Medical billing cpt modifiers and list of medicare modifiers.

Based on widespread probes of office evaluation and management (E/M) services, First Coast has discovered that the 24 modifier for E/M services, when billing within a global surgery period, has been billed incorrectly at least 60 percent of the time. Clinical review of documentation demonstrates that modifier 24 was either not supported for the encounter, or was improperly applied (i.e., a different modifier should have been submitted).

To address this widespread improper billing, First Coast implemented a pre-payment edit on April 16, 2012, applicable to office visit E/M claims (codes 99201-99205 and 99212-99215) billed with the 24 modifier.

Claims
For claims containing modifier 24 received on or after April 16, 2012, First Coast began developing to the provider to provide supporting documentation that justifies the use of the 24 modifier. Providers must respond within the specified timeframe included in the development letter. Failure to submit the documentation timely may result in a claim denial.

Reopenings

Also effective April 16, 2012, First Coast no longer accepts:

• Telephone requests via the interactive voice response or a customer service representative to add or change the 24 modifier on a previously denied claim.
• Written or fax requests (processed on or after April 16) to add or change the 24 modifier without supporting documentation. The provider will be sent a written notification that their request could not be completed.

Description

Bilateral services are procedures performed on both sides of the body during the same session or on the same day.

The HCPCS modifiers -LT and -RT are used when the procedure is valid for a modifier -50 procedure but the procedure is only performed on one side.

• As defined in the CPT, Modifier 50 “Bilateral Procedure: Unless otherwise identified in the listings, bilateral procedures that are performed at the same session should be identified by adding modifier 50 to the appropriate five digit code.”

• Modifier 50 is used to report diagnostic, radiology and surgical procedures. Modifier 50 applies to any bilateral procedure performed on both sides at the same session.

• Do not use Modifiers RT and LT when modifier 50 applies. A bilateral procedure is reported on one line, using modifier 50.

• Modifier 50 eligibility is based on procedure description, CPT guidelines, CMS directives and nationally recognized sources (e.g., Journal of AHIMA, CPT Assistant).

The modifier “50” is not applicable to:
• Procedures that are bilateral by definition.
• Procedures with descriptions including the terminology as “bilateral” or “unilateral.”

Harvard Pilgrim Reimburses1

Bilateral services performed on both sides of the body during the same session or on the same day at 150% of the fee schedule allowed amount.

• Bilateral payment adjustment applies to all providers except for those providers contracted as facility surgery case rate and percent of charge reimbursement methods.

Bilateral Service Billing
Bilateral services performed on both sides of the body during the same session or on the same day must be billed on a single detail line with CPT and modifier 50 appended.

Multiple Modifiers Billing
Modifier that reduces the fee schedule/allowable amount must be billed in the primary modifier position, and modifier 50 in the secondary position.

Counseling to Prevent Tobacco Use (for Asymptomatic Beneficiaries)

HCPCS/CPT Codes

G0436 – Smoking and tobacco cessation counseling visit for the asymptomatic patient; intermediate, greater than 3 minutes, up to 10 minutes

G0437 – Smoking and tobacco cessation counseling visit for the asymptomatic patient; intensive, greater than 10 minutes

ICD-10-CM Codes
F17.200, F17.201, F17.210, F17.211,
F17.220, F17.221, F17.290, F17.291, and
Z87.891

Who Is Covered

Outpatient and hospitalized Medicare beneficiaries:

• Who use tobacco, regardless of whether they exhibit signs or symptoms of tobaccorelated disease;
• Who are competent and alert at the time of counseling; and
• Who get counseling furnished by a qualified physician or other Medicarerecognized practitioner

Frequency

Two cessation attempts per year. Each attempt may include a maximum of 4 intermediate or intensive sessions, with the total annual benefit covering up to 8 sessions
per year

Beneficiary Pays
• Copayment/coinsurance waived
• Deductible waived

The Active Treatment (AT) modifier defines the difference between active treatment and maintenance treatment. Effective October 1, 2004, the AT Modifier is required under Medicare billing to receive reimbursement for CPT codes 98940-98942. For Medicare purposes, the AT modifier is used only when chiropractors bill for active/corrective treatment (acute and chronic care). The policy requires the following:

1. Every chiropractic claim for 98940/98941/98942, with a date of service on or after October 1, 2004, should include the AT modifier if active/corrective treatment is being performed; and 2. The AT modifier should not be used if maintenance therapy is being performed. MACs deny chiropractic claims for 98940/98941/98942, with a date of service on or after October 1, 2004, that does not contain the AT modifier.

The following categories help determine coverage of treatment.

1. Acute subluxation: A patient's condition is considered acute when the patient is being treated for a new injury (identified by x-ray or physical examination). (See SE1601 for details of the x-ray and examination requirements.) The result of chiropractic manipulation is expected to be an improvement in, or arrest of progression of, the patient's condition.

2. Chronic subluxation: A patient's condition is considered chronic when it is not expected to significantly improve or be resolved with further treatment (as is the case with an acute condition); however, the continued therapy can be expected to result in some functional improvement. Once the clinical status has remained stable for a given condition, without expectation of additional objective clinical improvements, further manipulative treatment is considered maintenance therapy
and is not covered.

Both of the above scenarios are covered by CMS as long as there is active treatment which is well documented and improvement is expected.

Maintenance: Maintenance therapy includes services that seek to prevent disease, promote health and prolong and enhance the quality of life, or maintain or prevent deterioration of a chronic condition. When further clinical improvement cannot reasonably be expected from continuous ongoing care, and the chiropractic treatment becomes supportive rather than corrective in nature, the treatment is then considered maintenance therapy. The AT modifier must not be placed on the claim when
maintenance therapy has been provided. Chiropractors should consider obtaining an Advance Beneficiary Notice (ABN) from beneficiaries in the event of a denial of a claim.

Key Points

For Medicare purposes, a chiropractor must place an AT modifier on a claim when providing active/corrective treatment to treat acute or chronic subluxation. However, the presence of the AT modifier may not in all instances indicate that the service is reasonable and necessary. As always, MACs may deny if appropriate after medical review determines that the medical record does not support active/corrective treatment.

Modifiers

Use the following modifiers, as applicable:

Bill Use Modifier Other Information

Bilateral surgery 50 Refer to the Bilateral Services and CPT Modifier 50 Payment Policy for billing directives

Reduced service 52 Use with CPT code representing the surgery(s) performed

Attempted service (discontinued procedure) 53

Decision for surgery 57 Use with evaluation and management code when appropriate

Staged or related procedure or service by the same physician or other qualified health care professional during the postoperative period 58 Use with procedure performed within the global period of another surgery when appropriate

Assistant surgeon 80, 81, 82, or AS• Use with CPT code representing the surgery(s) performed • Bill this modifier in the first modifier field

Co–surgery 62

Team surgery 66• Use with CPT code representing the surgery(s) performed
• Attach operative notes
• Bill this modifier in the first modifier field

Repeat procedures by the same physician 76 Use with a repeat of a same procedure performed within the global period when appropriate

Return to the operating room for a related procedure during the postoperative period 78 Use when a related procedure requires a return trip to the OR by the same physician within the global period of the first surgery when appropriate

Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period 79 Use when performing an unrelated procedure during the global period of a previous surgery

Glaucoma Screening

HCPCS/CPT Codes

G0117 – By an optometrist or ophthalmologist
G0118 – Under the direct supervision of an optometrist or ophthalmologist

ICD-10-CM Codes
Z13.5

Who Is Covered

Medicare beneficiaries who:
• Have diabetes mellitus;
• Have a family history of glaucoma;
• Are African-Americans aged 50 and older; or
• Are Hispanic-Americans aged 65 and older

Frequency
Annually for covered beneficiaries

Beneficiary Pays
• Copayment/coinsurance applies
• Deductible applies

Influenza Virus Vaccine and Administration

HCPCS/CPT Codes
90630, 90653, 90654, 90655, 90656, 90657,
90660, 90661, 90662, 90672, 90673, 90685,
90686, 90687, 90688, Q2035, Q2036, Q2037,
Q2038, Q2039 – Influenza Virus Vaccine
G0008 – Administration

ICD-10-CM Codes
Z23

Who Is Covered
All Medicare beneficiaries

Frequency
Once per influenza season Medicare covers additional flu shots if medically necessary

Beneficiary Pays
• Copayment/coinsurance waived
• Deductible waived

Intensive Behavioral Therapy (IBT) for Cardiovascular Disease (CVD) Also known as a CVD risk reduction visit

HCPCS/CPT Codes

G0446 – Annual, face-to-face intensive behavioral therapy for cardiovasculardisease, individual, 15 minutes

ICD-10-CM Codes
See https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/ICD10.html for individual Change Requests (CRs) and coding translations for ICD-10

Who Is Covered
All Medicare beneficiaries:

• Who are competent and alert at the time counseling is provided; and
• Whose counseling is furnished by a qualified primary care physician or other primary care practitioner and in a primary care setting

Frequency
One CVD risk reduction visit annually

Beneficiary Pays
• Copayment/coinsurance waived
• Deductible waived

Preventing duplicate claim denials

Providers are responsible for all claims submitted to Medicare under their provider number. Preventable duplicate claims are counterproductive and costly, and continued submission to Medicare may lead to program integrity action.

Please share this information with your billing companies, vendors and clearing houses: Claim system edits search for duplicate, suspect duplicate and repeat services, procedures and items within paid, finalized, pending and same claim details in history. Duplicate claims and claim lines are automatically denied. Suspect duplicate claims and claim lines are suspended and reviewed by the Medicare administrative contractor (MAC) to make a determination to pay or deny. Click here for additional information.

Medicare correct coding rules include the appropriate use of condition codes and/or modifiers. When you submit a claim for multiple instances of a service, procedure or item, the claim should include an appropriate modifier to indicate that the service, procedure or item is not a duplicate. Note that the modifier should be added to the second through subsequent line items for the repeat service, procedure or item. (An example is listed below.) In many instances, this will allow the claim to process and pay, if applicable.

However, in some instances, even if an appropriate modifier is included, the claim may deny as a duplicate, based on medically unlikely edits (MUEs). MUEs are maximum units of service that are typically reported for a service, medical procedure or item, under most instances, for a beneficiary on a single date of service. Note that these duplicate denials may not always be considered preventable.

However, in some instances, even if an appropriate modifier is included, the claim may deny as a duplicate, based on medically unlikely edits (MUEs). MUEs are maximum units of service that are typically reported for a service, medical procedure or item, under most instances, for a beneficiary on a single date of service. Note that these duplicate denials may not always be considered preventable. Click here for information on MUEs, including appeal rights.

Review your billing procedures and software, and use appropriate modifiers, as applicable. The following are examples of modifiers that may be used on your claim to identify that the service, procedure or item is not a duplicate. Please review the Current Procedural Terminology (CPT®) codebook for a complete list of modifiers.

• Modifier 59: Service or procedure by the same provider, distinct or independent from other services, performed on the same day. Services or procedures that are normally reported together but are appropriate to be billed separately under certain circumstances. Refer to MLN Matters® article SE1418 external pdf file for more details on the use of modifier 59, including numerous coding examples.

• The Centers for Medicare & Medicaid Services (CMS) established four new modifiers, effective January 1, 2015, to define subsets of modifier 59. Refer to MLN Matters® article MM8863 external pdf file for details.

• Modifier 76: Repeat service or procedure by the same provider, subsequent to the original service or procedure.

• Modifier 91: Repeat clinical diagnostic laboratory tests. This modifier is added only when additional test results are medically necessary on the same day.

• Example: Laboratory submits Medicare claim for four glucose; blood, reagent strip tests (CPT® code 82948).
Line 1: 82948
Line 2: 82948 and modifier 91
Line 3: 82948 and modifier 91
Line 4: 82948 and modifier 91

Note: All claims submitted to Medicare should be supported by documentation in the patient’s medical record.

B. Modifiers for PET Scans

Effective for claims with dates of service on or after April 3, 2009, the following modifiers have been created for use to inform for the initial treatment strategy of biopsy-proven or strongly suspected tumors or subsequent treatment strategy of cancerous tumors:

PI Positron Emission Tomography (PET) or PET/Computed Tomography (CT) to inform the initial treatment strategy of tumors that are biopsy proven or strongly suspected of being cancerous based on other diagnostic testing.

Short descriptor: PET tumor init tx strat PS Positron Emission Tomography (PET) or PET/Computed Tomography (CT) to inform the subsequent treatment strategy of cancerous tumors when the beneficiary's treatment physician determines that the PET study is needed to inform subsequent anti-tumor strategy.

Short descriptor: PS - PET tumor subsq tx strategy

Effective for claims with dates of service on or after April 3, 2009, contractors shall accept FDG PET claims billed to inform initial treatment strategy with the following CPT codes AND modifier PI: 78608, 78811, 78812, 78813, 78814, 78815, 78816.

Effective for claims with dates of service on or after April 3, 2009, contractors shall accept FDG PET claims with modifier PS for the subsequent treatment strategy for solid tumors using a CPT code above AND a cancer diagnosis code.

Contractors shall also accept FDG PET claims billed to inform initial treatment strategy or subsequent treatment strategy when performed under CED with one of the PET or PET/CT CPT codes above AND modifier PI OR modifier PS AND a cancer diagnosis code AND modifier Q0/Q1. Effective for services performed on or after June 11, 2013, the CED requirement has ended and modifier Q0/Q1, along with condition code 30 (institutional claims only), or ICD-9 code V70.7, (both institutional and practitioner claims) are no longer required.

Pneumococcal Vaccine and Administration

HCPCS/CPT Codes
90669 – Pneumococcal conjugate vaccine, polyvalent, for children under 5 years, for intramuscular use
90670 – Pneumococcal Conjugate Vaccine
90732 – Pneumococcal polysaccharide vaccine
G0009 – Administration

ICD-10-CM Codes
Z23

Who Is Covered
All Medicare beneficiaries

Frequency
• An initial pneumococcal vaccine to Medicare beneficiaries who never received the vaccine under Medicare Part B; and
• A different, second pneumococcal vaccine 1 year after the first vaccine was administered

Beneficiary Pays
• Copayment/coinsurance waived
• Deductible waived

For more information, refer to https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/MLN-Publications-Items/CMS1243321.html on the Centers for Medicare & Medicaid Services (CMS) website.

Incomplete Antepartum Care Service CPT

Billing for Incomplete Antepartum Care

59425 When billing for four to six prenatal visits
59426 When billing for seven or more prenatal visits with or without an initial visit

Postpartum Care

Service CPT Modifier

Billing for Multiple Deliveries For additional babies: 59409, 59514, 59612, or 59620 51 and 59

Oral and Maxillofacial

Surgery Service HCPCS

Oral and Maxillofacial Surgery
Do not use CPT procedure code 41899, as this is an unspecified code and will cause delay in payment for services.

Physician Service Policy Service Modifier

Locum Tenens and Reciprocal Billing
Q5 - Service furnished by a substitute physician under a reciprocal billing arrangement.
Q6 - Service furnished by a locum tenens physician

Adult Day Care (Health) HCPCS Description Modifier Place of Service

S5100 Day Care Services, Adult
1 Unit = 15 minutes
U2 modifier is no longer required when billing this service code.
12 Home 99 Other (Community)

The following chart outlines appropriate CPT codes to use when billing for well-child care services and the number allowed at each age interval.

ServiceProcedure Codes

Office Visit Hospital Visit 99381-99384, 99461, 99391-99394 99460, 99463

Developmental Test 96110, 96111

Immunizations 90460-90474, 90633-90634, 90645-90649, 90655-90658, 90660, 90664, 90666-90669, 90680, 90696, 90698, 90700-90708, 90710, 90712-90713, 90714-90715, 90716, 90718-90721, 90723, 90732, 90733, 90734, 90740, 90743-90744, 90747-90748, G0008-G0010, J1670, S0195

Preventive Medicine 99420, 99429

Preventive Counseling 99401-99404 99411-99412

TB 86580

UA 81000-81003

HCT 85004, 85007-85009, 85014, 85018, 85025

HBG85027, 85032, 85041

UC870861

Sickle - HB 83020

Sickle - SLD 85660

Lead 83655

PKU (In first month) 84030

Cholesterol 82465

Screening Ear 92551-92553 92585-92588 (infant)

Eye 92002, 92004, 92012, 92014, 99172, 99173

Clinic/Center-Federally Qualified Health Center (FQHC)

Bill the encounter using procedure code T1015 with the appropriate rate on the first detail line. Providers are required to list all the CPT/HCPCS services provided during the encounter priced at zero dollars on subsequent lines. CPT codes included with the T1015 encounter code must accurately indicate the service(s) provided during the encounter and conform to National Correct Coding Initiative (NCCI) standards. Claims submitted without the corresponding CPT/HCPCS codes will be denied.

Service HCPCS Diagnosis Description Modifier Place of Service

Clinic/ center -FQHC T1015 Use appropriate diagnosis code for services rendered. (i.e., Well Child Exam, Family Planning) All FQHC clinics must use procedure code T1015 for medical services. 76 (same day/ same provider) 77 (same day/ different provider) POS 50

Clinic/Center-Rural Health Clinics (RHC)
Bill the encounter using procedure code T1015 with the appropriate rate on the first detail line. Providers are required to list all the CPT/HCPCS services provided during the encounter priced at zero dollars on subsequent lines. CPT codes included with the T1015 encounter code must accurately indicate the service(s) provided during the encounter and conform to National Correct Coding Initiative (NCCI) standards. Claims submitted without the corresponding CPT/HCPCS codes will be denied.

Service HCPCS Diagnosis Description Modifier Place of Service

Clinic/ Center -Rural Health Clinics T1015 Use appropriate diagnosis code for services rendered. (i.e., Well Child Exam, Family Planning) All rural health clinics must use procedure code T1015 for medical services. 76 (same day/ same provider) 77 (same day/ different provider) POS 72

Indian Health Center (IHC)

Bill the encounter using procedure code T1015 with the appropriate rate on the first detail line. Providers are required to list all the CPT/HCPCS services provided during the encounter priced at zero dollars on subsequent lines. CPT codes included with the T1015 encounter code must accurately indicate the service(s) provided during the encounter and conform to National Correct Coding Initiative (NCCI) standards. Claims submitted without the corresponding CPT/HCPCS codes will be denied.

Service HCPCS Diagnosis Description Modifier Place of Service

Clinic/ Center -Indian Health Clinics T1015 Use appropriate diagnosis code for services rendered. (i.e., Well Child Exam, Family Planning) All rural health clinics must use procedure code T1015 for medical services. 76 (same day/ same provider) 77 (same day/ different provider) POS 5

Policy
Services rendered prior to a related inpatient admission are considered incidental to admission and are included in the inpatient reimbursement rate.
Services that are incidental to an admission include:
• Surgical day care
• Observation stay
• Emergency room care
• Diagnostic and/or testing services
Pre-admission services may be subject to post-payment audits and retractions.

Per Diem
Incidental services that are provided within one day of a related inpatient admission are included in the inpatient per diem reimbursement.

An observation stay that converts to an inpatient admission before midnight of the same day is included in the inpatient per diem rate and is not separately reimbursed.

An observation stay that converts to an inpatient admission after midnight of the observation day is not included in the per diem rate and is separately reimbursed.

Case Rate and Diagnosis-Related Groups (DRG)
• Diagnostic services that are provided within three days of an inpatient admission are included in the inpatient Case rate or DRG reimbursement.
• Non-diagnostic services related to the principal diagnosis that are provided within three days of an inpatient admissions are included in the inpatient case rate or DRG reimbursement.
• Any ambulatory day care, radiology or laboratory procedures that result in an inpatient admission are included in the inpatient case rate or DRG reimbursement

Screening for Sexually Transmitted Infections (STIs) and High Intensity Behavioral Counseling (HIBC) to Prevent STIs

HCPCS/CPT Codes

86631, 86632, 87110, 87270, 87320, 87490,
87491, 87810 – Chlamydia
87590, 87591, 87850 – Neisseria gonorrhoeae
87800 – Infectious agent detection by nucleic acid (DNA or RNA), multiple organisms; direct probe(s) technique
86592 – Syphilis test, non-treponemal antibody; qualitative (eg, VDRL, RPR, ART)
86593 – Syphilis test, non-treponemal, quantitative
86780 – Treponema pallidum
87340, 87341 – Hepatitis B (hepatitis B surface antigen)
G0445 – Semiannual high intensity behavioral counseling to prevent STIs, individual, face-toface, includes education skills training & guidance on how to change sexual behavior, 30 minutes

ICD-10-CM Codes
Z11.3, Z72.89, Z72.51, Z72.52, Z72.53, Z34.00,
Z34.01, Z34.02, Z34.03, Z34.80, Z34.81, Z34.82,
Z37.83, Z34.90, Z34.91, Z34.92, Z34.93, O09.90,
O09.91, O09.92, and O09.93

Who Is Covered

Certain Medicare beneficiaries who are:

• Sexually active adolescents and adults at increased risk for STIs; and • Referred for this service by a primary care provider and provided by a Medicare-eligible
primary care provider in a primary care setting

NOTE: More information on covered beneficiaries and a definition of “increased risk for STIs” can be found in the Medicare National Coverage Determinations Manual, Publication 100-03, Chapter 1, Section 210.10.

Frequency

• One annual occurrence of screening for chlamydia, gonorrhea, and syphilis in women at increased risk who are not pregnant
• One annual occurrence of screening for syphilis in men at increased risk
• Up to two occurrences per pregnancy of screening for chlamydia and gonorrhea in pregnant women who are at increased risk for

STIs and continued increased risk for the second screening

• One occurrence per pregnancy of screening for syphilis in pregnant women; up to two additional occurrences in the third trimester and at delivery if at continued increased risk for STIs

• One occurrence per pregnancy of screening for hepatitis B in pregnant women; one additional occurrence at delivery if at continued increased risk for STIs

• Up to two 20-30 minute, face-to-face HIBC counseling sessions annually Beneficiary Pays
• Copayment/coinsurance waived
• Deductible waived

Effective July 1, 2016, providers are required to:

• Use the JW modifier for claims with unused drugs or biologicals from single use vials or single use packages that are appropriately discarded (except those provided
under the Competitive Acquisition Program (CAP) for Part B drugs and biologicals) and

• Document the discarded drug or biological in the patient's medical record when submitting claims with unused Part B drugs or biologicals from single use vials or
single use packages that are appropriately discarded Make sure that your billing staffs are aware of these changes. Remember that the JW modifier is not used on claims for CAP drugs and biologicals

The “Medicare Claims Processing Manual,” Chapter 17, Section 40 provides policy detailing the use of the JW modifier for discarded Part B drugs and biologicals. The current policy allows MACs the discretion to determine whether to require the JW modifier for any claims with discarded drugs or biologicals, and the specific details regarding how the discarded drug or biological information should be documented.

Be aware in order to more effectively identify and monitor billing and payment for discarded drugs and biologicals, CMS is revising this policy to require the uniform use of the JW modifier for all claims with discarded Part B drugs and biologicals

Payment of DMEPOS Items Based on Modifiers

The following modifiers were added to the HCPCS to identify supplies and equipment that may be covered under more than one DMEPOS benefit category:

• AU Item furnished in conjunction with a urological, ostomy, or tracheostomy supply;

• AV Item furnished in conjunction with a prosthetic device, prosthetic or orthotic; and

• AW Item furnished in conjunction with a surgical dressing.

Codes A4450 and A4452 are the only codes that have been identified at this time that would require use of all three of the above listed modifiers. Providers must report these modifiers on claims for items identified by codes A4450 and A4452 that are furnished on or after January 1, 2005. Modifier AU may also be applicable to code A4217. Providers must report modifier AU on claims for items identified by code A4217 that are furnished in conjunction with a urological, ostomy, or tracheostomy supply on or after January 1, 2005. Items identified by code A4217 that are furnished in conjunction with durable medical equipment are reported without a modifier. In the future, other codes may be identified as codes that must be submitted with these modifiers. Medicare contractors base payment for the codes A4217, A4450, and A4452 on the presence or absence of these modifiers.

Codes L8040 thru L8047 describe facial prostheses. Providers must report the following modifiers on claims for replacement of these items:

• KM Replacement of facial prosthesis including new impression/moulage; and

• KN Replacement of facial prosthesis using previous master model.

Providers must report these modifiers on claims for replacement of items identified by codes L8040 thru L8047 that are furnished on or after January 1, 2005. Medicare contractors base payment for the codes L8040 thru L8047 on the presence of these modifiers. These modifiers are only used when the prostheses is being replaced.

In accordance with section 302(c) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), the fee schedule update factors for 2004 thru 2008 for durable medical equipment (DME), other than items designated as class III devices by the Food and Drug Administration (FDA), are equal to 0 percent. The HCPCS codes for DME designated as class III devices by the FDA are identified on the DMEPOS fee schedule available on the above mentioned web site by presence of the KF modifier.

Elevating/stair climbing power wheelchairs are class III devices. Suppliers billing the DMERCs must submit claims for the base power wheelchair portion of this device using HCPCS code K0011 (programmable power wheelchair base) with modifier KF for claims submitted on or after April 1, 2004, with dates of service on or after January 1, 2004. For claims with dates of service on or after January 1, 2004, the elevation feature for this device should be billed using HCPCS code E2300 and the stair climbing feature for this device should be billed using HCPCS code A9270.

Regional home health intermediaries (RHHIs) will not be able to implement the KF modifier until January 1, 2005. Therefore, for claims with dates of service prior to January 1, 2005, HHAs must submit claims for the base power wheelchair portion of stair climbing wheelchairs with HCPCS code E1399. For claims with dates of service on or after January 1, 2005, HHAs must submit claims for the base power wheelchair portion of stair climbing wheelchairs with HCPCS code K0011 with modifier KF.

The fee schedule amounts for K0011 with and without the KF modifier appear on the fee schedule file referenced at www.cms.hhs.gov/providers/pufdownload/default.asp#dme. For claims with dates of service prior to January 1, 2005, RHHIs should pay claims for stair climbing wheelchair bases billed with code E1399 using the fee schedule amounts for K0011 with the KF modifier. All other claims for programmable power wheelchair bases should be paid using the fee schedule amounts for K0011 without the KF modifier.

Effective for claims with dates of service on or after January 1, 2005, HHAs must submit modifier KF along with the applicable HCPCS code for all DME items classified by the FDA as class III devices.

Screening Pap Tests

HCPCS/CPT Codes

G0123, G0124, G0141, G0143, G0144,
G0145, G0147, G0148 – Screening cytopathology, cervical or vaginal
P3000 – Screening Pap smear by technician under physician supervision
P3001 – Screening Pap smear requiring interpretation by physician
Q0091 – Screening Pap smear; obtaining, preparing and conveyance to lab

ICD-10-CM Codes

High risk – Z77.22, Z77.9, Z91.89, Z72.89,
Z72.51, Z72.52, AND Z72.53
Low risk – Z01.411, Z01.419, Z12.4, Z12.72,
Z12.79, and Z12.89

Who Is Covered
All female Medicare beneficiaries

Frequency
• Annually if at high risk for developing cervical or vaginal cancer or childbearing age with abnormal Pap test within past 3 years; or
• Every 2 years for women at normal risk

Beneficiary Pays
• Copayment/coinsurance waived
• Deductible waived

Payment for Evaluation and Management Services Provided During Global Period of Surgery

A. CPT Modifier “-24” - Unrelated Evaluation and Management Service by Same Physician During Postoperative Period

Carriers pay for an evaluation and management service other than inpatient hospital care before discharge from the hospital following surgery (CPT codes 99221-99238) if it was provided during the postoperative period of a surgical procedure, furnished by the same physician who performed the procedure, billed with CPT modifier “-24,” and accompanied by documentation that supports that the service is not related to the postoperative care of the procedure. They do not pay for inpatient hospital care that is furnished during the hospital stay in which the surgery occurred unless the doctor is also treating another medical condition that is unrelated to the surgery. All care provided during the inpatient stay in which the surgery occurred is compensated through the global surgical payment.

B. CPT Modifier “-25” - Significant Evaluation and Management Service by Same Physician on Date of Global Procedure

Medicare requires that Current Procedural Terminology (CPT) modifier -25 should only be used on claims for evaluation and management (E/M) services, and only when these services are provided by the same physician (or same qualified nonphysician practitioner) to the same patient on the same day as another procedure or other service. Carriers pay for an E/M service provided on the day of a procedure with a global fee period if the physician indicates that the service is for a significant, separately identifiable E/M service that is above and beyond the usual pre- and post-operative work of the procedure. Different diagnoses are not required for reporting the E/M service on the same date as the procedure or other service. Modifier -25 is added to the E/M code on the claim.

Both the medically necessary E/M service and the procedure must be appropriately and sufficiently documented by the physician or qualified nonphysician practitioner in the patient’s medical record to support the claim for these services, even though the documentation is not required to be submitted with the claim.

If the physician bills the service with the CPT modifier “-25,” carriers pay for the service in addition to the global fee without any other requirement for documentation unless one of the following conditions is met:

• When inpatient dialysis services are billed (CPT codes 90935, 90945, 90947, and 93937), the physician must document that the service was unrelated to the dialysis and could not be performed during the dialysis procedure;

• When preoperative critical care codes are being billed on the date of the procedure, the diagnosis must support that the service is unrelated to the performance of the procedure; or

• When a carrier has conducted a specific medical review process and determined, after reviewing the data, that an individual or a group has high use of modifier “-25” compared to other physicians, has done a case-by-case review of the records to verify that the use of modifier was inappropriate, and has educated the individual or group, the carrier may impose prepayment screens or documentation requirements for that provider or group. When a carrier has completed a review and determined that a high usage rate of modifier “-57,” the carrier must complete a case-by-case review of the records. Based upon this review, the carrier will educate providers regarding the appropriate use of modifier “-57.” If high usage rates continue, the carrier may impose prepayment screens or documentation requirements for that provider or group.

Carriers may not permit the use of CPT modifier “-25” to generate payment for multiple evaluation and management services on the same day by the same physician, notwithstanding the CPT definition of the modifier.

C. CPT Modifier “-57” - Decision for Surgery Made Within Global Surgical Period

Carriers pay for an evaluation and management service on the day of or on the day before a procedure with a 90-day global surgical period if the physician uses CPT modifier “-57” to indicate that the service resulted in the decision to perform the procedure. Carriers may no pay for an evaluation and management service billed with the CPT modifier “-57” if it was provided on the day of or the day before a procedure with a 0 or 10-day global surgical period.

NDC Code

An NDC (National Drug Code) is a unique identifier which identifies a specific drug. Even though an NDC Code is assigned to a drug, the drug may not be approved by the FDA. The NDC code(s) reported by the manufacture is the billable NDC code and is generally found on the drug container (i.e. vial, bottle, tube, etc).

Note: In select instances, the manufacture reports the NDC code on the drug package which would be the billable NDC code based upon this being the NDC Code reported by the manufacture.

When coding a claim, the following NDC information is required to identify the drug services provided and prevent the services from being rejected:

• NDC Qualifier (N4)

• NDC Code (11 digits-see below)

• NDC Description (optional)

Refer to the below instructions for converting NDC codes into an 11-digit format (5-4-2) when the drug’s NDC code is fewer than 11 digits:

NOTE - Any NDC code that is billed outside of the 11-digit format will be rejected.

Digit NDC format is Then add a zero (0) in Report NDC as

4-4-2 (9999-9999-99) first position, 09999-9999-99 09999999999

5-3-2 (99999-999-99) sixth position, 99999-0999-99 99999099999

5-4-1 (99999-9999-9) tenth position, 99999-9999-09 99999999909

NDC Quantity

NDC Quantity is based on the National Council for Prescription Drug Programs (NCPDP) standard billing units per NDC. The NDC Quantity identifies the drug dosage amount submitted for the NDC Code billed. In order to accurately report the NDC Quantity, the Unit of Measurement (UoM) assigned to the NDC Code must be applied and used to calculate the dosage amount. The dosage amount billed in the NDC Quantity must be billed with the actual metric decimal quantity (up to two decimal places) for the unit of measurement assigned to the NDC to prevent the services from being denied or underpaid. Note: The NDC quantity must be rounded up to 0.01 in the metric quantity is less than 0.01 (i.e. 0.003, 0.0014, etc) There are four valid values (F2, ML, GR, UN) that can be used when reporting the unit of measurement. Each NDC Code is assigned a single UoM for the drug based upon how the drug is supplied. Below is the unit of measurement descriptions and examples to assist with determining the unit of measurement (UoM) assigned to the NDC code to calculate the appropriate NDC quantity when billing claims.

• UN (Unit) - used when the products are dispensed in discreet units or vials that are powder form and have to be reconstituted before administration. These products are not measured by volume or weight. The NDC Code's reporting billing unit of "EA" applies to the
"UN" unit of measurement.

Examples of drug products defined as "UN" Include but are not limited to:

Drug Name NDC Code NDC Billing Unit Reported UoM

Adcetris 50 MG SOLR 51144-0050-01 UN EA

Kyprolis 60 MG SOLR 76075-0101-01 UN EA

• F2 (International Units) - used for measuring medications reported in International Units (e.g. antihemphilic factor)

• GR (Gram) - used to report a product measured by its weight. Commonly used in products supplied in ointment, cream, inhaler, or bulk powder in a jar. These are measured in as "GR" unit of measurement.

Examples of drug products defined as "GR" include but are not limited to:

Drug Name NDC Code NDC Billing Unit Reported UoM

Morphine Sulfate POWD 00406-1521-53 GR GM

Combivent Respimat 20-100 00597-0024-02 GR GM
MCG/ACT AERS

• ML (Milliliter) - used to report a product measured by its liquid volume.

Examples of drug products defined as "ML" include but are not limited to:

Drug Name NDC Code NDC Billing Unit Reported UoM

Simponi 50MG/0.5ML SOLN 57894-0070-01 ML ML

Zaltrap 100MG/4ML SOLN 00024-5840-01 ML ML

When coding a claim for an unclassified drug, the following NDC Quantity values are required NDC Quantity

• Unit of Measurement (UN, F2, ML, or GR)

Providers must be able to enter and transmit the required NDC fields on professional claims (electronic or CMS-1500) submitted to Florida Blue and receive information about those fields on error messages and remittance advices (electronic and/or paper). This may require technical updates to your claim submission and billing systems. Availity includes the required NDC fields on its input screens. If your practice management system does not accommodate this requirement, contact your vendor to coordinate changes.

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