & management code to represent physician supervisor or interpretation of another provider's performance of a XXX procedure that has no physician work relative value units (RVUs).


Bonus tip: If both bilateral upper and lower studies are carried out on the same date and/or session, report 93970 twice and modifier 59 (Distinct procedural service) to one of the codes.

Resource: Take a look at the CCI manual online at www.cms.gov/NationalCorrectCodInitEd/.