Practice Profitability

More on Modifiers

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In the January-February issue, I discussed modifiers -21, -24 and -25, which are three of the six basic (level I) modifiers listed in Appendix A of the CPT coding book that apply directly to evaluation and management coding. This issue, I'd like to discuss the other three, -32, -52 and -57.

The purpose of modifiers is to clarify the usual circumstance of a patient encounter, service or procedure. The primary purpose of attaching a modifier to any CPT code is to provide additional information to assist with the processing of a claim.

It is essential that PAs understand that patient encounter documentation must support the use of modifiers by correctly reflecting the circumstances that require a modifier in the first place. A lack of adequate medical documentation, or incorrect usage of modifiers, might lead to charges of fraud or abuse. A modifier is the method by which a provider or a facility identifies an alteration to a service without changing the basic code used.

Modifier 32

On occasion, an insurance company or other third-party payer sends a patient to a provider for a second opinion, for a specific evaluation or for a determination of disability. When the provider is aware of one of these circumstances, modifier 32 is used to indicate that this is a "mandated service."

The use of modifier 32 is not appropriate when the patient, family members or other parties request second opinions or other services. A common circumstance in which this modifier might be appropriately used is when a patient is sent to a provider by a workers' compensation carrier asking for a second opinion. Another might be when children in state custody are sent to your office for health examinations after being placed in temporary custody or foster care.

Generally speaking, when an encounter is requested by a third party (insurance company, state agency, law enforcement, etc.), consider it a mandated service.

Modifier 52

There may be times in which a service or a procedure is reduced or even stopped for some reason. When this occurs, the usual CPT code is reported with the attached 52 modifier, "Reduced Services," to indicate that the usual work of the service or procedure was reduced in some way and should not be paid at the full rate.

Surgical procedures billed with this modifier require detailed documentation about how this particular encounter differs from the usual service or procedure described in the CPT book. Submitting the operative report is beneficial, and the report should contain this descriptive information.

Modifier 52 is not to be used to reduce charges when a patient is unable to pay because of financial hardship. That is an incorrect application of this modifier.

If a service or procedure is terminated because of a situation that threatens the well being of the patient, it may be more appropriate to use modifier 73 or 74, which are specific to surgical situations in which sedation or anesthesia was administered to the patient before termination of the service or procedure.

Insurance carriers may not always recognize the use of modifier 52, so it is important to check into a carrier's policy. Using modifier 52 with E&M codes isn't very common but may be appropriate, depending on the circumstances of the encounter.

One example of using modifier 52 might be during a preventive medicine visit that requires a comprehensive history and a comprehensive physical exam, and that also requires that anticipatory guidance be provided to the patient at the time of the encounter. If any one of these requirements is not met for whatever reason, a preventive medicine code could still be used, but with the 52 modifier added to indicate that the expected level of service was reduced. Documentation notes should indicate which part of the encounter was not performed, and why.

When a procedure that normally includes bilateral structures (a vasectomy, for example) is begun and then is terminated after only one side has been completed, the correct CPT code is reported with the attached 52 modifier. Operative notes should include details about why that procedure was reduced.

Modifier 57

Modifier 57, "Decision for Surgery," usually is attached to an E&M code when a decision for surgery is made, and then that surgery is scheduled on the day of or the day after the E&M encounter.

Medicare has established postoperative periods for surgical procedures. Those with a 90-day post-op period are considered "major" surgery. Procedures with zero- to 10-day post-op periods are considered "minor" surgery.

In the case of major surgeries, a preoperative period is included as part of the 90 days and is defined as the day before or the day of surgery. E&M services provided within this pre-op period (such as a hospital admission H&P) fall under the global fees of the surgical procedure, unless the 57 modifier is used to indicate that the decision for surgery was made at that time.

Using modifier 57 implies that an E&M service (consultation, office visit, nursing home visit, etc.) was performed, and during the course of the E&M service a decision was made to perform surgery on that day or the following day. This allows for payment of the E&M service provided during the pre-op/post-op care period of 90 days, as defined by Medicare.

It is inappropriate to use modifier 57 with a hospital visit code on the day before or the day of a surgical procedure when the decision for surgery was made before that time. Generally speaking, it is also inappropriate to use modifier 57 with an E&M code on the same day as a minor procedure. When a decision to perform a minor procedure is done on the same day as the procedure, it is considered to be part of the pre-op care and is included in the global fee for the procedure. An E&M code should not be billed at the same time. You should, however, check with third-party carriers in your area for their definition of a minor procedure and determine whether they recognize this code.

Modifier 57 should be attached only to E&M codes and to ophthalmologic codes 92002, 92004, 92012 and 92014. It should not be applied to procedure codes.

Jim Meeks is a family practice PA who works in Orem, Utah, and is the founder of Medical Professional Education and Consultation Services (MPECS). For more information or to find out about the author's four-hour workshops, visit www.mpecs.org or go to www.advanceweb.com/pa and follow the links to MPECS.


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