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Reimbursement
The Use of Modifiers in a Hospital Outpatient Wound Clinic
by Gloria Miller, Chief Financial Officer
Comprehensive Healthcare Solutions, Inc.
(800) 232-5070
gam@comprehensive-healthcare.com
(Written April 2005)
In my capacity as a business partner to various hospitals throughout
the United States, I often receive questions about modifiers. A modifier
is a two digit alpha or numeric descriptor that is appended to the end of
a HCPCS code to clarify the services billed. It is used when the doctor or
provider needs to elaborate or report extra information about the service
being billed. The use of a modifier shows that the service was changed by
some specific circumstance, without changing the intent of the service.
Modifiers eliminate the need for duplicate billing and unbundling, and are
an integral part of the Outpatient Prospective Payment System (OPPS).
Correct use of modifiers does not ensure payment. As always, medical
necessity and documentation for services billed must be included in the
record.
The use of a modifier is needed in several different scenarios. Some
examples are as follows:
- To show that a patient returned for a second surgical procedure to treat
a complication of the surgery performed earlier in the day
- To show that 2 procedures were done together, when they usually are not,
such as removing two blood vessels through the same incision
- To show that the same procedure was done several times on different
parts of the body (for instance, removal of skin lesions)
- To indicate that an office visit was done on the same day as a surgical
procedure and that it was separately and distinctly identifiable from the
reason for the surgery
The most commonly used Modifiers are--#25 and #59.
Modifier #25 should be appended to an Evaluation and Management
(E/M) code (92002-92014, 99201-99499, and G0175) to indicate that the
physician or provider performed a significant, separately identifiable E/M
service above and beyond the other service provided. It should be used in
the following circumstances:
Same patient, same day encounter or same physician or provider or
the patient’s condition required a clearly separate and identifiable
service above and beyond the usual care related to the service or
procedure.
Modifier 25 should be appended to the E & M code when reported with
another procedure on the same day. For example, this would indicate that
in the clinic setting, an evaluation and management visit was rendered to
an established patient for symptoms related to a right foot wound for the
past five weeks. During the exam, the patient adds that he noticed a skin
lesion on his ischium. After examination, the doctor performs a biopsy of
the skin lesion, an excisional debridement of the right foot wound, and
discharges the patient with instructions for follow up care. The use of
both the modifier 25 and the two HCPCS codes to describe two separately
distinct services clearly defines this encounter. The actual billing is
done using HCPCS 99213-25, HCPCS 11042 and 11100.
Modifier #59 is used when a physician or provider wants to indicate
that a service or procedure was distinct or independent from other
services performed on that same day. This procedure may reflect a
different session or patient encounter (visit), a different procedure, a
different body site or organ system, a separate incision/excision or
lesion or separate injury or area of injury. It would be used when the
service is independent from other services done on that day, or when they
are not usually reported together, or when no other modifier would
suffice. For example, a physician performed a simple repair of a
superficial wound (12001) and also a partial thickness skin debridement of
another site on the same extremity (11040-59). The actual billing is done
using HCPCS 12001 and HCPCS 11040-59.
Additional resources on the use of modifiers can be found at
www.cms.gov . The CMS
National Correct Coding Initiative (NCCI) edits also provide many specific
instructions for using modifiers.
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